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Posture-Directed vs. Image-Directed Dentistry: Ergonomic and Economic Advantages Through Dental Microscope Use
By Gerard M. Cuomo, DDS
Gerard M. Cuomo, DDS, is a graduate of Northwestern University Dental School, and is a recognized author and lecturer on the integrated use of chair-mounted microscopes in dentistry. He maintains a private practice in Boca Raton, Florida, and teaches hands-on dental microscopy courses for dentists and students throughout the U.S.

The modern dental practice incorporates office designs that create an "at-home" atmosphere while using "high-tech" equipment to promote improved efficiency and increased productivity. The purpose of this article is to analyze the ergonomic and economic advantages of the dental microscope over the now obsolete dental loupes. In order to appreciate the benefits of this 21st-century equipment, one must understand the distinctions between posture-directed and image-directed dentistry. The term "ergonomics" is the applied science of equipment design for the workplace with the intent of enhancing productivity by reducing operator fatigue and discomfort. An ergonomically designed product implies that a device must blend smoothly with a person's body and actions. To understand equipment design, one should initially recognize the fact that certain risk factors such as poor body positioning and its related repetitive movements can alter the ergonomic purpose, thus contributing to pain and injury over time to various parts of the dental professional’s body. Musculoskeletal disorders such as herniated discs of the lower back and rotator cuff impingement are the end products of trying to work more efficiently while ignoring the proper pathways to maintain muscle balance. 8,9

Mechanisms related to muscle balance can be explored by first understanding the differences between posture-directed dentistry and image-directed dentistry as each relates to the ergonomic well-being of the dentist. 5 "Image-directed" dentistry is associated with dental procedures performed by using a "direct line of sight." A good example of "image-directed" dentistry is the dentist viewing an oral image by using dental loupes (Figure 1).

Figure 1

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In this instance, the eyes are looking directly at the image through various lenses aligned with one another attached to a frame. The head posture of the loupe wearer remains in a constant tilt position with the chin angled downward. Typically, the dentist’s head moves toward the image to find and maintain focus at a set focal length. As the image moves out of focus, it is only natural for one to refocus by moving their head back inline with the image. As the need to increase magnification becomes apparent when going from 2.0X to 6.0X, the loupe lens size becomes larger and heavier while the field of view becomes smaller. Dental loupes add an additional amount of weight to the front portion of the dentist’s head, therefore requiring straps to secure the loupes to the back side of the head to maintain stability. 1-2,5,7 In other words, the image dictates the movement of the dentist’s head, as shown below

"Posture-directed" dentistry is associated with dental procedures that are performed by using an "indirect line of sight." 5 The best way to achieve "posture-directed" dentistry is by viewing an oral image using a dental microscope (Figure 4).

Figure 4

Here the eyes are looking indirectly at the image through various lenses and prisms aligned with one another and supported by a mechanical arm apparatus. It is the use of the microscope’s inclinable binocular eyepieces that permit the dentist to raise his or her chin in a more level position. The optics of dental microscope bend the path of the image to almost 90 º, allowing the dentist to sit comfortably erect with the head, neck, and back arranged in a straight line when viewing an object. 3,10 Posture-directed dentistry also includes several techniques for maintaining focus. The simple method of reclining the patient’s head backward into a more healthy ergonomic working position helps to form the foundation of the workplace. Posture-directed dentists rest their patients in the supine position for maxillary arch procedures and in a semisupine position for mandibular arch procedures. The dentist’s seating zone is usually in the 11 and 12 o’clock positions (Figure 5). Figures 2 & 3
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Figure 5

This ergonomic positioning helps the dentist avoid twisting and turning movements when using the microscope and receiving hand instruments. As the image moves out of focus, the dentist relies more on verbal commands directed toward the patient to move the image back into focus (Figure 6). 2,3,5 Other focusing methods of posture-directed dentistry include use of the dental microscope’s fine-focus adjustment when changing

magnification from 2.0X to 20X.6 In addition, the hands, the forearms, and the shoulders are often well supported by stools with built-in adjustable arms. In order to achieve posture-directed benefits, the dentist must first be willing to accept the need for change and give up old image-directed bad habits. Dental school undergraduate curriculums teach image-directed techniques. Today’s dental students migrate from using no magnification to using dental loupes during their four years of undergraduate studies. The combination of using dental loupes with only limited four-handed dentistry available creates a breeding ground for the formation of bad habits. Based upon this fact, image-directed habits are primarily formed in dental schools and continue to shape the ergonomic foundation of the dentist’s method of practice. Postgraduate endodontic curricula currently accept and require microscope proficiency of graduate students. Even though posturedirected dentistry has minimal acceptance in dental school restorative curricula, one can anticipate a change will occur with the increasing number of practicing dentists transitioning to dental microscopy. 4 At the time this article was written, pre-dental students attending Florida Atlantic University participated in their first hands-on dental microscope course without having any previous dental microscope experience. Each of the four students was given a molar to perform a root canal. They were then instructed to restore the same tooth using current composite modalities.

Figure 6
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Figures 7 & 8

These new generations of students are more open to accepting advances in technology. Following the single-tooth exercise, each student was asked to prepare teeth on the mannequin’s head (ergonomically placed) in the dental chair using the various posture-directed techniques previously discussed in this article. The end result indicated that all four pre-dental students had achieved an acceptable basic level of proficiency within four hours by using the dental microscope (Figures 7 and 8). This exercise clearly supports the "law of primacy" which states, "Things first learned are best remembered." Despite the fact that many innovative ideas such as computer software and hardware, digital X-rays, automated perio-probes, and image capturing devices have helped to modernize the dental industry by saving time, none of them have had as much ergonomic effect on dentists than that of the dental microscope. 10 Use of a dental microscope improves the dentist’s overall performance. Connected to flat-screen monitors located in each operatory, the dental microscope visually adds a whole new dimension for viewing and recording real-time images.

It is this combination of microscope optics and video that have a tremendous effect on the profitability of the dental business. Dental assistants and patients now have a front row seat to viewing the dentistry being performed at several levels of magnification (Figures 9 and 10). Dentists who use microscopes are able to see more and do more dentistry. One can detect early crack formation which will ultimately determine the type of restoration to be placed. 4,11 Dentists are able to find hidden calculus around margins much more precisely prior to impression taking. They are able to make more accurate determinations on whether to use sealants, flowables, or composite resins for conservative dentistry. Final preparation design can be easily placed without compromise.11,12 Today’s dental microscopes can be mounted via ceiling, wall, or a more ergonomic space-saving chair-mount. Aside from ergonomic advantages, the dental microscope user enjoys shadow-free coaxial lighting and the ability to detach and transport the microscope head between workstations and office (portability). In summary, vision in dentistry makes up the very fabric that determines how successful we become as dentists. It is our choice

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Figure 9 & 10

to practice with either yesterday’s technology, or wake up to the advances of the 21st century with an exciting new way to practice dentistry. Current and incoming students are more tech savvy than previous generations. Not only do they accept new technologies, but they go out of their way to look for them. Having been exposed early to eye-hand coordination teaching tools such as Play Stations and Xboxes, their skills have been honed, and they are ready to take on advanced magnification methods. Experienced dentists need not fear this new technology either. Technology should be embraced as an opportunity rather than an impediment. With proper instruction, repetition, and a willingness to learn, the practicing dentist can enjoy all the benefits of the dental microscope. Posture-directed dentistry is the logical progression for the industry. Those who make the transition to microscopy early on, will realize the distinct advantage they have over those who have not made similar choices.

Dr. Cuomo & students

Acknowledgements The author acknowledges Gerard J. Cuomo (writing consultant), Maria Martinez (dental assistant), and Florida Atlantic University (pre-dental students): Ashley Millstein, Salvatore Colombo, David Miller, and Justin Grossmayer.

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References
1. Friedman MJ. Magnification in a Restorative Dental Practice: From Loupes to Microscopes. Compend Cont Educ Dent 2004; 25:48–55. 2. Sheets CG, Paquette JM, Hatate K. The Clinical Microscope in an Esthetic Practice. J Esthet Restor Dent 2001; 13:187–200. 3. Friedman MJ, Landsman HM. Microscope-Assisted Precision (MAP) Dentistry – A Challenge for New Knowledge. J Calif Dent Assoc 1998; 26:900–905. 4. Garcia A. Dental Magnification: A Clear View of the Present and a Close-up View of the Future. Compend Cont Educ Dent 2005; 26:459–463. 5. Cuomo GM. A Fresh Look at the Biomechanics of Advanced Magnification. Dent Econ 2004; 94:66–69. 6. Nase JB. Enhanced Vision in the Improvement of Patient Care. Dental Collab 2005; 2:19–20. 7. Pace SL. Seeing Through the Eyes of Magnification. Contem Dent Assist 2005; 2:14-18. 8. Valachi B, Valachi K. Mechanisms leading to Musculoskeletal Disorders in Dentistry: J Am Dent Assoc 2003; 134:1344–1350. 9. Valachi B, Valachi K. Preventing Musculoskeletal Disorders in Clinical Dentistry: J Am Dent Assoc 2003; 134:1604–1612. 10. Kotlow LA. Using a Dental Operating Microscope in a Pediatric Dental Practice: Compend Cont Educ Dent 2004; 25:482–488. 11. van As GA. The Use of Extreme Magnification in Fixed Prosthodontics. Dent Today 2003; June:93–99. 12. Clark D. Do Traditional Sealants Have a Place in the New, Super-Magnified World? Dent Today 2004; Sept:92, 94–98.

COURSE SPONSOR Sullivan-Schein is course sponsor. Sullivan-Schein’s ADA CERP recognition runs from November 2001 to June 2006. COURSE CREDITS All participants scoring at least 80% on the examination will receive a certificate verifying 2 CEUs. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. The current term of acceptance extends from December 2001 to June 2006. Participants are urged to contact their state dental boards for continuing education requirements. PARTICIPANT FEEDBACK If any participant wishes to communicate with the author of this course, please direct questions to Sullivan-Schein by fax at 1-800-781-6337. Be sure to provide us with the following information: name, address, E-mail address, telephone number, and course completed. COURSE EVALUATION We encourage participant feedback pertaining to all courses. Please be sure to complete the attached survey included with the answer sheet. RECORD-KEEPING Sullivan-Schein maintains records of your successful completion of any CE Seminars. Please contact our offices at Sullivan-Schein, Attn.: CEHP, 26600 Haggerty Rd., Farmington Hills, MI 48331, by mailing a note requesting a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. IMPORTANT INFORMATION The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author and do not necessarily reflect those of Sullivan-Schein. Completing a single continuing education course does not provide enough information to make the participant an expert in the field related to the course topic. It is a combination of many educational courses and clinical experiences that allows the participant to develop the skills, broad-based knowledge, and expertise related to the subject matter. COURSE FEE/REFUND POLICY The cost for this course is $55.00. Any participant who is not 100% satisfied with this course can request a full refund by contacting: Sullivan-Schein Attn: CEHP 26600 Haggerty Road Farmington Hills, MI 48331

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Continuing Education Test Questions
ANSWER SHEET
1. The term "Ergonomics" includes the following except: a. increased productivity b. equipment design for the workplace c. can not be altered by poor body positioning d. reduced body fatigue 2. Which of the following regarding "image-directed" dentistry is correct? a. "image-directed" dentists use dental microscopes b. "image-directed" dentist’s head posture is in constant tilt position c. "image-directed" dentists view oral images using dental loupes d. b and c e. all of the above 3. "Image-directed" habits are first learned in dental school undergraduate curricula. a. True b. False 4. Which of the following regarding "posture-directed" dentistry is correct? a. "posture-directed" dentists use "direct line of sight" b. "posture-directed" dentist’s head is in an upright position c. "posture-directed" dentists use microscopes that only mount to the wall d. b e. b and c 5. Dental loupes add weight to the front side of the dentist’s head and need straps. a. True b. False 6. Which of the following is correct regarding the dental microscope? a. chair-mounted microscopes contain a series of prisms and lenses that attach to the dentist’s head b. chair-mounted microscopes demonstrate "indirect line of sight" c. chair-mounted microscopes have inclinable binocular eyepieces d. b and c e. all of the above

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7. As the need for increasing magnification becomes apparent, dental loupe lenses become larger and heavier, while the field of view becomes smaller in size. a. True b. False 8. "Posture-directed" dentistry includes the following except: a. positioning the patient and the dentist into a healthy ergonomic zone b. dentist’s seating zone is in the 11 and 12 o’clock position c. utilizing verbal commands to move the patient’s head d. constant movement of the microscope head 9. Dental microscopes are mandated in all endodontic postgraduate curricula. Students must demonstrate proficiency using the dental microscope before receiving their degrees. a. True b. False 10. Dental loupe wearers often refocus an image by moving their head toward the object. a. True b. False 11. All of the following are correct regarding the pre-dental hands-on exercise noted in this article except: a. each of the students explored molar root canals b. each of the students successfully prepared teeth on a mannequin’s head using posture-directed techniques c. each of the students achieved an acceptable basic level of proficiency using the dental microscope in four hours d. each of the students performed image-directed dentistry

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Posture-Directed vs. Image-Directed Dentistry: Ergonomic and Economic Advantages Through Dental Microscope Use By Gerard M. Cuomo, DDS
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