THE INTERNATIONAL JOURNAL OF MICRODENTISTRY 56

REVI EW
MICRODENTISTRY: CONCEPTS, METHODS, AND
CLINICAL INCORPORATION
Carlos Murgel, DDS, PhD
1
Microdentistry can be dened as the practice of minimally invasive dentistry
with the aid of any optical device that magnies the operative eld. As a direct
consequence of the better visualization obtained, treatment can be more precise
and less invasive, thus preserving the oral tissues and dental structures from
unnecessary substance loss during procedures such as diagnosis, caries removal,
and cavity preparation. This concept can and should be applied to dentistry as a
whole, not only to those specialties that need to see more. This misconception
is one of the factors preventing dental professionals from seeing the complete
picture of magnied dentistry. The advantages of microdentistry for the dental
team are numerous: lower stress levels, efective control of the operatory eld,
less fatigue, improved ergonomics, and more efciency. The result is satisfaction
and pride for the dental team and an unprecedented level of clinical excellence
in treatment. This paper provides a brief summary of the primary factors
to consider when transitioning from traditional treatment to the practice of
microdentistry with the operating microscope. INT J MICRODENT 2010;2:5663
The search for magnifcation
methods to improve vision using
optical devices dates far into his-
tory. In Egypt 2,800 years ago, sin-
gle lenses were used to improve
the vision of people with visual
defciencies. In the 13th century,
double convex lenses were intro-
duced for reading. In 1674, Anton
van Leeuwenhoek developed a
rudimentary microscope with a
compound lens to observe blood
cells. Optics also played an impor-
tant part in the development of as-
tronomy, with the pioneering work
of Galileo and others.
1
Unfortunately, magnifcation
came late in clinical applications
for health care, and its initial use
was sporadic. Shanelec
2
explains
that circa 1876, the German physi-
cian Dr Edwin Smisch introduced
the use of binocular loupes dur-
ing surgery. In 1950, Barraquer
and Perit
1
introduced the operat-
ing microscope for eye surgery.
A decade later in 1960, Jacobsen
and Suarez
1
utilized the operating
microscope for vascular surgery.
In neurosurgery, the operating
microscope became a subject
of controversy by 1966 and was
viewed by many neurosurgeons
with disdain.
1

This paper provides a brief over-
view of the transition from tradi-
tional treatment to the practice of
microdentisty using the operating
microscope.
MAGNIFICATION IN
DENTISTRY
It is well documented that visual
capacity considerably diminishes
over time. Burton and Bridgman
3

evaluated the visual capacity of 172
dentists and found that 27% failed
a 25-cm reading test and 18%
failed a 35-cm reading test. The
authors also showed that 96% of
the dentists who failed the 25-cm
test and 93.5% of those who failed
the 35-cm test were 45 years old
or older and that the working dis-
tance of this group was longer than
the conventional one.
1
Private practice, Campinas, Brazil.
Correspondence to:
Dr Carlos Murgel
Sampaio Peixoto 206
Campinas BR-SP 13024420
Brazil
Email: c.murgel@terra.com.br
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Volume 2Number 12010 57
Murgel
Dentistry has become a more
visually demanding profession, es-
pecially in recent decades. Caplan
4

argued that the use of more sophis-
ticated and complex techniques
and materials demands an increase
in manual dexterity. To achieve im-
proved dexterity, the author rec-
ommended the use of prismatic
loupes because of their superior
quality compared to conventional
acrylic loupes.
Even today, there is some resist-
ance to the incorporation of mag-
nifcation methods in dentistry.
Forgie et al
5
evaluated 1,280 gener-
al clinicians in Scotland and found
that only 9% of the participants
were using some kind of magnif-
cation method routinely. In 1993,
Friedman and Atchison
6
suggested
that a lack of visual acuity may lead
to a signifcant variability in diagno-
sis and treatment planning.
It is important to emphasize that
the use of magnifcation by dental
students, lab technicians, hygien-
ists, dental assistants, and general
dentists and dental specialists can
improve the quality of treatment.
7

The widespread use of magnifca-
tion will provide benefts for both
dental health care providers and
their patients.
METHODS OF
MAGNIFICATION
There are several methods of mag-
nifcation available for the dental
team that can be useful in all clini-
cal and laboratorial stages of den-
tistry. The equipment varies widely
in technical specifcations, optical
quality, expandability, and price. It is
up to the professional to select the
method that is best suited to his or
her needs and fnancial capacity.
Of all the magnifcation meth-
ods available, the two most popu-
lar are loupes and the operating
microscope.
7
Both methods are
widely used. There are fundamen-
tal differences between these
methods not only in their optical
characteristics, but also in their
clinical use and capabilities.
The posture of the operator dif-
fers according to the method cho-
sen. Krueger et al
8
showed that
professionals who routinely used
loupes had more physical com-
plaints than those who used the
operating microscope. This differ-
ence was a direct consequence
of the better ergonomics obtained
with the operating microscope as
well as the higher-quality optics.
The fnal decision about which
magnifcation method to use
should be based on an analysis
of needs and technical specifcity
rather than on marketing or initial
cost. To maximize the beneft of
such equipment, critical self-eval-
uation is needed to identify what
changes must be made to incor-
porate magnifcation on a daily
basis. These changes will certainly
include learning new instruments
and techniques to take full advan-
tage of magnifed vision.
Fig 1 A clinical simulation showing
how to determine your working dis-
tance, which is necessary for proper
selection of dental loupes.
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Loupes
There are several different types
of loupes available today, which
can be divided into three groups
based on their optical character-
istics: simple, compound, and
prismatic. Loupes are easy to use
and generally do not require major
changes in the way that one prac-
tices.
2
Selection should be based
on the short- and long-term needs
anticipated by the user. It is wise
to choose the highest quality of
optics available to match the an-
ticipated applications.
The greatest advantage of
loupes is their easy incorporation
and portability. Major disadvan-
tages include fxed magnifcation,
eyestrain from convergent optics,
and poor ergonomics that lead to
a strained posture in the cervical
region. The most commonly used
level of magnifcation in dentistry
is around 2.5 and up to 5. A
key step in the correct selection
of loupes is to fnd ones own pre-
ferred working distance and then
match it to the focal distance of
the loupes (Fig 1).
Operating Microscope
The operating microscope is an ex-
cellent tool with several advantages
when compared to loupes. These
include different levels of magni-
fcation and excellent coaxial light
transmission via fber optics.
7
The
operating microscope provides not
only excellent magnifcation and
illumination, but also the opportu-
nity for digital documentation, im-
proved ergonomics, and enhanced
precision. Further, the microscope
makes it possible to share the mag-
nifed operating feld with the den-
tal assistant using an assistants
binocular attachment. The biggest
disadvantage of this technology is
the longer learning curve and the
need for a paradigm shift concern-
ing many of the traditional concepts
in dentistry.
7
Incorporating the operating mi-
croscope into a dental practice will
require changes to many key con-
cepts and techniques. The techni-
cal skills and treatment philosophy
needed to effectively use the mi-
croscope can be a revolutionary
way to achieve superior clinical
results. Following the complete
incorporation of this powerful
technology, these new techniques
become a way of life that can be
far removed from the old way of
practicing dentistry (Fig 2).
TRANSITION TO
MICRODENTISTRY
Teamwork
Traditionally in the medical feld,
the surgeon is never alone when
the operating microscope is being
used. A well-trained team must be
present to provide assistance. This
allows the surgeon to remain fo-
cused on the operating feld while
team members pass instruments,
medicaments, and other materials.
By using a team approach, the sur-
geon can work without interruption.
In dentistry, the opposite is often
true because many professionals
prefer to work alone or because
they work with an undertrained
dental assistant. This presents dif-
fculties when learning to use the
operating microscope. The lack of
training and teamwork makes it dif-
Fig 2 An example of microdentistry
performed by the clinician and dental
assistant. Note the perfect ergonomic
positioning of the dental team.
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Volume 2Number 12010 59
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fcult to effectively incorporate the
operating microscope into routine
practice and leads some dentists
to comment that they are slower
and less productive when using
the microscope.
9
The do it alone approach is
one of the major diffculties for
dentists who wish to learn this
technology. It is mandatory to de-
velop a highly trained team that is
able to work under constant mag-
nifcation. Repeated interruptions
caused by looking away from the
magnifed feld to reach for in-
struments or materials, incorrect
posture, patient movement, and
improper microscope positioning
can be true effciency killers.
A poorly trained dental team will
be an obstacle to fully realizing the
potential of the operating micro-
scope. Unfortunately, frustration
and anger are often the conse-
quence, and this usually leads to
improper and ineffcient use of the
equipment.
With proper training, each mem-
ber of the dental team has specifc
duties and tasks to accomplish
during any given procedure. Ideal-
ly, the dentist and dental assistant
are both viewing the magnifed
operative feld through the mi-
croscope, and their equipment
and materials are carefully placed
for effcient use and transfer. This
allows for a smooth workfow,
which will improve the precision,
effciency, and productivity of any
specialty.
Ofce Design
In the medical feld, the surgical
suites that house the microscope
are generally quite large, and
much of the other equipment in
the room is also large. In dentistry,
the operatories are usually small-
er, and thus there is a need for
smaller equipment. Many dental
offces use a design concept that
dates back to G.V. Blacks mod-
el, in which sets of cabinets are
placed inside the operatory. Unfor-
tunately, besides being antiquated
and unproductive, such an offce
design can be an impediment to
the incorporation of the operating
microscope.
11
Ideal incorporation
of the microscope often requires
changes in operatory design and
organization (Fig 3).
Most dental operatories are
based on old methods of practice,
making it diffcult to accommo-
date modern technologies such
as computers, digital radiographic
equipment, and the operating mi-
croscope. When such technologies
are introduced to traditional opera-
tories, they may compound an al-
ready ineffcient workfow. This will
often lead the clinician to blame the
new technology. It can also create
enormous frustration and lead to a
loss of both time and money.
Gary Carr, considered by many
to be the father of microdentistry,
developed a system where the op-
erating microscope is at the center
of the operatory design.
11
In this
design, all of the ergonomic move-
ments necessary to work with this
technology are accounted for.
Since 2002, the authors have col-
laborated with Dr Carr to develop
the Total Digital Offce system. This
is a design concept that was cre-
ated to maximize effciency and
productivity in all dental proce-
dures by incorporating existing
technologies while also planning
for the future.
Fig 3A traditional operatory lled
with cabinets and equipment may lack
adequate space to practice microden-
tistry (in fact, not even traditional den-
tistry is going to be productive here).
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Simplicity and effciency are the
core features of these new design
concepts. Unlike in traditional of-
fce design, in the new arrange-
ment the dentist no longer moves
around the dental chair using po-
tentially harmful posture and posi-
tioning. Now the dental chair and
patient rotate and move around the
clinician while allowing visual and
working access to both arches.
This operatory design was cre-
ated to be as simple as possible
with only the essential equipment
and materials necessary to pro-
duce excellent clinical results with
minimal movement and disruption
of the workfow. With this design,
the fnancial investment can be re-
duced by saving thousands of dol-
lars on unnecessary cabinets and
equipment (Fig 4).
The Total Digital Offce system
is under constant development to
create an ideal operatory. The in-
corporation of new technologies
and concepts demands new ap-
proaches to offce design and a
major paradigm shift (Fig 5).
Microscope Selection
Microscope selection is fun-
damental to success and to
maximizing the beneft of this
technology. It is mandatory to buy
equipment developed specifcally
for dentistry. This is a long-term
investment that should take into
Fig 5Total Digital Ofce, version
5. Note the clear evolution from the
previous version with a much cleaner
operatory but the same key elements.
(Photograph courtesy of Dr Gary B. Carr,
San Diego, California, USA.)
Fig 4Total Digital Ofce, version
4. Note how spacious and clean this
design is compared to the traditional
one. The key elements are the oper-
ating microscope, cart, back wall, as-
sistant table, stool with arm support,
computer integration, and rotational
chair.
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Volume 2Number 12010 61
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Fig 6Intraoral view under the
op erating microscope (simulated
equipment: 160-mm binoculars, 10
oculars, 250-mm objective lens, 2.1
initial magnication level, and 95-mm
illuminated eld).
Fig 9Intraoral view under the op-
erating microscope (simulated equip-
ment: 160-mm binoculars, 10 oculars,
250-mm objective lens, 2.6 initial
magnication level, and 65.6-mm illu-
minated eld).
Fig 12Intraoral view under the op-
erating microscope (simulated equip-
ment: 160-mm binoculars, 10 oculars,
250-mm objective lens, 3.2initial
magnication level, and 62-mm illumi-
nated eld).
Fig 13Intraoral view under the op-
erating microscope (simulated equip-
ment: 160-mm binoculars, 12.5oculars,
250-mm objective lens, 5 initial mag-
nication level, and 60-mm illuminated
eld).
Fig 7Intraoral view under the op-
erating microscope (simulated equip-
ment: 160-mm binoculars, 12.5
oculars, 250-mm objective lens, 2.5
initial magnication level, and 88.5-mm
illuminated eld).
Fig 10Intraoral view under the op-
erating microscope (simulated equip-
ment: 159-mm binoculars, 10 oculars,
250-mm objective lens, 2.6 initial
magnication level, and 61-mm illumi-
nated eld).
Fig 8Intraoral view under the op-
erating microscope (simulated equip-
ment: 170-mm binoculars, 12.5
oculars, 250-mm objective lens, 2.7
initial magnication level, and 80.9-mm
illuminated eld).
Fig 11Intraoral view under the op-
erating microscope (simulated equip-
ment: 160-mm binoculars, 12.5 oculars,
250-mm objective lens, 3 initial mag-
nication level, and 60-mm illuminated
eld).
consideration applications one
may wish to incorporate over an
entire professional career. Unlike
other electronic equipment, the
optical quality of a microscope
does not become outdated. With
this in mind, one should buy the
best equipment possible to pre-
vent the need to buy upgraded
equipment in a few years. The
wrong decision today may jeop-
ardize plans to use this equipment
to its full extent in the future.
There are two critical character-
istics of an operating microscope:
the level of magnifcation and the
size of the illuminated feld. These
characteristics will defne what you
can and cannot do with the micro-
scope. Many users think that the
operating microscope should mag-
nify the operating feld as much as
possible and that the lower levels
of magnifcation are not important.
However, as a simple rule, the ini-
tial magnifcation should be as low
as possible and the illuminated
feld should be as large as pos-
sible. The ideal equipment should
have a wide range of magnifcation
with the lower end close to what is
available with a good pair of loupes
(2.5) and a large illuminated feld
available at all magnifcation levels.
To illustrate these two principles,
Figs 6 to 13 show the infuence
of these factors when viewing the
same object under different simu-
lated microscope confgurations.
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DISCUSSION
The concepts presented here may
be met with some resistance by
those who are satisfed with the
status quo. The questions we need
to ask ourselves are (1) can we see
the operating feld with the level of
visual acuity needed to appreciate
the full anatomical details, and (2)
can we expect to provide the high-
est level of care to our patients with-
out using the microscope? These
questions require refection on the
part of each practitioner. Change is
not easy, but the benefts for prac-
titioners and patients are worth
the effort and investment. When
practicing dentistry based on real
vision rather than on tactile sen-
sation or clinical experience, the
change is transformative. The revo-
lution in quality and excellence is
unquestionable, and clinicians will
feel no desire to return to the tra-
ditional way of practicing.
12
Fig 17Frontal view at high magni-
cation.
Figs 15 and 16Occlusal evaluation at mid-magnication.
Fig 14 At low magnication, the mi-
croscope provides a clear view of the
lips and arches.
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Volume 2Number 12010 63
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The pace of technological change in dentistry has
been rapid over the last few decades, but the true
revolution still lies ahead. This will occur when we ful-
ly understand the importance of enhanced vision and
the accompanying techniques on our patient care,
allowing for excellence in all clinical and laboratory
stages of treatment (Figs 14 to 20).
CONCLUSION
Excellence is not a luxury but a goal we must all as-
pire to. The practitioners of such a noble profession
as dentistry cannot afford to see less and do less. It
is time for students in all felds of dentistry to learn
from day one that they cannot adequately visualize
the working feld without high-quality magnifcation.
The revolution in dentistry has fnally begun.
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Fig 20 Vitality test of the right central incisor with an ice
stick at low magnication.
Fig 19The color diference between the tooth and resto-
ration is even more visible at high magnication.
Fig 18Palatal view at mid-magnication achieved
through the mirror. Note the color diference between the
tooth and restoration.
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