It’s true, did you ever meet an orthopaedic surgeon who could mend a broken leg blindfolded ? Visualisation is everything in any procedure and if you can’t see it you can’t treat it. In many cases not seeing can result in mistakes, errors or missed opportunities which unfortunately result in problems for the tooth and also the patient.
The following are my top ten tips as to why you need magnification for endodontics
1 Cracks & Fractures This is slowly becoming the bane of most dentists as more and more patients attend with cracked tooth syndrome. One very frustrating thing when providing endo is finding out the tooth is cracked AFTER you have nailed a curvaceous obturation-like when your numbers come up on the lottery but you have lost the ticket-very frustrating! Many endodontically treated teeth can be successfully maintained despite having cracks present-it all depends on the extent of the crack and whether it has propagated. Notifying the patient provides some scope on the future prognosis.
2 Access Some may say the access cavity is the key to open the door for successful endodontics. If it is good everything goes smoothly and predictably. You can see the canal orifices clearly, you have enough space for files during working length determination, straight lines access, the list goes on and on. Poor access cavity design, where too big, can undermine the remaining tooth tissue and compromise structural integrity. Too small and you are unable to see what you are doing. The use of a scope allows you to cut the optimal access without compromising on needless damage to the tooth.
3 Anatomy Finding all the pesky canals, it’s difficult ! The landmark paper by Kulild and Peters in 1990 demonstrated how crucial a scope was to finding the second mesio-buccal canal in maxillary molars. They were able to find the vast majority of MB2s with a scope, with the naked eye they were unable to visualise anywhere near the same. This not only plays a role for molars but with all teeth as root canal anatomy from one tooth to another is seldom the same.
4 Obliterations & Calcifications Bearing in mind the average lifespan of our patients is slowly increasing the prevalence of sclerosed canal systems will too. Calcified canals provide a huge challenge-the orifice maybe small and the canal system obliterated resulting in landmarks being completely erased. It requires alot of ‘investigative’ work on the part of the clinician. A scope makes a huge difference in these cases.
5 Denticles & Pulp Stones These provide a bit of a novelty ! They are formed by epithelial remnants surrounded by odontoblasts they can obstruct canal orifices or they are just idle in the middle of the chamber. Depending on their size and their level of connectivity to the pulp chamber removal can be achieved with ultrasonics or gooseneck burs.
6 Open apex management Open apices provide a different challenge than the other items on here, visualising the apex is easy as is disinfection. The key here is controlling apical extent of the obturation especially if you are packing MTA, Biodentine etc.
7 Gutta Percha removal Well condensed gutta percha is hard to remove especially if you can’t see where it is. You may be able to remove the bulk without magnification but total removal and so accessibility to the complete canal system is likely to need a scope.
8 Perforation management Appropriate compaction of a repair material needs visualisation. Fully sealing the perforation can be tricky due to the cavity being of unorthodox design AND the need to prevent blockage of any nearby canals.
9 Apicocectomy In a landmark study by Rubinstein and Kim (1999) the value of magnification was correlated with the success of apicocectomy and signalled a paradigm shift in how treatment was delivered. The retrograde cavity needs to be exact and angulated to match the apical curvature utilising an ultrasonic contra-angled tip in, a sometimes, small bony crypt.
10 Post endodontic restoration One luxury magnification provides is the ability to closely examine the marginal integrity of the restoration. This can be quite humbling to see your crown margins aren’t quite as good as they were without the scope !
And lastly…peace of mind !
The pioneer of magnification in Endodontics, and some may say dentistry, is Gary Carr. Below is a link to a paper he did jointly with Castelucci and is an excellent overview of the use of microscopes in Endo.