Virtual Reality-Based System for Training

in Dental Anesthesia

Cléber G. Corrêa1, Fátima de Lourdes dos Santos Nunes2 , and Romero Tori1
1
Escola Politécnica da Universidade de São Paulo, Interactive Technologies
Laboratory, Sao Paulo, Brazil
cleber.gimenez@usp.br
2
School of Arts, Science and Humanities, University of Sao Paulo, Laboratory of
Computer Application for Health Care, Sao Paulo, Brazil

Abstract. This paper presents the development and preliminary evalu-

ation of a Virtual Reality-based system for training in dental anesthesia.
The development focused the simulation of an anesthesia procedure task.
The evaluation involved graphic and haptic issues and had the presence
of experts in the dentistry area. The assessment aimed at attributes that
may influence the human-computer interaction, hindering realism, an im-
portant challenge in systems of this type. The attributes selected were:
the update rate, the appearance of the virtual models and the number
of viewpoints of the virtual environment, as well as the characteristics of
the haptic device. Despite constraints were found, in the perception of
the experts, the system may provide realism and help with the training
of certain tasks.

Keywords: dental anesthesia, human-computer interaction, Virtual

Reality.

1 Introduction

Systems based on Virtual Reality (VR) are widely used in the health area,
especially in the training context, for acquiring of knowledge and sensorimotor
skills.
This may be related to the benefits provided by VR, such as: reducing risks
to patients due to unsuccessful procedures, avoiding damage to health [1]; in-
creasing the safety of novices, who can practice several times before dealing with
real patients [2] [3] [4]; automatic evaluations of performance [5] and repeated
training.
Moreover, benefits also include levels of training, situations and degrees of
difficulty [6]; VR may minimize or eliminate costs involved in maintaining phys-
ical laboratories, which can count on cadavers or animals. Although cadavers
and animals provide the physical presence, cadavers present physiological dif-
ferences and animals have divergences in anatomy when compared to human
beings. Additionally, their use involves ethical issues [1].

R. Shumaker and S. Lackey (Eds.): VAMR 2014, Part II, LNCS 8526, pp. 267–276, 2014.

c Springer International Publishing Switzerland 2014
268 C.G. Corrêa, F. de Lourdes dos Santos Nunes, and R. Tori

Another benefit of VR is flexibility, because mannequins, for example, allow

physical presence; however, they include limitations in the physiological replica-
tion and anatomical variation [1].
A procedure that does not enjoy such benefits yet is the training for dental
anesthesia administration, especially the procedure to block the inferior alveolar
nerve [7]. This procedure presents a high number of failures and the novices
commonly train in their colleagues [8].
Therefore, this paper presents the development and preliminary experiments
of a VR system for training in dental anesthesia. An important challenge in
VR systems is the degree of realism, commonly defined by subjective tests with
experts [9]. The realism in this context is directly influenced by the human-
computer interaction, including the haptic approach, which plays an important
role in applications of this type.
The paper is organized as follows: in Section 2, the main related works are
described; Sections 3 and 4 present the implementation of the system and the
experiments, respectively; in Section 5 the results, and finally, the conclusions
in Section 6.

2 Related Work
There are a number of simulators for dental procedures [10] [11] [12] [13] [14]
[15] [16] [17], but just one virtual training system for the purpose related to this
work, which was not formally assessed [18].
However, as the procedure to be simulated involves needle insertion, a set of
similar training systems can be mentioned. Table 1 presents the main works,
including the procedure, the region of the body and whether the procedure is

Table 1. Needle insertion procedures [8]

Number Procedure Target region MI

1 Anesthesia [19] [20] Spin No
2 Biopsy [21] - Yes
3 Biopsy [22] - No
4 Biopsy [23] Lumbar No
5 Biopsy [24] Prostate Yes
6 Biopsy [25] Thyroid Yes
7 Brachytherapy [26] Prostate Yes
8 Catheter [27] - Yes
9 Chinese acupuncture [28] - No
10 Epidural anesthesia [29] [30] Spinal No
11 General [31] [32] - Yes
12 Regional anesthesia [33] Inguinal No
13 Regional anesthesia [34] - No
14 Suturing [35] - No
15 Vertebroplasty [36] Spinal No
 Virtual Reality-Based System for Training in Dental Anesthesia 269

aided by Medical Images (MI). The term General in the field Procedure means
that the needle insertion is not restricted to a specific procedure. The hyphen (-)
indicates that the paper does not present the information or it may be employed
in several regions.
Line 8 in Table 1 lists the insertion of catheters, which are procedures initiated
for the insertion of a kind of needle. Moreover, it is worth noting that there are
other more complex minimally invasive procedures that start with the insertion
of certain instruments, as laparoscopy, endoscopy, arthroscopy and endovascular
procedures [1].

3 Development of the System

The development of the system started with a requirements elicitation conducted
in collaboration with an dentistry learning institution (School of Dentistry of
Bauru - University of Sao Paulo). Students and professors of the institution
provided videos and details about the dental anesthesia procedure, and also
allowed us to watch real procedures [8].
Considering that the simulator is based on VR, the human-computer inter-
action is a fundamental characteristic. According to [37], the human-computer
interaction in virtual environment may be classified into the following categories:
navigation, selection and manipulation, control system and symbolic input.
Our system considered two categories:

– Navigation - visualization of the models from several viewpoints using the

keyboard, allowing the study of the anatomy of the head (bones, blood ves-
sels, gums, muscles, tongue, teeth and nerves) in various angles of vision;
– Manipulation - effected through a device, typically a specific device1 , which
offers a haptic sensation and captures movements of position and rotation
[38], being used to modify synthetic models that represent instruments (sy-
ringes or needles).

There are several types of haptic feedback, such as [39]: force, tactile, kines-
thetic and proprioceptive. In this context, the force feedback was adopted due
the task and characteristics of the device. The force feedback was defined as a
constant value to the anatomical structures.
In the second step, the system was implemented using a VR framework [40]
which allows: (1) - loading 3D (three-dimensional) synthetic models to represent
anatomical structures and instruments; (2) - specifying properties of the models
(elasticity, viscosity and thickness); (3) - detecting collision among models; (4)
- deforming models, modifying their shapes; and (5) - supporting devices for
interaction, including haptic device and dataglove. Figure 1 allows observing the
screen of the training system, containing anatomical structures and syringe.
Due to the complexity of its development, in the third step, the procedure was
segmented into tasks. The target task is the correct manipulation of the syringe,
1
http://www.dentsable.com/haptic-phantom-omni.htm
270 C.G. Corrêa, F. de Lourdes dos Santos Nunes, and R. Tori

Fig. 1. Screen of the training system

encompassing certain parameters: velocity of manipulation, regions reached by

the needle, movements of translation and rotation of the syringe and duration
of the injection.
During the insertion, the needle must be in an angle of about 45 degrees;
the motions of the syringe must be slow; the needle cannot reach nerves, bones,
blood vessels and skin; and it must remain in the tissues some minutes before
extracting, simulating the time for anesthetic injection. Thereby, the user could
manipulate the syringe using the haptic device and could navigate in the envi-
ronment using the keyboard.
In this step, an adaptation of the haptic device also was made. The adaptation
consisted in replacing the pen with Carpule syringe (Figure 2) [8]. The Carpule
syringe is the instrument used by dentists in the anesthesia procedure. For the
tests, different versions of the same system were generated, considering several
attributes.

4 Experiments Description
As the degree of realism is usually defined by experts in the area, to evaluate
the system, experiments were made with a group of experts of the dentistry
institution mentioned, comprising 2 teachers and 2 students who had already
accomplished the procedure. The experiments considered two issues: graphic
and haptic, which directly influence the human-computer interaction.
Considering the experts as system users, the hypotheses to be corroborated
were: (1) users prefer the models with textures; (2) users prefer two viewpoints
to determine the position and rotation of the syringe, as well as the distance
between it and anatomical structures; (3) the maximum force provided by device
is not enough to simulate the needle insertion; (4) the workspace of the device is
not enough to capture all movements of the insertion task and (5) users prefer
the device adapted with the real syringe.
The graphic issue aimed at certain attributes, such as: the appearance of
the models (wire, color and texture - Figures 3, 4 and 5), and the number of
viewpoints (Figures 6 and 5).
 Virtual Reality-Based System for Training in Dental Anesthesia 271

Fig. 2. Adaptation of the haptic device replacing the pen with the Carpule syringe

Fig. 3. Virtual models in wire mode

The haptic issue dealt with examining the ergonomic attributes of the device
(shape of the manipulation “pen”, workspace and maximum force). The update
rate during the human-computer interaction was analyzed with several values
to verify the minimum value required for the task, being a critical point in the
haptic issue. The frequency values were decreased according to users’ perception,
identifying suitable delays in the haptic human-computer interaction.
In order to collect the users’ preferences questionnaires were used after ex-
periments. The task to be performed was detailed before experiments, including
the presentation of the training system.
272 C.G. Corrêa, F. de Lourdes dos Santos Nunes, and R. Tori

Fig. 4. Virtual models in colors

Fig. 5. Virtual environment with textures and presented in two viewpoints

Fig. 6. Virtual environment presented in one viewpoint

5 Results

After analyzing the answers, in the graphic issue the experts preferred the models
with textures and two viewpoints. The two viewpoints improved the orientation
 Virtual Reality-Based System for Training in Dental Anesthesia 273

in the virtual environment; however, the textures were not considered correlated
to reality.
In the haptic issue, the adaptation of the device was considered a positive
point because the pen of the device differs from the syringe, which compromises
realism. The experts highlighted the importance of the force feedback, and the
maximum force provided by the device (3.3 Newtons) was considered enough
to simulate the contacts with the anatomical structures, including bones, which
must offer the higher stiffness during the contact with the needle.
The capture and reproduction of the movements between the device and the
syringe in the virtual environment were considered suitable. The workspace of
the device (170 millimeters, 120 millimeters and 70 millimeters in the axes x, y
and z, respectively) was not considered enough, specially in the z axis.
A constraint identified was the direction of the force feedback because the
device provides three degrees of freedom for force feedback (axes x, y and z) and
the syringe must be inserted diagonally, making the force feedback impossible
in this position.
The experts did not want to use the navigation in the virtual environment,
opting for mere manipulation. Finally, it is worth noting that in the evaluation
of the update rate, the value of 40 Hertz did not affect the human-computer
interaction, generating acceptable delays.

6 Conclusion

Considering the results, hypotheses 1, 2, 4 and 5 were confirmed, because the

experts who participated in the experiment preferred the models with textures
(hypothesis 1), however, the textures should be improved; the experts preferred
two viewpoints to determine the position of the syringe and to orientate the ac-
tions inside the virtual environment (hypothesis 2); the workspace of the device
was not enough, which was only observed in movements in the z axes (hypoth-
esis 4), being resolved for reducing the distance between the syringe and the
anatomical structures; and the experts preferred the device adapted with the
real syringe (hypothesis 5).
According to the experts, the adaptation of the device provided a way to
hold the instrument as in the real world. Figure 2 shows how people usually
manipulate the device with and without the syringe.
Hypothesis 3 was rejected because the maximum force provided by the device
was considered enough; yet, as the device does not offer six degrees of freedom of
force feedback, considering the position of the models and the orientation of the
syringe, the direction of the feedback cannot be simulated. One possible solution
would be acquire a device that offers six degrees of freedom of force feedback.
Regarding to update rate, the haptic update rate is recommended to be about
1.000 Hertz, with some different cases, for instance, 300 Hertz and 550 to 600
Hertz [1]; nevertheless, the value of 40 Hertz was considered acceptable.
In summary, the degree of realism was considered satisfactory, showing that,
despite constraints were found, the system may currently contribute to training
274 C.G. Corrêa, F. de Lourdes dos Santos Nunes, and R. Tori

of an anesthesia procedure task. Future works include an analysis of the low

update rate and the perception of the experts; force feedback values according
to properties of each anatomical model, including sets of models; tests with the
participation of more experts and more realistic textures for the models.

Acknowledgements. The authors would like to thank CAPES (National Coun-

cil for the Improvement of Higher Education Personnel) for the scholarship to
Cléber Gimenez Corrêa, INCT-MACC (National Institute of Science and Tech-
nology - Medicine Assisted by Scientific Computing) and Design Group in Health
Care - Pediatric Dentistry (School of Dentistry of Bauru - University of Sao
Paulo).

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