Figure 1a-b: The author Dr. David Clark and partner Dr. Jihyon Kim at work with
their microscopes – G6 and Entree Global surgical microscopes.
Figure 2a: Diastema and undersized lateral incisor at 2X magnification.
Figure 2b: Significant detail is shown at 4X.
Figures 2c-g: At 8X magnification the Bioclear Diastema Closure Matrix can be
truly appreciated as the gingival apron is inserted gently and deeply into the sulcus.
In Fig. 2f, we can see that too much distal pressure is being placed on the matrix and
it is beginning to invert. 2g demonstrates the ideal adaptation pressure and the first
small layer of flowable composite has been placed and light cured.
Figure 2h: Second phase of staged wedging shown at 4X. If the wedge had been
placed before the “hip” of flowable composite was placed and cured, the Bioclear
Diastema Matrix would have been smashed resulting in a poor contour.
Figure 2i: 4X magnification view of immediate post operative result of diastema closure.
Figure 2j: 8X view of immediate post operative result of diastema closure.
Figure 2k: 6 week view at 8X demonstrates not only that we have cultivated a perfect
papilla where there was once a black triangle. Extreme magnification confirms
that the tissue is perfectly healthy as the stippling continues along the entire length of
the new papilla “If it is pink and stippled, it’s healthy. Period.”
Figures 2l-m: Pre- and post-operative radiographs demonstrate the aggressive yet
healthy cervical shape required for the optimal hard and soft tissue interface 3-6.
|Part I: Why
Magnification, Advanced Magnification, Extreme Magnification.
What does that mean to a general dentist? To help
explain lets explore the parallel continuum of magnification and
computer processing power. However, because powers of magnification
have a squared, not linear relationship to visual information,
a seemingly small jump in magnification creates a level of
visual information that will profoundly impact the potential for
clinical accuracy (Figs. 1a & 1b). Early on, during the advances in
the power of computer processing, a prediction was made that
every 18 months a ten-fold speed increase would warrant an
upgrade in the processing chip. And sure enough we all kept
upgrading our computers from 286 to 386 to 486 to the Pentium
to the dual processor, etc. Ten-fold power
change is key for computer speed as well as
The general consensus is that at 3.5X magnification it’s not
just better dentistry, its different dentistry. Then at 10X it happens
again. In other words, at 3.5X you can do things that you simply
cannot predictably perform without advanced magnification. See
example in the diastema closure/peg lateral series (Fig. 2 mural).
At 10X (extreme magnification) another world opens up that is
demonstrated in the endodontic images (Figs. 3, 4).
Restorative Microdentistry: New Possibilities in Direct
Aesthetic Resins Featuring Staged Wedging
Microscopes allow the clinician to see and create new possibilities.
The case featured in Fig. 2 is a perfect example. The concept
of staged wedging was invented under the microscope. In this
example, the patented Bioclear Diastema Closure Matrix is self
wedging and the first increment of flowable composite is placed
and cured without a traditional wedge. Once the “hip” or undercut
is established, heavy wedging pressure is applied before the
contact portion of the composite is placed and cured. The six week
extreme magnification photograph shows a perfectly pink
and perfectly stippled new papilla that has grown into the microscopically
smooth and round embrasure. While a microscope
(10X) magnification is not required to perform the procedure, it
was microscopic analysis that inspired the technique and the more
clinical magnification used, the greater the ease and enjoyment of
In the Fig. 5 mural, everyday diagnosis is challenged by
advanced and extreme magnification. As one of the first clinicians
in dentistry to document cracks with a clinical microscope,
I published the first guide to dentinal and enamel
cracks1 based on 16X magnification. I recommend that everyone
read the guidelines – some of which might surprise you (www.bioclearmatrix.com).
The naysayer’s point is “Who cares about predicting dentinal
cracks? Magnification is for the lab, not the clinic.” The
answer to that is patient retention, fee collection and scheduling
issues. For example in the case of Fig. 5, I diagnosed pathological
cracks in the enamel, but scheduled the appropriate time for
a direct intracoronal restoration knowing that the tooth was not
cracked (No dentinal crack = tooth is not cracked). If I had misdiagnosed
the case and discovered a dentinal crack upon
removal of the amalgam, I would have had to “back my way”
into collecting a much higher fee for an extra-coronal (crown or
onlay) procedure not to mention the aggravation to the staff
when the procedure runs overtime.
Clinical Microscopes; Luxury or Necessity?
The operating microscope is not just simply higher magnification
than oculars (loupes). It is better magnification. Oculars
have been very helpful and may always have a role in dentistry,
but the optics are crude when compared to the Infinity
Corrected Optics of a stereoscopic microscope (Figs. 6-9).
When combined with the shadowless coaxial light source, they
transform the clinician’s potential for accuracy of nearly every
aspect in the different disciplines in dentistry.
Increasing levels of magnification produce a squared, not
linear relationship to visual acuity. In other words, a clinician
working at 3.5X sees over 10 times more visual information. 10x
magnification allows the human retina to acquire 100 times more information. 20x allows 400 times the visual information
(Table 2, below).
Tactile Endo vs. Micro-Endodontics;
Do We Have Two Standards of Care?
In Fig. 7, we see a huge lateral system that could have easily
been missed with traditional tactile (blind) endodontics. The
crazy thing about endo is that if this had been a vital case (no
lesion) I might have gotten away with missing that lateral system.
In fact in a vital case you can often get away with 4mm underfills
or even missed canals. I have personally disassembled several
cases where the dentist shaped canal systems and somehow forgot
to insert the gutta percha into one of the canals and yet the
case was succeeding years later. Invariably, these crude yet successful
cases were infection free at the obturation appointment.
In contrast, for the lesion case like the one featured in Fig. 3,
you can’t be too good. And the research shows that your success
rate will be significantly higher if you allow a six-week to three month calcium hydroxide therapy in infected cases.² A first rate
CaOH therapy in a lesion case combined with finding all of the
canal systems under the microscope is “top shelf ” treatment.
Unless you only treat vital cases and simple cases; without a
microscope, you are a second-class citizen. That said, there are
other factors that you will need to address if you want to get to a
98 percent success rate that should be the goal of a general dentist
or 93 percent specialist success, which Dr. John Khademi (my
co-author and endodontist extraordinaire) shoots for based from
analysis of his TDO database (Endodontists treat more complex
cases than we should be treating, hence the 98 versus 93).
The final word in endo: Poor, even terrible endo succeeds far
too often (almost exclusively in non lesion cases). “Excellent”
endo performed under the microscope sometimes fails, often
because it was an infected [lesion] case treated in one appointment.
Regardless, microscopes are the single most important
tool in the pursuit of zero defect endodontics.
Part II: How
How do you integrate the microscope? Once you take the
plunge to a clinical microscope, how do you integrate it into
your routine? Where can you find training? What about patient
education and documentation? I will provide a brief outline of
how it can work best for you. At the end of the article there is a
list of resources for further information.
The following is a roadmap for gradual introduction of the
microscope into your practice.
||Do a full-day or two-day course with a microscope (Find out first hand if a microscope is right for you. Don’t dismiss the idea without giving it a good try.).
||Buy a microscope.
||Pick one part of one procedure and use the
microscope every single time.
||Once you master that pick another. Don’t go
back and forth – it’s maddening.
||Perform and record all of your new patient
examinations through the microscope.
||Attend a microscope “boot camp” like the two-day
course at NCOFI in Newport Beach,
California (For a list of other facilities and
courses, visit www.microscopedentistry.com).
Step one is the microscope course. I do dozens of courses
every year for endodontics and Bioclear composite techniques
using microscopes. The dentists are having such a good time
learning the techniques that they forget that they are even using
a microscope. By the end of the day they are either “hooked” or
they have given up and put on their loupes. These tend to be the
best way to become comfortable with a microscope without
Step three, the one-procedure-at-a-time training, is an interesting
approach. Learning to use a clinical microscope is a bit
like eating an elephant. Instead of running around the elephant
biting off little bites in a haphazard way, sit down and eat the
trunk. When that’s gone eat the left ear, and so on. What are the
best, most productive and easiest procedures to start with using
a microscope? Examples include a Class V on a central incisor,
occlusal composites or any procedure that allows you to work on
one surface for an extended period, like endo. Cutting a quadrant
of crowns or posterior composites needs to wait until you
are further along in your progress. Some dentists like Glenn van
As jump right in and incorporate the microscope all at once. His
approach is discussed below. Most dentists, however, will follow
the gradual method mentioned above.
Step five is the breakthrough commitment. It is the key to
the creation of a microscope centered practice.
The single most important element in realizing significant
ROI and to create a microscope centered practice is to allow
patient and staff to see the incredible view that the doctor
sees. A live and recorded video broadcast is the first step to
bring about these fundamental changes. Trust, cost versus
value, and patient loyalty are but a few of the principles that
are deeply impacted.
Make sure that you have a video camera installed when you
purchase your microscope. An inexpensive television or LCD
screen is placed in patient’s view and should always be turned
on (Fig. 1). The key to the creation of a microscope centered
practice is video taping the tooth and soft tissue portion of the
comprehensive exam. We present the video later as part of the
comprehensive treatment consult. This simple process requires
almost no technical learning curve and no interruption of your
clinical routine. It will literally transform your practice by revolutionizing
the most important appointment; the new patient
experience. Just as importantly, you are teaching yourself to
visualize every surface of every tooth through the microscope
in a low stress (non operative) environment. Microscope clinicians
report finding a wealth of subtle disease that they could
not see before:
Micro pathology – This new term describes important
pathology that is either invisible or not compelling at less than
12X. This includes signs of occlusal disease (tell tale facets and
enamel loss), early incomplete fractures, micro leakage, early
recurrent decay, and isolated periodontal inflammation surrounding
crude dentistry that has a violation of the three new
parameters of marginal integrity.
Dramatic Results – Patient motivation is, in a word, incredible.
Productivity – The average adult older than 30 presents
with two posterior teeth with fairly dramatic early Incomplete
Coronal Fracture that their last dentist never saw. Many of these teeth have a history of symptoms. In the average practice
it will take several years of several procedures per week to treat
The Glenn van As Model of Microdentistry
Glenn van As, BSc, DMD, was not the first restorative
dentist to use a microscope, but was definitely one of the
first to use the microscope for pretty much everything, and
nearly all of the time. He inspired me to transition from a
“loupes first, microscope second” to a “microscope first,
loupes second” routine for my clinical day. Glenn was practicing
under the burden of the Canadian fee system where
the College of Dental Surgeons of British Columbia sets a
fee schedule. That fee schedule is about 40 percent lower
than my fees in Tacoma, Washington. Although he had a
much higher volume practice (because of
lower fees) he beat me to the punch to
adopt the microscope as the center of his
clinical day. I told myself, “If Glenn can do
it, then so can I” and in 6 months it came
to fruition. Never underestimate the power
In 18 years of restorative microdentistry,
what have I learned? Here are seven of hundreds
of things you will discover on your
- Early crack diagnosis occurs at 16X.
Anything less is a guess or end stage
diagnosis¹ (End stage referring to loss
of pulp or fracture causing loss of cusp or fracture requiring
- Dentistry is way more complex and way more iatrogenic
than I thought before.
- Tooth colored restorations require far more magnification
than metal restorations.
- Black triangles are unhealthy.
- Rounded cervical profiles in porcelain and composite can
create great health and great aesthetics but magnification
is required to pull it off and not leave an overhang.
- Without a microscope, you might become a second-class
- I sleep far better at night knowing “I truly gave it my
- Academy of Microscope Enhanced Dentistry:
- Training and DVDs by David Clark, DDS:
- Dr. Glenn van As DVDs: firstname.lastname@example.org; www.drvanas.com
- The Newport Coast Oral Facial Institute (Training): www.ncofi.org
- Clark DJ, Sheets CG, Paquette JM. Definitive diagnosis of early
enamel and dentinal cracks based on microscopic evaluation. J
Esthet Restor Dent. 2003;15(special issue):7:391-401
- Sjögren U, Figdor D, Persson S, Sundqvist G. Influence of infection
at the time of root filling on the outcome of endodontic treatment of
teeth with apical periodontitis. Int Endod J. 1997 Sep;30(5):297-
306. Erratum in: Int Endod J 1998 Mar;31(2):148.
- Clark DJ, Kim J. Optimizing gingival esthetics; a microscopic perspective.
Oral Health. 2005 April; 116-26
- http://www.ncbi.nlm.nih.gov/,Tarnow DP, Magner AW, Fletcher P.
The effect of the distance from the contact point to the crest of bone
on the presence or absence of the interproximal dental papilla. J
Periodontol. 1992 Dec;63(12):995-6
- Holmes CH. Morphology of the interdental papillae. J Periodontol
- De Boever JA, De Boever AL, De Vree HM. Periodontal Aspects of
cementation: materials, techniques and their biologic reactions. Rev
Belge Med Dent. 1998;53(4):181-92.
|Dr. David Clark founded the Academy of Microscope Enhanced Dentistry, an international association
formed to advance the science and practice of microendodontics, microperiodontics,
microprosthodontics and microdentistry. He is a course director at the Newport Coast Oral
Facial Institute in Newport Beach, California. He is co-director of Precision Aesthetics
Northwest in Tacoma, Washington, and an associate member of the American Association of
Endodontists. He lectures and gives hands-on seminars internationally on a variety of topics
related to microscope-enhanced dentistry. He has developed numerous innovations in the
fields of micro dental instrumentation, imaging, and dental operatory design. Dr. Clark has
authored several landmark articles about microscope dentistry including Aesthetic Dentistry,
Sealants, The Role of Ultrasonics in Three Dimensional Shaping and Restoration of Non Vital
Teeth, Micro-Imaging and Practice Management, and Crack Diagnosis. Dr. Clark is a 1986
graduate of the University of Washington School of Dentistry. He maintains a microscope centered
restorative practice in Tacoma, Washington. He can be reached at email@example.com, firstname.lastname@example.org or www.bioclearmatrix.com.
NOTE: Dr. Clark will present at least one follow-up article in Dentaltown Magazine detailing techniques developed
under advanced and extreme magnification including: Injection Molded Composite Dentistry, Pulpal Microsurgery,
Restoratively Driven Papilla Regeneration, and Biomimetic Minimally Invasive Endodontic Shaping.