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The modern dental practice incorporates office designs that create Mechanisms related to muscle balance can be explored by first
an "at-home" atmosphere while using "high-tech" equipment to understanding the differences between posture-directed dentistry
promote improved efficiency and increased productivity. The and image-directed dentistry as each relates to the ergonomic
purpose of this article is to analyze the ergonomic and economic well-being of the dentist. 5
advantages of the dental microscope over the now obsolete dental
"Image-directed" dentistry is associated with dental procedures
loupes. In order to appreciate the benefits of this 21st-century
performed by using a "direct line of sight." A good example of
equipment, one must understand the distinctions between
"image-directed" dentistry is the dentist viewing an oral image by
posture-directed and image-directed dentistry.
using dental loupes (Figure 1).
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
Figure 1
Distributed by:
In this instance, the eyes are looking directly at the image through "Posture-directed" dentistry is associated with dental procedures
various lenses aligned with one another attached to a frame. The that are performed by using an "indirect line of sight." 5 The best
head posture of the loupe wearer remains in a constant tilt position way to achieve "posture-directed" dentistry is by viewing an oral
with the chin angled downward. Typically, the dentist’s head image using a dental microscope (Figure 4).
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
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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06AS4306 June CE Seminar 4/27/06 10:34 AM Page 3
12
9 3
Figure 5
This ergonomic positioning helps the dentist avoid twisting and magnification from 2.0X to 20X.6 In addition, the hands, the
turning movements when using the microscope and receiving hand forearms, and the shoulders are often well supported by stools with
instruments. As the image moves out of focus, the dentist relies built-in adjustable arms. In order to achieve posture-directed
more on verbal commands directed toward the patient to move the benefits, the dentist must first be willing to accept the need for
image back into focus (Figure 6). 2,3,5 change and give up old image-directed bad habits.
Other focusing methods of posture-directed dentistry include use Dental school undergraduate curriculums teach image-directed
of the dental microscope’s fine-focus adjustment when changing 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 posture-
directed 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
3
06AS4306 June CE Seminar 4/27/06 9:55 AM Page 4
Figures 7 & 8
These new generations of students are more open to accepting It is this combination of microscope optics and video that have a
advances in technology. Following the single-tooth exercise, each tremendous effect on the profitability of the dental business.
student was asked to prepare teeth on the mannequin’s head Dental assistants and patients now have a front row seat to viewing
(ergonomically placed) in the dental chair using the various the dentistry being performed at several levels of magnification
posture-directed techniques previously discussed in this article. (Figures 9 and 10).
The end result indicated that all four pre-dental students had
Dentists who use microscopes are able to see more and do more
achieved an acceptable basic level of proficiency within four hours
dentistry. One can detect early crack formation which will
by using the dental microscope (Figures 7 and 8).
ultimately determine the type of restoration to be placed. 4,11
This exercise clearly supports the "law of primacy" which states, Dentists are able to find hidden calculus around margins much
"Things first learned are best remembered." more precisely prior to impression taking. They are able to make
more accurate determinations on whether to use sealants, flowables,
Despite the fact that many innovative ideas such as computer
or composite resins for conservative dentistry. Final preparation
software and hardware, digital X-rays, automated perio-probes, and
design can be easily placed without compromise.11,12
image capturing devices have helped to modernize the dental
industry by saving time, none of them have had as much ergonomic Today’s dental microscopes can be mounted via ceiling, wall, or a
effect on dentists than that of the dental microscope. 10 Use of a more ergonomic space-saving chair-mount. Aside from ergonomic
dental microscope improves the dentist’s overall performance. advantages, the dental microscope user enjoys shadow-free coaxial
lighting and the ability to detach and transport the microscope
Connected to flat-screen monitors located in each operatory, the
head between workstations and office (portability).
dental microscope visually adds a whole new dimension for
viewing and recording real-time images. In summary, vision in dentistry makes up the very fabric that
determines how successful we become as dentists. It is our choice
4
06AS4306 June CE Seminar 4/27/06 9:55 AM Page 5
Figure 9 & 10
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.
5
06AS4306 June CE Seminar 4/27/06 9:55 AM Page 6
References
PARTICIPANT FEEDBACK 4. Garcia A. Dental Magnification: A Clear View of the Present and
If any participant wishes to communicate with the author of this course, a Close-up View of the Future. Compend Cont Educ Dent 2005;
please direct questions to Sullivan-Schein by fax at 1-800-781-6337.
26:459–463.
Be sure to provide us with the following information: name, address,
E-mail address, telephone number, and course completed.
5. Cuomo GM. A Fresh Look at the Biomechanics of Advanced
COURSE EVALUATION Magnification. Dent Econ 2004; 94:66–69.
We encourage participant feedback pertaining to all courses. Please be
sure to complete the attached survey included with the answer sheet. 6. Nase JB. Enhanced Vision in the Improvement of Patient Care.
Dental Collab 2005; 2:19–20.
RECORD-KEEPING
Sullivan-Schein maintains records of your successful completion of any 7. Pace SL. Seeing Through the Eyes of Magnification. Contem
CE Seminars. Please contact our offices at Sullivan-Schein,
Attn.: CEHP, 26600 Haggerty Rd., Farmington Hills, MI 48331,
Dent Assist 2005; 2:14-18.
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 8. Valachi B, Valachi K. Mechanisms leading to Musculoskeletal
generated and mailed to you within five business days of receipt.
Disorders in Dentistry: J Am Dent Assoc 2003; 134:1344–1350.
IMPORTANT INFORMATION
9. Valachi B, Valachi K. Preventing Musculoskeletal Disorders in
The opinions of efficacy or perceived value
of any products or companies mentioned in this course and expressed Clinical Dentistry: J Am Dent Assoc 2003; 134:1604–1612.
herein are those of the author and do not necessarily reflect those of
Sullivan-Schein. Completing a single continuing education course does 10. Kotlow LA. Using a Dental Operating Microscope in a
not provide enough information to make the participant an expert in the
Pediatric Dental Practice: Compend Cont Educ Dent 2004;
field related to the course topic. It is a combination of many educational
courses and clinical experiences that allows the participant to develop 25:482–488.
the skills, broad-based knowledge, and expertise related to the subject
matter. 11. van As GA. The Use of Extreme Magnification in Fixed
Prosthodontics. Dent Today 2003; June:93–99.
COURSE FEE/REFUND POLICY
The cost for this course is $55.00. Any participant who is not 100%
12. Clark D. Do Traditional Sealants Have a Place in the New,
satisfied with this course can request a full refund by contacting:
Sullivan-Schein Super-Magnified World? Dent Today 2004; Sept:92, 94–98.
Attn: CEHP
26600 Haggerty Road
Farmington Hills, MI 48331
6
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06AS4306 June CE Seminar 4/27/06 9:56 AM Page 8
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