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Loupes - Gimmick or Useful Tool? Wm. Randol Womack, DDS, Editorial Director, Orthotown Magazine

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by Wm. Randol Womack, DDS, Board Certified Orthodontist
Editorial Director, Orthotown Magazine

The more offices I visit, the more often I see orthodontists using magnification. Each year when I visit my timeshare in Maui, I visit Dr. Mickey Damerill's office. For the past three years, I've noticed Mickey has worn loupes around his neck when he is seeing patients. I am on the Adjunct Faculty in the Orthodontic department at the Arizona School of Dental and Oral Health (ASDOH) in Mesa, Arizona. Our eight first- and second-year residents all use loupes when they are treating patients. This is how they start their clinical experience and I assume they will continue this practice when they graduate and start working.

So what exactly is it with magnification in orthodontics? Orthotown.com ran a poll on magnification from September 19 to October 16, 2008. Sixty-six percent of all of the respondents stated that they did not use magnification/loupes in their clinic and 50 percent of them stated that they were "inconvenient and obnoxious." However, 49 percent of all of the respondents indicated, "I am still considering magnification."

So what are the pros and cons of magnification? When I questioned Dr. Damerill about why he started using loupes, he told me he wanted to enhance his visual acuity and treatment quality and also to improve his comfort and working posture. Ergonomic design was also important to him. When you research the companies that sell and market loupes they all agree that non-ergonomic loupes can actually create strained working postures leading to musculoskeletal disabilities, usually in the neck, back and/or shoulders. Therefore, it is important to get educated about what works best for you so you can make an informed decision.

To save you some time, I have summarized what I feel are the important articles of my research that would apply to the practice of orthodontics.

Orascoptic – a Kerr company – has a very comprehensive buyer's guide. The visualization of a loupe system is truthfully governed by (in order of importance):
  1. Resolution
  2. Field Width
  3. Field Depth
  4. Magnification
Orascoptic states that resolution and then field size is more important than the actual size of the image, not just the magnifying power. Loupes that resolve small features are more valuable than loupes that provide a larger but somewhat blurry image. This is similar to comparing a 52-inch rear-projection TV to a 36-inch high definition TV. The larger picture shows more, but fuzzy, activity where the smaller HD TV will show you the beads of sweat running down Kobe Bryant's face.

If we apply this principle to some of the orthodontic procedures, it would be fair to conclude that the accuracy of evaluating bracket/tooth adaptation and optimum bracket placement would be enhanced by magnification.

Likewise, the correctness of bracket/bonding material removal would be enhanced by using loupes. To precisely visualize when the bonding material is gone and the tooth enamel is exposed is the goal of every orthodontist and clinical assistant when de-bonding a case. One would conclude that magnification could make this judgment more accurate.

With self-ligating brackets, the process of getting the archwire(s) fully inserted into the bracket slot and the "door" closed can be an issue with certain mal-alignment issues. More than once we have had a beginning patient return with a rotated tooth disengaged from the archwire because we didn't observe that the wire and the self-ligating bracket were not engaged fully. In my opinion, magnification would have prevented this error that occurred with normal vision.

Many of the newer technologies being used in orthodontic practice today can be enhanced by the use of magnification. In my practice, laser tissue exposure of impacted teeth, placement of temporary anchorage devices (TADs) and reviewing CBCT scans are just a few applications where I have benefited from a more accurate field of vision.

One factor that is addressed by the major manufacturers is posture. Using magnification that requires the operator to move to a specific distance from the viewed object can negatively influence posture. Bending over and/or twisting to focus the magnification can be hazardous to your body and to your health. Therefore the "focal distance" (the distance between the operator's eyes and the operating site) significantly influences posture. Optivision gives a guide to determining your usual and customary "working distance." After you evaluate your preferred operating distance you can match that with the correct focal length of the loupes. In our office, the patient position for me to work, sitting at the chair, is fixed by the pre-selected chair position feature.

Another measurement noted by Optivision is "declination angle" (or the angle of your eyes) when in your preferred operating position (sitting? or standing?). The downward angle of your eyes toward the work area should be about 20 degrees (or less). Other variables include nose bridge height and inter-pupillary distance.

In addition, the frame size influences the placement of the scope on the lens. With Through the Lens (TTL) loupes, generally the larger the frame, the lower the placement of the scope, which is desirable.

Finally, how much magnification is recommended? Carl Zeiss International provides an "Optical Systems Table" that suggests magnification based on your working distance. For many routine orthodontic working distances, 2.5x to 3.5x is a good guideline.

An interesting company is PeriOptix. It provides a self-adjustable magnification system. The PeriOptix Performance Plus Optics allow you to set your inter-pupillary, convergence and declination angle for perfect optical alignment.

One way to determine what is right and effective for you is to arrange a free trial period with the manufacturer of your choice. Keep in mind that loupes require an accommodation period. All the companies recommend that, at first, you only wear loupes for 20 to 30 minutes at a time totaling a couple of hours/day for the first few days, increasing gradually over five to 10 days. This allows adjustment to the new acuity, field of vision and posture.

Which is the best, TTL or flip-up loupes? From the various manufacturers that I researched I have summarized a comparison for you.

TTL
Pro: They generally weigh less and offer a wider field of vision. They are custom fit for each individual and are more comfortable.

Con: They cost more. They can be a problem if you already wear prescription glasses. They can be inconvenient when communicating with the patient.

Flip-up
Pro: They cost less. They can be flipped up for communication or doing other tasks such as paperwork. They are not operator specific.

Con: They weigh more and have a narrower field of vision. Another feature of the flip-up configuration is that not all procedures require magnification but might require some form of eye protection. The flip-up feature allows the optics to be moved out of the way for communicating with patients/ parents, reading charts and various other clinic procedures. Thus the clinician can avoid having to remove and replace loupes repeatedly, which is particularly inconvenient if the doctor wears protective glasses or needs prescription glasses when not using magnification.

Finally, what do the residents at ASDOH say about loupes? Four of them use Surgitel loupes and three of them generally state that they like them. The TTL loupes seem to be preferred to the "flip-up" loupes. Two have Orascoptic loupes. They say they are lighter weight and not as bulky. Two other residents are satisfied with their Design for Vision loupes, once they had them adjusted.

Just when you think you have the latest in loupes, I spoke with a rep from Orascoptic at a recent dental meeting. He showed me the company's newest product, the Through The Flip (TTF) loupes. This model has a frame with an interchangeable lens insert supporting a carrier lens on which the scopes are mounted. The carrier lens can "flip" up out of the way leaving the protective lens in place. The neat feature is that the protective lens can snap out and a laser-protective lens can snap in – so you can flip the scopes down over the laser lens giving you the best of both worlds when doing laser procedures. A laser lens will be available later this year.
Summary
In spite of the cost and learning curve associated with loupes, magnification can assist orthodontists in producing a higher quality of care. Seeing better also means decreased operating time. Properly fitted loupes can improve posture and can reduce the risk of muscle pain in the back, neck and shoulders. The improved ergonomic factors can have significant ramifications for your health and career longevity. Today, with economics the way they are and the way the future is shaping up, I submit to you that career longevity has more meaning now than it ever has in the past.
Orthotown Magazine
November 2025
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