My "High-Powereds"

A few weeks ago, my dental partner and I were both preparing 8-unit veneer cases on opposite ends of the hall- "dueling veneers", if you will. Upon case completion, we inspected each other's provisionalization prior to the patients' departure-shrink-wrapped, 8-unit Luxatemp temporary veneers. During this brief visit, we "ooh'd" and "ah'd" to make the patient feel good, but we were, of course, interested in seeing each other's results. Later, during a relaxed lunch, my partner, a gifted dentist possessing an excellent set of hands, commented, "Both of our temps looked nice, but how come your soft tissue looked like it hadn't been touched (Figure 1a), and mine had the usual battle-scarred look?" (Figure 1b) He was referring to the small gingival nicks and scrapes that we as dentists have been accustomed to seeing when finishing restorative work in close proximity to the gingiva. At the end of his sentence, it occurred to me that since I upgraded my level of magnification, the days of battle-scarred gingiva had essentially passed. I offered this as an explanation. Apparently he bought it, because an hour later he was on the phone to my Orascoptic rep. It was time to retire his 2.5x loupes.


This article will strive first to explain the difference between the 2x to 2.5x loupes that you may be using currently and the 5x loupes that I am presently using. Most importantly, I will offer up the benefits realized upon embracing what I sometimes term "my mobile microscope". No, they're technically not a microscope (although many operating microscopes begin at 5x magnification), but the capabilities afforded the practitioner using higher-powered loupes parallel some of the benefits enjoyed by dentists employing microscopy in their practices.

 

Figure 1a. Gingiva remains untouched. Figure 1b. Gingival scrapes and nicks.
Figure 2. Orascoptic's loupe classification system. Figure 3. Compound loupes.
Figure 4. Prismatic lens components. (Photo courtesy of Dennis A. Shanelec, DDS.) Figure 5. EyeMax class IV loupes.
Figure 6. A forced upright posture for a healthy back. Figure 7. Low and high magnification compared.
Figure 8. Orascoptic Zeon light. Figure 9. Few bleeders with high magnification.
Figure 10. Oblique coronal fracture more readily seen. Figure 11. Higher magnification reveals defective amalgams

A FEW TECHNICALITIES

If you are currently using loupes that are said to have 2x or 2.5x magnification (called class II magnification by Orascoptic), then you are employing compound loupes. Rather than using a single lens to increase magnification, multiple lenses are combined with intervening air spaces (Figure 2). They are typically said to have a "Galilean design" named after Galileo Galilei, the 17th century astronomer. Most of us currently using loupes were weaned on such systems. They are lightweight, relatively unobtrusive,  and sold in both flip-up and through-the-lens designs (Figure 3).


Prismatic loupe systems, such as the Orascoptic EyeMax system that I am currently using, employ prisms that increase the length of the light path via a series of prismatic mirror reflectors built into the loupe. In effect, they "fold" the light several times upon itself, allowing the barrel of the loupe to remain manageable in length (Figure 4). In truth, such eyewear is really a low-powered telescope (Figure 5). Prismatic systems afford the user better magnification without sacrificing depth or width of field. Most importantly, longer working distances are possible, resulting in ideal posture when operating (Figure 6). Class IV systems, such as the EyeMax system, offer approximate magnifications of 3x to 4.9x (class IV high). Absolute magnification classifications are difficult to state, as it is general knowledge within the industry that there can be as much as 15% difference among manufacturers in what might be termed a 4x magnification, owing to variances in structural design. That said, when you purchase a class IV high system, you will be purchasing a prismatic system that will open up new worlds to you.

Figure 7 approximates the difference in view between a class II and a class IV high system. What is not apparent from this rendering is that this enhanced and enlarged view is attainable with the operator's eyes laughably far away from the patient's mouth. In essence, one is "forced" into a healthier and more ergonomic operating position. I use the phrase "laughably" because if you were to see yourself comfortably treating the distal surface of a maxillary second molar from this distance, you'd smile and think to yourself "NO WAY!!!"

 

VISUAL ANXIETY!

I'll coin a phrase: "visual anxiety" or "VA." It's the subtle but omnipresent uneasiness felt by a dentist barely able to see what he or she is doing, hoping that sense of touch will bail him or her out of harm's way. Remember our credo "Do No Harm?" Harm equals nicking adjacent teeth; nicking gingival tissue, cheeks, and tongues; cutting too deep when removing amalgam; leaving a finish line that looks like the steps of the Lincoln Memorial...the list is long. But the profession falls prey to VA daily, owing to the type of environment that we've chosen to work in: wet, dark, and distant. VA is stressful. It erodes our confidence. It tires us too early in the day.


The great news is that you don't need to take anti-anxiety medications to control VA. You need only move up to higher magnification (preferably with a light source such as Orascoptic's Zeon light, Figure 8). I assure you that the visual powers afforded you by doing so will vanquish VA almost overnight. Perched a distance away from your patient's mouth and seeing everything as if you were standing on your patient's tongue will afford you a sense of power that you must experience. Imagine practicing without VA. It's a heady feeling.

 

Moving Along: You Don't Know What You Don't Know

What follows is an accounting of several practical benefits that this author encountered upon embracing a higher-powered prismatic system-little things, but unexpected and pleasant to experience.

 

Anesthesia

Take a peek at Figure 9. Notice how the syringe tip has been placed in the "bare" area amidst a web of arterioles and capillaries. The result? Far fewer bleeders than before. This is particularly true when administering the relatively shallow injections in the anterior maxilla. I tear fewer vessels when I am able to visualize needle placement clearly. The other benefit is also unexpected but notable. The zoomed-in view "crops" out your patients' grimaces and scrunching eyes (even if they are not really in pain), allowing you to concentrate on the injection process and feel less like an agent of torture.

 

Cosmetics

Certainly the benefits noted here apply to most indirect restorative techniques, but as was noted in the anecdote in the introduction, bur control is particularly important when preparing anterior veneer preps and finishing provisionals. It's equally important when removing shrink-wrapped provisionals because bleeding tissue will slow the cementation procedure considerably. The ability to section resin temps accurately that hug gingival tissue without concomitantly slicing the adjacent tissue is a "must-have."

 

Crown and Bridge

The most notable change you will encounter upon stepping up to higher magnification will be the improved continuity of your finish lines (provided you dry your preps upon "near final" inspection). The sins resultant from interrupted diamond contact with the tooth will become apparent, as will scattered, unsupported shards of enamel extending beyond a typical chamfered or shouldered finish line. You will feel compelled to correct these issues by joining discontinuous segments of finish line and shaving off exogenous enamel shelves. Your labs will thank you for it. You will also be grateful at cementation time since the unsupported enamel would have quickly broken off the cast at die trim time, creating an ill-fitting crown. The final product, having been a product of better quality control on your part, will go to place with far fewer hitches. Additionally, you'll be less apt to scrimp on interocclusal space because  you'll better visualize the space you've created. This translates to fewer "spot the opposing, doc" notes from your lab.


Here's another little gem:  The small bits of temporary cement formerly left behind because you couldn't see them will now be removed before your patient leaves. They will return with less tissue inflammation. Another score for the good guys at cementation time. Can it get any better?!

 

Endodontics

Today's enlightened endodontist typically features a surgical microscope such as those marketed by Global and Zeiss, to name a few. They've proven invaluable. I had the pleasure of using one on loan from Global for more than a month and came to recognize its value not only for endodontic purposes but for restorative dentistry as a whole. The wonderful magnification, resolution, and 3-D view would appear to be a perfect fit for dentistry, but there is a tradeoff-mobility. The practitioner must learn to sit still and more or less move the subject around the position and viewing axis of the microscope. Certainly, the scope is maneuverable, but not as much as a set of high-powered loupes perched on your nose; and it is certainly more cumbersome to maneuver when in the midst of doing a prep and needing to see a section of a tooth that is blocked out by an adjacent tooth. With high-powereds, you simply move or tilt your head and line up your view; with a scope you stop what you're doing, reposition the scope, the patient's head, or the operating chair, and continue. In light of this, it's easy to see why endodontics is such a good fit for a surgical scope. Typically, one can work in one view and see all that needs to be seen for the entirety of the procedure, changing only the depth of focus.  


As mentioned, surgical scopes often have a 5x magnification as their starting point, some going as high as 24x. So a class IV high system might be thought of as a distant relative to a surgical scope, affording the practitioner a high-powered view with unlimited mobility, which brings me to an interesting endo tale.

Having nearly completed instrumenting a maxillary bicuspid that featured 2 separate canals in a single root  separated by an isthmus of dentin, my LightSpeed rotary NiTi instrument somehow "fell in" below the isthmus and got stuck due to a tortuous bend, not allowing me to withdraw it from the canal space. After disconnecting the instrument from the handpiece and trying to nudge it out from multiple directions without breaking it and leaving the cutting tip in the canal space, I knew I had to try another approach. I managed to introduce a small Gates Glidden bur alongside the isthmus and gradually shave it away until the LightSpeed instrument was freed up. It occurred to me afterwards that the view afforded me by my high-powereds and Zeon headlight had allowed this to happen without me breaking a sweat; that is, I could see well enough into the canal to view the Gates Glidden cutting the isthmus. I didn't have to rely upon feel alone.

Point: If you're a GP doing a fair amount of endodontics, and the total package that accompanies a surgical scope is not yet in the cards, then the next stop is high-powered loupes coupled with a reliable headlight. Consider it just about mandatory!

 

Diagnosis

This area is fairly obvious but deserves mention. Consider the ubiquitous intracoronal fracture, particularly the ones located underneath a cusp, exposed when an amalgam is removed. When stained by corrosive products and microleakage, they are fairly easy to see, even with the naked eye. The ones that aren't stained, however, are a challenge to see and diagnose. To beat the dead horse, class IV high magnification and a headlight will make it happen for you. Couple your finding with a digital photo enlarged and on a 17-inch monitor in front of your patient, and your recommendations approach gospel status (Figure 10).


Mobile view box: It seems obvious to me, but if your loupes are around your neck throughout the day, you are never without an enhanced view of films. Whether you are peering in the direction of an overhead fluorescent light or directly at your hygienist's view box, slide your high-powered loupes up onto your nose for a flawless view of the film at hand. You'd be surprised at what you would have missed.

Do they or don't they? Brux, that is: "But doctor, I'm not aware of clenching or grinding?I  really doubt I'm doing it."?

Heard that before? Put on the high-powereds and become dentistry's version of Sherlock Holmes. The often-subtle wear facets, characteristic of closet bruxers, now come into view. You might even be able to pick these up on a well exposed digital photo, ready for the evidence pool.

Finally, a high-powered look at an amalgam that looks good from a distance will often reveal multiple reasons to replace it when viewed with a "mobile microscope." (Figure 11) The result is a win-win for you and your patient, for obvious reasons.

 

PERIODONTICS AND PREVENTION

Periodontists, you're probably already there. How can periodontal surgery not benefit from increased magnification? As Forrest Gump would say, like "peas and carrots," particularly with the vast numbers of implants being sewn by the subspeciality. I'd propose, however, that the prime benefactor of a higher-powered view would be the advanced dental hygienist, entrusted to root plane and scale and/or conduct a soft-tissue management regimen effectively. I sheepishly admit that I often feel like I have an unfair advantage when inspecting my hygienist's efforts under high magnification when they've been toiling away with 2x, or worse yet, no magnification. Also consider their ability to pick up defective restorations and subtle signs of coronal fracture. Again, the benefits are obvious.

 

IT'S NOT ALL ROSES

While the glory of high magnification is undeniable, take the following into account:

(1) They are more expensive than your 2 and 2.5s (more complexity, more cost).

(2) They take longer to get used to. (It took me 2 to 3 weeks of switching back and forth before putting my 2.5s to rest on a shelf.)

(3) Due to the reduced light allowed in, a head light is recommended.

(4) Once you use them for an extended period, you will become dependent on them in the sense that you will feel you are not seeing what you need to be seeing unless you are wearing them when you work. (I keep a spare.)

(5) Some operators, particularly those with natural vision that requires considerable correction with glasses, will not be able to adapt to class IV high magnification, settling perhaps in the class III or low class IV range. A reputable company will allow you to make an exchange should you be unable to accommodate to a new set of loupes.


Disclaimers aside, I'm comfortable in predicting that the majority of those who turn up the power will not only be delighted with the way they feel at the end of the day, but will discover a new and higher level of quality in the treatment that they render; once again, a win-win situation for both doctor and patient.

Additional reading

Caplan SA. Magnification in dentistry. J Esthet Dent. 1990;2(1):17-21.

Freedman G, Goldstep F. Magnification: getting bigger every day. Dent Today. 2003;2(8):108-113.

Morris GA, Kokott MI. A clear view no longer means a stiff neck. Dental Economics. July 1999.

Shanelec DA. Optical principals of dental loupes. CDA J. 1992;20(11):25-32.

Strassler HE, Syme SE, Serio F, et al. Enhanced visualization during dental practice using magnification systems [published correction

 appears in Compend Contin Educ Dent. 1998;19(9):894]. Compend Contin Educ Dent. 1998;19(6):595-602.


Dr. Goldstein, a graduate of the University of Connecticut School of Dental Medicine, practices general dentistry in a group setting in Wolcot, Conn.  He enjoys promoting the cosmetic side of his practice and has found it helpful to incorporate high-tech methodology into his daily routine to accomplish this. Dr. Goldstein serves on the staff of contributing editors at Dentistry Today and contributes regularly to multiple dental periodicals. He can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it . He lectures on both digital photography in dentistry and on the use of such high-tech methodology to further the cosmetic and restorative practice. Information on his lecture schedule can be found at drgoldsteinspeaks.com or dhapc.com. More information on the Comfort Zone Cosmetics hands-on seminar series can be found at smilevision.net.