International Dental Education

Evaluation of a Virtual Reality Simulation

System for Porcelain Fused to Metal Crown
Preparation at Tokyo Medical and Dental
University
Hirono Kikuchi, D.M.D., Ph.D.; Masaomi Ikeda, R.D.T., B.Sc., Ph.D.;
Koji Araki, D.D.S., Ph.D.
Abstract: The use of virtual reality simulation (VRS) is a new teaching modality in dentistry, and there is scope for further
research evaluating its use under different educational programs. The purpose of this study was to evaluate how VRS with or
without instructor feedback influenced students learning and skills related to porcelain fused to metal (PFM) crown preparation. In this study, forty-three dental students in their fifth year of study at Tokyo Medical and Dental University, Tokyo, Japan,
were randomly divided into three groups: the first group used VRS (DentSim) with the instructors feedback (DSF) (n=15), the
second group used VRS without the instructors feedback (DS) (n=15), and the third group neither used features of VRS (NDS)
(n=13) nor received the instructors feedback. All the students performed PFM crown preparation under the same setup once a
week for four weeks. Total scores, preparation time, and twelve evaluation items were compared among the three groups and four
experiments. The total scores of students in the DSF and DS groups were significantly higher than those in the NDS group. The
presence of the instructor did not result in significant difference when VRS was used for training, while it shortened the preparation time at early stages. The results of this study suggested that the use of the VRS system improved student training for PFM
crown preparation.
At the time this study was conducted, Dr. Kikuchi was a graduate student, Graduate School, Educational System in Dentistry,
Tokyo Medical and Dental University, Tokyo, Japan; Dr. Ikeda is Lecturer, Department of Oral Health Care Sciences, Faculty
of Dentistry, Tokyo Medical and Dental University, Tokyo, Japan; and Dr. Araki is Professor, Center of Education Research
in Medicine and Dentistry, Tokyo Medical and Dental University, Tokyo, Japan.Direct correspondence and requests for reprints
to Dr. Hirono Kikuchi, Oral Diagnosis, Tokyo Medical and Dental University, 1-5-45 Yushima, Tokyo, 113-8549, Japan;
suugend@tmd.ac.jp.
Keywords: computer simulation, computers in dentistry, dental students, educational methodology, virtual reality simulation,
crown preparation, Japan
Submitted for publication 12/27/11; accepted 8/6/12

ractical experience is necessary to acquire

skills in clinical dentistry. Clinical training
is a requirement in the curriculum for dental
students in Japan, and all twenty-nine dental colleges in the country are affiliated with their own
clinics where the dental students receive training;
however, the length of training period differs among
the colleges. Many of the patients understand that a
university dental clinic is an educational institution
and volunteer to be training cases, yet there are not
enough training cases for students in many dental
colleges to obtain sufficient clinical skills before
they graduate.1,2 The fact that many students become
dentists without sufficient experience with techniques
required for dental practice is a challenging issue in

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Japanese dental education. Therefore, development

of effective training methods is required to compensate for the shortage of practical experience and
establish objective evaluation of skills.3
Developments of virtual reality simulation
(VRS) methods enable training in a realistic environment that is similar to an actual practice. VRS has been
commonly implemented for training in various fields,
including aerospace, military, security, and arts.4,5 A
wide variety of VRS devices has also been developed
in the medical field; VRS is currently used in cardiology, anesthesiology, laparoscopy and bronchoscopy,
and for simulation of implant therapy in dentistry.6-13
It is expected that dental training using VRS would
improve dental care through better student training.14-16

Journal of Dental Education Volume 77, Number 6

DentSim (Image Navigation, New York, NY)

is a preclinical simulator that provides real-time
image processing with the use of three dimensional
(3D) graphics as a VRS. The DentSim unit includes
a manikin head and torso, KaVo dentoform, dental
handpiece, light source, infrared camera, and software.17 Students are able to see the illustration of their
preparation in real-time on the monitor. It is believed
that if students see illustrations of their procedures,
they can possibly understand inadequacies in their
skills objectively and visually, leading to high effectiveness for technical training.
Many studies have examined the training
effectiveness and objectivity of evaluation of the
VRS system. Leblanc et al. suggested that student
performance was improved by the use of VRS at an
early stage,18 while Fakhry et al., Steinberg et al., and
Marras et al. referred to the improvement in learning
effectiveness using visual information.19-21 Feeney et
al. and Welk et al. suggested that instruction using
VRS could improve the interest and desire to learn
in many students.22-24 Esser et al. similarly referred to
the value of education using VRS and raised issues
concerning the conventional curriculum.25
While a large number of previous studies have
compared VRS to the traditional bench type training
laboratories, few have evaluated the actual effect of
instructions provided by VRS or provided by VRS in
addition to a human instructor on the student training
under the same setup. Yasukawa reported that instructor feedback improved the Class II cavity preparation
technique;26 however, no study has evaluated VRS
training for porcelain fused to metal (PFM) crown
preparations and the effect of instructors feedback.
Therefore, the purpose of this study was to
evaluate how VRS influenced students techniques
for crown preparation by comparing total scores,
preparation time, and scores of specific items. The
specific aim of the study was to determine whether
there were differences among the group that used
VRS with feedback from an instructor, the group
that used VRS without feedback from an instructor,
and the group that did not use VRS and received no
feedback from an instructor. Total scores, preparation
time, damage to mesial adjacent tooth, damage to
distal adjacent tooth, occlusal reduction, wall incline,
retention, resistance, wall smoothness, margin location, chamfer width, interproximal clearance, finish
line continuity, and undercut as evaluated by the VRS
were compared.

June 2013 Journal of Dental Education

Materials and Methods

The equipment used is shown in Figures 1
and 2. A VRS program, the DentSim was used for
preparation and evaluation of students preparations.
PFM crown preparation Version A10 was selected in
the system. The DentSim unit combines a dentoform
integrated with seven tracking light emitting diodes
(LEDs), standard jaw and standard turbine 650B
LUX-3 (KaVo Dental GmbH, Germany) with sixteen
tracking LEDs, dual Charge Coupled Device (CCD)
infrared tracking camera, the computer that includes
tracking software and the DentSim software, and a
monitor. When a student starts preparation, the overhead camera tracks the LED light on the mannequin,
and the computer calculates the positional relation
between the dentoform and the turbine and projects
the illustrations on the monitor.17 While preparing a
tooth, the system immediately notifies the student
about any incorrect preparation procedures such
as damage to the adjacent tooth. The preparation is
analyzed by the DentSim, comparing the students
preparation to the preparation that has previously
been defined according to certain standards and
criteria depending on the doctrine selected by the
instructor. The system can be switched to evaluation
mode, which shows error messages, error details,
graphic presentation, and points lost.
In November 2010, all sixty-seven students
in their fifth year in the Faculty of Dentistry, Tokyo
Medical and Dental University, were invited to participate in this study during a large-group session.
The purpose and details of the study were explained
verbally and in writing by one of the authors (HK).
The students were informed that they would be
divided into three groups at random and were given
details of difference between the three groups. Fortyfive volunteered; however, two students (male)
dropped out of the study after the first experiment due
to schedule conflicts. Therefore, forty-three students
(twenty-one males and twenty-two females) participated in the study. The study protocol was approved
by the Institutional Review Board of the Faculty of
Dentistry, Tokyo Medical and Dental University (approved on November 5, 2010; No. 591). Six months
before the experiment, the students had all done a
full cast crown preparation of the left mandibular
first molar with dentoforms once in their prosthetic
practice class. All students performed PFM crown
preparation of the artificial left mandibular first molar
(KaVo Dental GmbH, Germany).

783

Figure 1. Screen view of evaluation using the DentSim

Note: The upper left figure shows a three-dimensional picture during crown preparation. On the right side of the screen, the standard
shape of the tooth after preparation is shown, for comparison with the present shape of the tooth. A list of scores is shown on the lower
left.

The students were randomly assigned to one of

three groups: the first group used the DentSim with
the instructors feedback (DSF) (n=15), the second
group used the DentSim without the instructors
feedback (DS) (n=15), and the third group received
neither DentSim nor the instructors feedback (NDS)
(n=13). In group DSF and group DS, students were
able to see the VRS monitor during preparation procedures and switch to evaluation mode while preparing.
The students in group NDS used the VRS unit, but
they were able to see only a static standard shape of
the prepared tooth on the monitor and a preparation
tooth model. As feedback in DSF, the instructor gave
only the information obtained on the VRS evaluation
mode to the students, but no technical advice. The
same person provided all instructions to the students.
The instructor was the only person who could start
up and set the VRS, so that students could not use it
by themselves except for the experiments. To prevent
the students assigned to group NDS from being at an
educational disadvantage, all students gave feedback

784

on PFM crown preparation using the VRS evaluation mode and performed the preparation again after
completion of the study and data collection.
The instructor explained the anatomical characteristics of the left mandibular first molar and gave a
ten-minute instruction about PFM crown preparation
to all students in all groups, as well as directions using
VRS to students in group DSF and group DS. Reference models and figures of PFM crown preparation
were also presented to the students in all groups.
All students prepared a PFM crown preparation once a week for four weeks (referred to as Ex.
1 to Ex. 4, respectively) in the same setting as the
initial experiment with the DentSim unit. Since there
was only one VRS unit available in the facility, the
experiments were carried out with one student at a
time. All experiments took place during regular and
after hours. The experiment lasted one month. It was
started after the students completed their practice
classes and before the start of clinical training. During the period of this experiment, the students did not

Journal of Dental Education Volume 77, Number 6

Figure 2. PFM crown preparation using the DentSim

perform any crown preparations in clinical training

or receive any additional practice.
The VRS was used to collect and analyze the
data from the three groups. Consequently, all groups
could be compared based on the same assessment.
The parameters for evaluation were not customized
for this study. The maximum score of 100 was decreased with the sum of error scores. The prepared
artificial teeth were scored using twelve items in the
DentSim evaluation system: the selected doctrine
tested damage to mesial adjacent tooth, damage to
distal adjacent tooth, occlusal reduction, wall incline,
retention, resistance, wall smoothness, margin location, chamfer width, inter-proximal clearance, finish
line continuity, and undercut. Preparation time included the time needed for preparation and feedback
from the instructor and switching to evaluation mode
or preparation mode. Students could spend as long
as they wanted for preparation.
Wall incline is an index for evaluation of the
taper. The DentSim specifies a taper of 3 to 6 and
scores an excessive or short taper of >15 and >8
as -2 and -1, respectively, with evaluation of three or

June 2013 Journal of Dental Education

four sites of a single wall. The presence of undercut

was evaluated, and significant was evaluated as Fail.
Incorrect occlusal reduction was also evaluated as
Fail for either overreduction or insufficient reduction
(<1 mm). When undercut or occlusal reduction error
was found, the score dropped to -41 points; however,
to compare scores among evaluation items, -41 points
was replaced with zero so that statistical analysis
could be performed. For the damage to mesial or
distal tooth, three points were reduced when the bur
touched the adjacent tooth and ten points were reduced when the adjacent tooth was actually ground.
Total scores, total time, margin location scores,
and wall incline scores for each evaluation item were
compared among group DSF, group DS, and group
NDS, using two-way analysis of variance (ANOVA)
and a t-test with a Bonferroni correction. Damage to
adjacent tooth, occlusal reduction scores, wall smoothness scores, resistance scores, chamfer width scores,
inter-proximal clearance scores, finish line continuity
scores, and retention scores were evaluated by Wilcoxon rank sum test with a Bonferroni correction. The
presence of undercut case was evaluated by chi-square

785

analysis with a Bonferroni correction. P-values of 0.05

or smaller were considered significant in all tests. The
data were analyzed using the Statistical Package for
Social Science (SPSS Version 11 for Windows, SPSS,
Chicago, IL, USA) for statistical procedures.

Results
The total scores are presented in Figure 3. Total
scores in group DSF and group DS were significantly
higher than those in group NDS (p<0.05) at Ex. 2,
Ex. 3, and Ex. 4. Total scores tended to increase with
experience (from Ex. 1 to Ex. 4) in group DSF and
group DS. In contrast, there was no significant difference in total scores in group NDS between experiments. The results for preparation time are presented
in Figure 4. In Ex. 1, preparation time in group DS
was significantly longer compared to group NDS
(p<0.05). Moreover, preparation time in group NDS
was significantly shorter compared to group DSF and
group DS in Ex. 3 and Ex. 4 (p<0.05).
The scores for each item are shown in Figures
5-7. The percentage of undercut case is shown in
Figure 8. Scores for wall incline in group DSF and
group DS were significantly higher than those in
group NDS in all experiments (p<0.05). Scores for

occlusal reduction in Ex. 3 and Ex. 4 in group DSF

and group DS were significantly higher than that in
group NDS (p<0.05). In group DSF and group DS,
scores tended to increase with significant differences,
but there was no significant difference between experiments in group NDS.
The percentage of undercut cases differed between group NDS and groups DS or DSF (p<0.05).
In group DSF, undercut was found in 40 percent of
preparations at Ex. 1, in 13 percent at Ex. 2, in 6
percent at Ex. 3, and in none at Ex. 4, showing that
undercut cases decreased with experience. Similarly,
in group DS, undercuts were found in 46 percent of
preparations at Ex. 1, in 33 percent at Ex. 2, and in
6 percent at both Ex. 3 and Ex. 4. However, in group
NDS, undercuts were found in 77 percent, 84 percent,
84 percent, and 53 percent of preparations at Ex.1
through Ex. 4, respectively.
Damage to mesial and distal adjacent teeth did
not differ significantly among the three groups in any
experiments (p>0.05). However, in the case of mesial
adjacent teeth, there were significant differences between Ex. 1 and Ex. 3 in group DS and group NDS
(p<0.05). Damage to distal adjacent teeth in group
DS significantly decreased with experience (p<0.05).
Scores for margin location in group DSF and group
DS were significantly higher than those in group NDS

Figure 3. Average of total scores for PFM crown preparation in each weekly experiment in each experimental group
Note: Total scores were addition of each evaluation item. Data are represented as meanSD.

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Journal of Dental Education Volume 77, Number 6

Figure 4. Average time required for PFM crown preparation in each weekly experiment in each experimental group
Note: Data are represented as meanSD.

in Ex. 4 (p<0.05). Scores for chamfer width, wall

smoothness, finish line continuity, inter-proximal
clearance resistance, and retention were not different
among the groups and did not significantly change
with experience in any of the three groups (p>0.05).

Discussion
The use of VRS in dental education has
increased over the last decade.24,27 As reported in
previous studies, VRS can provide advantages such
as self-evaluation, objective evaluation, and faster
acquisition of skills.18,22,27 Our study clearly indicated
the efficacy of instructions provided by VRS on the
quality of preparations performed by the students.
Students who used the simulations earned higher total
scores and needed longer time to prepare a tooth than
students who did not use the DentSim VRS. Scores
for occlusal reduction and wall incline were higher
in the DentSim groups than the non-DentSim groups.
Regardless of the instructor feedback, students using
VRS were able to prepare PFM crowns with fewer
undercuts than those not assisted by VRS.
The higher scores in group DSF and group DS
compared to group NDS indicate the effectiveness

June 2013 Journal of Dental Education

of technical training with VRS, because students

in group DSF and group DS were able to see their
preparation visually and quantitatively. The result
that there was no difference in total scores between
group DSF and group DS suggests that real-time
error messages and instructions provided by VRS
during the preparation as well as the comparison
with the standard preparation in the evaluation mode
were adequate.
In this regard, it has been reported that, with
the use of VRS, students may need less supervision,
and fewer instructors would be needed for the training process and feedback evaluations.28 Rees et al.
found that the DentSim could be used for training
without an instructor and had the advantage of allowing students to review self-preparation from various
perspectives.27 It should be noted that a significant
difference in the preparation time between DS and
DSF only at Ex. 1 may suggest that our students
needed more time to understand the error and the
evaluation on the monitor at their first exposure to
VRS in the absence of an instructor; therefore, instructor feedback may accelerate the learning speed
of students at the early stage of training by VRS.
Time is an important factor affecting the performance of a dental practitioner. While a shorter
787

Figure 5. Average scores for damage to mesial and distal adjacent tooth, margin location, and chamfer width in each
experimental group
Note: Points of damage to mesial and distal adjacent tooth deductions were made if present. Maximum points of margin location and
chamfer width were 10. Data are represented as meanSD.

time spent for preparation may bear advantages such

as less patient anxiety and an increased capacity of
patients to be served in a clinic, a possible association
between the time spent for a preparation and its quality should be considered. The psychomotor skills of
the dentist play a vital role in this regard. Preparation
times were shorter in group NDS than in group DSF
and group DS since the students performed preparation without having to follow VRS instruction or error
messages or stop cutting to check for the accuracy of
their work. On the other hand, significantly inferior
outcomes of the NDS group suggest that the shorter
preparation times in these cases cannot be considered
as an advantage. Scores for wall incline were higher
in group DSF and DS than group NDS in the four experiments, suggesting it is a major advantage of VRS
for students without clinical experience to be able to

788

confirm the taper during the procedure. Using VRS,

students can obtain a 3D understanding of standard
images of the tooth during or after tooth preparation.
Scores for occlusal reduction in group DSF
and group DS were higher than those in group NDS.
Furthermore, repeated training increased the scores
of group DSF and group DS. However, repeated
training did not increase the scores of group NDS.
The amount of reduction in the occlusal site had a
direct effect on clearance, and use of VRS provided
a better sense of the amount of reduction required
and prevented overreductionthereby leading to
development of better skills. While distinguishing
between enamel and dentin during preparation of
a tooth requires a certain clinical skill level, on the
VRS monitor, dentin is colored yellow, and enamel
is white. Thus, students can visually understand the

Journal of Dental Education Volume 77, Number 6

Figure 6. Average scores for wall smoothness, wall incline, finish line continuity, and inter-proximal clearance in each
experimental group
Note: Maximum points of wall smoothness and inter-proximal clearance were 10. Maximum points of wall incline were 16, and maximum points of finish line continuity were 4. Data are represented as meanSD.

anatomical shape of the structure and appropriate

amount of reduction. Also, in evaluation mode, the
difference between the standard preparation and students preparation was shown quantitatively, which
guided the students.
The number of students who made undercut
in Ex. 1 to Ex. 4 differed between group NDS and
groups DS and DSF. A total of twenty-two sites are
evaluated for undercut by the DentSim, and only
a single undercut site is enough for the case to be
judged as a Fail. Without the use of VRS, the students
had difficulty performing the preparation even after
four experiments, as reflected by the similar scores in
group NDS for Ex. 1 to Ex. 4. It is worth mentioning
that the evaluation system of VRS is an objective
means of evaluating clinical skills, but the scoring
system may be too strict for novice students. Selection of the doctrine or customizing the parameters
for evaluation might be required.
June 2013 Journal of Dental Education

Iatrogenic damage to the adjacent, and possibly,

intact tooth is of a great importance in clinical practice today, as such damage, even superficially, may
cause further complications. In this study, it seemed
that it was difficult for novice students to understand
the positions of the mesial and distal adjacent teeth
and the bur by looking at the illustration on the monitor. The buccal margin location can be confirmed by
visual observation, but the locations of the mesial and
distal adjacent teeth and the lingual margin are difficult to observe even with a mirror and experience,
and advanced skills are needed. The scores hardly
differed between groups DSF and group DS because
the margin from any directions could be seen on the
VRS monitor in real-time. This suggests that the use
of the DentSim provided effective understanding of
the margin location. The scores for inter-proximal
clearance, retention, resistance, chamfer width, and
wall smoothness did not differ significantly among
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Figure 7. Average scores for retention, occlusal reduction, and resistance in each experimental group
Note: Maximum points of retention and resistance were 10. Maximum points of occlusal reduction were 20. Data are represented as
meanSD.

Figure 8. Percentage of undercut case in each experimental group

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Journal of Dental Education Volume 77, Number 6

the groups or experiments. It appears that, with regard

to these items, the conventional training had been as
effective as VRS.
Buchanan found that students who used feedback learning with VRS arrived at the same level of
performance faster than students who learned using a
conventional training program.29 Our study also indicated that, with repetition of training and evaluation by
the DentSim VRS, students could efficiently acquire
skills with a better overall performance outcome.
The effect of feedback contents provided by the
instructor needs to be considered in further studies.
In our study, the VRS messages were explained only
to the students in the DSF group, but students usually
receive technical advice during practice class. Further
experiments and considerations are needed for the
evaluation criteria and points reduction in the VRS.
Especially, additional studies are needed to compare
students performance using both faculty evaluation
and DentSim evaluation. VRS may be an effective
means not only for students, but also for practicing
dentists. Wierinck et al. showed that the VRS was
effective for training of dental specialists.30 Future
tasks include a shift from conventional model training
to computer-based learning using VRS. However,
the cost of the system is another issue. The VRS is
expensive, and purchasing several units for use by
all the students may be beyond the financial ability
of many dental institutions. Moreover, as indicated
by Quinn et al., routine maintenance was needed for
tuning and installation of the equipment.31
Based on the results, our study found that
DentSim with access to its VRS evaluation was
effective for PFM crown preparation training. The
presence of the instructor did not result in significant
difference when VRS was used for training, while it
shortened the preparation time at early stages. Combination of conventional preparation training and the
use of VRS can be a more effective training approach
that produces a major improvement in clinical skills.

REFERENCES

1. Kikuchi M. The Japanese system of dental clinical training. Prosthodont Res Pract 2007;6:78-80.
2. Torii Y. Current status and future directions in dental
clinical education. J Okayama Dent Soc 2007;26:75-81.
3. Araki K. The status of education before graduation. J
Japan Dent Assoc 2006;58:1080-5.
4. Seymour NE, Gallagher AG, Roman SA, OBrien MK,
Bansal VK, Andersen DK, Satava RM. Virtual reality
training improves operating room performance: result
of randomized double-blinded study. Ann Surg 2002;
236(4):458-63.

June 2013 Journal of Dental Education

5. Zyda M. From visual simulation to virtual reality to games.

Inf Sci Inst 2005;38:25-32.
6. Larsson JE, Hayes-Roth B, Gaba DM, Smith BE. Evaluation of a medical diagnosis system using simulator test
scenarios. Artif Intell Med 1997;11(2):119-40.
7. Reinig KD, Spitzer VM, Pelster HL, Johnson TB, Mahalik
TJ. More real-time visual and haptic interaction with anatomical data. Stud Health Technol Inform 1997;39:155-8.
8. Taffinder N, Sutton C, Fishwick RJ, McManus IC, Darzi
A. Validation of virtual reality to teach and assess psychomotor skills in laparoscopic surgery: results from randomized controlled studies using the MIST VR laparoscopic
simulator. Stud Health Technol Inform 1998;50:124-30.
9. Colt HG, Crawford SW, Galbraith O 3rd. Virtual reality
bronchoscopy simulation: a revolution in procedural training. Chest 2001;120(4):1333-9.
10. Rogers DA, Regehr G, Yeh KA, Howdieshell TR.
Computer-assisted learning versus a lecture and feedback
seminar for teaching a basic surgical technical skill. Am
J Surg 1998;175(6):508-10.
11. Issenberg SB, McGaghie WC, Hart IR, Mayer JW, Felner
JM, Petrusa ER, et al. Simulation technology for health
care professional skills training and assessment. JAMA
1999;282(9):861-6.
12. Ota D, Loftin B, Saito T, Lea R, Keller J. Virtual reality in
surgical education. Comput Biol Med 1995;25(2):127-37.
13. Seipel S, Wagner IV, Koch S, Schneider W. Oral implant
treatment planning in a virtual reality environment. Comput Methods Programs Biomed 1998;57(1-2):95-103.
14. Welk A, Splieth C, Seyer D, Rosin M, Siemer M, Meyer
G. German dental faculty attitudes towards computerassisted simulation systems correlated with personal and
professional profiles. Eur J Dent Educ 2006;10(2):87-95.
15. Al-Jewair TS, Qutub AF, Malkhassian G, Dempster LJ.
A systematic review of computer-assisted learning in
endodontics education. J Dent Educ 2010;74(6):601-11.
16. Urbankova A. Impact of computerized dental simulation
training on preclinical operative dentistry examination
scores. J Dent Educ 2010;74(4):402-9.
17. Rose JT, Buchanan JA, Sarrett DC. The DentSim system.
J Dent Educ 1999;63(5):421-3.
18. LeBlanc VR, Urbankova A, Hadavi F, Lichtenthal RM.
A preliminary study in using virtual reality to train dental
students. J Dent Educ 2004;68(3):378-83.
19. Fakhry A, Dehkordi-Vakil FH. Video-assisted clinical
instruction in dentistry (VACID) enhances real-time
visualization of clinical procedures. Eur J Dent Educ
2007;11(4):238-44.
20. Steinberg AD, Bashook PG, Drummond J, Ashrafi S,
Zefran M. Assessment of faculty perception of content
validity of PerioSim, a haptic-3D virtual reality dental
training simulator. J Dent Educ 2007;71(12):1574-82.
21. Marras I, Nikolaidis N, Mikrogeorgis G, Lyroudia K, Pitas
I. A virtual system for cavity preparation in endodontics.
J Dent Educ 2008;72(4):494-502.
22. Feeney L, Reynolds PA, Eaton KA, Harper J. A description of the new technologies used in transforming dental
education. Br Dent J 2008;204(1):19-28.
23. Welk A, Maggio MP, Simon JF, Scarbecz M, Harrison JA,
Wicks RA, et al. Computer-assisted learning and simulation lab with 40 DentSim units. Int J Comput Dent 2008;
11(1):17-40.

791

24. Welk A, Splieth C, Wierinck E, Gilpatrick RO, Meyer G.

Computer-assisted learning and simulation systems in
dentistry: a challenge to society. Int J Comput Dent 2006;
9(3):253-65.
25. Esser C, Kerschbaum T, Winkelmann V, Krage T, Faber
FJ. A comparison of the visual and technical assessment
of preparations made by dental students. Eur J Dent Educ
2006;10(3):157-61.
26. Yasukawa Y. The effectiveness of cavity preparation
training using a virtual reality simulation system with or
without feedback. Kokubyo Gakkai Zasshi 2009;76(2):
73-80.
27. Rees JS, Jenkins SM, James T, Dummer PM, Bryant S,
Hayes SJ, et al. An initial evaluation of virtual reality
simulation in teaching preclinical operative dentistry in
a UK setting. Eur J Prosthodont Restor Dent 2007;15(2):
89-92.

792

28. Jasinevicius TR, Landers M, Nelson S, Urbankova A. An

evaluation of two dental simulation systems: virtual reality
versus contemporary non-computer-assisted. J Dent Educ
2004;68(11):1151-62.
29. Buchanan JA. Experience with virtual reality-based technology in teaching restorative dental procedures. J Dent
Educ 2004;68(12):1258-65.
30. Wierinck E, Puttemans V, Swinnen SP, van Steenberghe
D. Expert performance on a virtual reality simulation
system. J Dent Educ 2007;71(6):759-66.
31. Quinn F, Keogh P, McDonald A, Hussey D. A pilot study
comparing the effectiveness of conventional training and
virtual reality simulation in the skills acquisition of junior
dental students. Eur Dent Educ 2003;7(1):13-9.

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