Dental Tribune USA

Dr Assad Mora: The man behind the microscope

By Fred Michmershuizen, DTA
February 03, 2009

Dr Assad F. Mora is a native of Syria who came to the United States in the early 1970s to study prosthodontics. Today he maintains a private practice in Santa Barbara, CA, USA, with his wife, Kathy Patmore, an endodontist. As inventor of the MORA Interface and the MoraVision 3D system, Dr Mora pioneered a new era in visualization technology by introducing the use of stereoscopic 3-D video technology for viewing the operating field in real time for performing clinical dental procedure. Dr Mora spent some time with Dental Tribune discussing how he became involved with microscope-enhanced dentistry, the thinking behind MoraVision 3D system, and what he sees for the future of microdentistry.

How did you get started in microscope dentistry?
In 1993 I was introduced to the first stereoscopic 3-D video system, which was made by Zeiss for their microscopes. The live and recorded stereoscopic video was intended for enhancing the teaching experience and documentation of microsurgery. I instantly recognized the great impact 3-D video can have on dentistry. Not only does it have the potential to change the clinical teaching model, but also to change how dentistry is practiced. For the first time, the operating field could be viewed on a screen in real time with accurate 3-D depth perception to usher in the era of 'posture-independent vision.' By doing so, dental operations would be performed without the traditional leaning and craning over the patient, and without peering into the binocular tube of a traditional operating microscope. Posture-independent vision could free the operator from assuming traditionally harmful musculoskeletal postural positions in order to gain visual access into the oral cavity.

Did the first stereoscopic 3-D video system have limitations?
Unfortunately, the low resolution of early video technology produced an image quality that was far inferior to that of the optical image seen through the microscope. In 1998, Zeiss introduced a compact 3CCD stereoscopic system for their microscopes. The marked improvement in image quality at the higher ranges of magnification made stereoscopic video vision a clinically acceptable working tool. I bought the system, got rid of the binocular tube, and started working by viewing the operating field directly on the screen. It made dentistry far less frustrating, more accurate, more comfortable, more accessible, more enjoyable and improved my productivity. The search for improving the system, however, continued, and the display graduated from a 27-inch CRT stereoscopic monitor with battery-powered active liquid crystal glasses, to dual projection on a 6-foot silver screen and lightweight passive polarized glasses. Still, image quality, user-friendly ergonomics, compactness, simplicity, reliability and reasonable pricing remained elusive.

What led to the breakthrough?

The advent of consumer high-definition video in 2005 was the impetus I needed to embark on the development of a new 3-D system that took advantage of 13 years of knowledge and experience with microscopes and stereoscopic 3-D video. It took three years of hard work, many failures and setbacks, and tremendous resources to bring to the profession not only a video viewing system that is usable, but a system that will make the practice of dentistry easier, improve the quality of patient care and revolutionize clinical dental education. Stereoscopic video of the operating field as seen by the operator can now be the foundation for a new clinical teaching model. It can be viewed by any number of students, live during demonstrations or recorded for viewing at their convenience. This new, three-dimensional clinical teaching model can give the students an unprecedented level of understanding and clarity of the visual clinical information under consideration. Leaving no gaps in their conceptual understanding of the clinical information presented, the students will no longer need to struggle to acquire the incomplete visual information in bits and pieces and to fill in for the missing information with inaccurate assumptions that might be proven wrong upon validation. Instead, they can immediately proceed to spend their efforts on getting their hands to develop the necessary skills based on complete understanding of what needs to be accomplished. As a result, valuable time and resources can be saved while improving the quality of clinical dental education.

Please describe the MoraVision 3D system.
It is a digital stereoscopic microscope system that delivers to the viewer an accurate, three-dimensional depth perception in real time, with the clarity and color fidelity of 'full HD' 1920-by-1080 video resolution to each eye. It also delivers two different perspectives of the same operating field, one for the doctor and another for the assistant. It enables the operator to sit in the 12 o’clock position and view the operating field straight ahead on a stereoscopic LCD Module. At the same time the assistant, who is seated in the 3 o’clock position, can view the same operating field from his or her own correct perspective on a second stereoscopic LCD module placed straight ahead. The MoraVision 3D system is unique in that the assistant vision is provided as a standard configuration with the system, not an option. It considers the assistant an integral part of the operating team.

What comprises the system itself?
The MoraVision System has two main components: the MoraScope and the MoraVu3D. The MoraScope is made of two self-contained digital stereoscopic microscopes in one housing. It combines the powers of two zoom stereo microscopes and their HD video cameras into one compact 5-inch cube to provide magnification levels from 0.5Xto 30X. A foot control and built in HD imaging capabilities, for the dental practice and dental education, are standard features. There is no need for a standard optical microscope or additional cameras and accessories. The HDMI outputs insure a superb image quality for recording and viewing. Two adjustable special LCD light sources provide coaxial lighting, important for viewing root canals, and redundancy. The MoraScope is suspended on an ergonomic low profile floor stand that is stable, intuitive and easy to adjust and will not obstruct the view of the monitors. The MoraVu3D is a real time stereoscopic display module based on two HD LCD monitors and a beam splitter. 37-inch monitors are used in landscape view for the operator’s module, while 26-inch monitors in portrait view are used for the assistant’s module. 19-inch modules are available as an option.

How can MoraVision 3D help specialists and GPs provide better patient care?
The benefits of the MoraVision 3D system extend to all phases of dentistry, for specialist and GPs alike. It does not only improve the quality of dental care for the patient, but it can save the back and the neck of the dentist and the assistant. It improves the quality of dental care by virtue of providing an unobstructed magnified view of the operating field, which raises the bar on improving early detection of dental disease and oral pathology, and increasing precision of dental operations. The quality of dental operations is further improved by giving the assistant the unique ability to see the exact operating field and conditions as seen by the operator. This allows the assistant to deliver intelligent and focused assisting in a precise, gentle and effective manner, without prompting and without leaning and craning. For the dentist and the assistant, dentistry has been a disability in progress due to assumption of working postures that are strenuous and harmful to the musculoskeletal structures of their back and neck. The resulting injuries can lead to temporary or permanent disabilities and consequently loss of income. The MoraVision 3D system can extend the productive life of working dentists and assistants and make it more enjoyable and pain free.

What are some of the other benefits of this stereoscopic visual communication tool?
A picture is worth a thousand words. A stereoscopic 3-D picture is worth a thousand pictures, and a stereoscopic 3-D video is worth a thousand 3-D pictures. The amount of visual information that can be conveyed through stereoscopic video is enormous. It does not leave anything to speculation and imagination. Live 3-D video is an effective tool for reducing patient anxiety, an anxiety based on the fear of the unknown. By giving the patient the ability to see the procedure in 3-D, it gives them the power of visual control over the procedure as they become full participants and not only on the receiving end. Empowering the patient with this kind of visual information produces a more educated patient who is more cooperative, motivated, appreciative and one who takes ownership of their problem. Visually educating the staff with office procedures increases their competence, which in turn elevates their morale and excitement about the work they do. Communication with colleagues with referral information using stereoscopic clinical visual records can convey the most comprehensive picture of the clinical condition with accuracy and completeness unmatched by any other method. This can cut down on wasted time and resources for on-site consultations and facilitate the delivery of patient care in a timely fashion.

What sets the MoraVision 3D system apart?
There are several video-vision systems on the market today claiming the same benefits. One of the major differences that makes the MoraVision 3D system unique is 'stereoscopic vision.' The other systems are monoscopic and do not provide the operator with accurate depth perception. Instant and accurate hand-eye coordination is essential for precision operations like dentistry and neurosurgery. Working with monoscopic vision is basically working with only one eye. Insurance companies classify vision loss in one eye as 100% disability for dentists. There are other factors to consider with the MoraVision 3D system, such as the short learning curve. If you can operate a computer mouse, you will have no problem operating with the system. All the people who have tested or used the MoraVision 3D system described it as easy to use, fast to learn, and provides unprecedented working comfort, when compared to a traditional microscope or to working without visual aids at all.

Please describe your involvement with the Academy of Microscope Enhanced Dentistry.
I joined AMED as a charter member when Dr David Clark called the first meeting in 2002, and I started serving on the board right away. In 2003, I introduced Stereoscopic 3D to the academy in a presentation titled Microdentistry: The Past, the Present and the Future. The power of the three-dimensional teaching model in clinical dentistry was demonstrated and was well received. In 2004 I chaired the scientific session, and we dedicated Saturday morning as the Stereoscopic Session. During the year prior to the meeting, I visited several dental offices with my 3-D video equipment and recorded master microscope operators performing dental procedures during the course of their daily practices and without interruption to their work flow, for their presentations at the stereoscopic session. Those master clinicians were Dr Dennis Shanelec, Dr Mark Friedman, Dr David Garber, Dr Cherylin Sheets, Dr Jacinthe Paquette and Dr Peter Nordland. I also spend a day in the operating room with neurosurgeons Dr Peter Jannetta and Dr Kenneth Casey recording nerve decompression surgeries performed by them and their residents in Pittsburgh. The stereoscopic session and the program proved successful. It was never possible before to show people in mono vision what we really see under the microscope stereoscopically. 3-D video makes that possible. I served as chairman of the program for three years, and we continued and expanded the 3-D into a normal occurrence at AMED. I served as executive director in 2004, and we moved the meeting to Tucson, AZ, USA, for three years. In 2005 I was elected vice president, then went through the chairs and served as president in 2007.

Where do you see microscope dentistry going in the next five to 10 years?
Emerging technologies can play a significant role in advancing the principles of microsurgery and microdentistry and gain acceptance by a larger segment of the practicing dentists. Unfortunately there has been a tremendous resistance to the adoption of these principles, due to several factors:

  • 1. They have to be convinced of the value the new technology brings to their life and to patient care.
  • 2. Pride. Human nature tells us that when people are challenged to make a change, pride kicks in, in an attempt to defend the status quo and their position. People will not change until they would consider change as a victory not defeat, particularly when they have been proud of what they have already been doing.
  • 3. Learning a new skill is intimidating and exposes the person vulnerabilities. Have you tried upgrading your software lately? This is particularly notable when the new skill to be acquired does not perceptibly change the outcome. They argue that good crowns last for 20 years. How much longer will they last if made with the new technique?
  • 4. While a microscope is relatively expensive, loss of productivity due to a steep learning curve is much more costly to the practitioner. Dentists are people too. They have financial obligations like anyone else. Taking on a project like the microscope will compete for the limited resources.
  • 5. The necessity to change will be dictated by changing the standards of care. Setting a new standard of care has to come from the educational institutions. The educational institutions are manned by people, too. Please refer to 1, 2 and 3 above.

By bringing the comfort of posture independent stereoscopic vision, ease of use, a short learning curve and ease of documentation to microscope magnification, the profession should find it more compelling to adopt this new paradigm for improving the standards of dental care, for both the patient and the treating team. Also, bringing real-time stereoscopic video vision and simplified stereoscopic documentation to clinical dental education can create a new paradigm in teaching. The required one-on-one instructions in the clinical setting can now be extended to a much larger number of students through stereoscopic video. This new clinical teaching method can be more economical, efficient and effective. It can convey the three dimensional information, as seen by the operator from his/her own perspective, to the student, and visa versa, for monitoring student performance in the clinic. Bringing stereoscopic vision to clinical teaching, documentation and presentation can fill the gaps in conceptual understandings of the clinical tasks under consideration and would allow the student to start practicing, immediately, for proficiency instead of wasting valuable time looking for direction to prove or disprove a point of understanding.

Change will come to the profession when the compelling evidence is accepted based on a perceived need assessment. It will only come when the time is right.

If you could send one key message to dentists and specialists, what would it be?The microscope is not the end. It is the means to challenging the status quo and achieving a higher quality in patient care. Constant decisions are made every second during exams and treatments based on visual feedback. To drive the point home please allow me to use the following example: An image made of 20-by-30 pixels has 600 pixels, or 600 points of information. The same image made of 200-by-300 pixels has 60,000 pixels or 60,000 points of information. The second image is considered 10 times larger than the smaller image. However, it has 59,400 points of information more than the first image. Or, the first image has 1 percent of the information present in the second image. Could it be that if we were not working with 10X magnification, we are then working with 1 percent of the information that could be available to us? When performing a dental operation, clinical decisions have to be made constantly. Visual feedback is the main source of information upon which clinical decisions are made. Dentistry has been and will continue to be an assumption based endeavor. The closer our assumptions are to reality, the better will be our decisions leading to more successful outcomes. Microscope magnification improves the odds in 'assumption-based dentistry.'

You can’t diagnose or treat what you can’t see. You don’t know what you can’t see, and you can’t see what you don’t know.

The Academy of Microscope Enhanced Dentistry (AMED) recently presented its coveted Master of Innovation award to Dr Assad Mora. The award, established in 2004 as the highest honor that can be bestowed upon an AMED member, was presented to Dr Mora in recognition of his pioneering work in the field of microdentistry. Past recipients of the award include such notables as Dr Gary Carr in 2004, Dr Dennis Shanelec in 2005, Dr Eric Herbranson in 2006 and Dr Mark Friedman in 2007.

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