Kaohsiung Journal of Medical Sciences (2018) 34, 243e248

Available online at www.sciencedirect.com

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journal homepage: http://www.kjms-online.com

Review Article

Augmented reality (AR) and virtual reality (VR)

applied in dentistry
Ta-Ko Huang a, Chi-Hsun Yang b, Yu-Hsin Hsieh c,d, Jen-Chyan Wang e,f,
Chun-Cheng Hung e,f,*

a
School of Dentistry, Kaohsiung Medical University, Kaohsiung, Taiwan
b
Department of Biomedical Engineering, National Cheng Kung University, Tainan City,
Taiwan
c
Department of Business Administration, University of North Carolina at Greensboro,
Greensboro, USA
d
Department of Engineering Science and Ocean Engineering, National Taiwan University,
Taipei, Taiwan
e
Department of Prosthodontics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
f
School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung,
Taiwan

Received 7 November 2017; accepted 12 January 2018

KEYWORDS Abstract The OSCE is a reliable evaluation method to estimate the preclinical examination of
OSCE; dental students. The most ideal assessment for OSCE is used the augmented reality simulator
Dental simulator; to evaluate. This literature review investigated a recently developed in virtual reality (VR) and
Augmented reality; augmented reality (AR) starting of the dental history to the progress of the dental skill.
Virtual reality; As result of the lacking of technology, it needs to depend on other device increasing the
Dentistry success rate and decreasing the risk of the surgery. The development of tracking unit changed
the surgical and educational way. Clinical surgery is based on mature education. VR and AR
simultaneously affected the skill of the training lesson and navigation system. Widely, the
VR and AR not only applied in the dental training lesson and surgery, but also improved all field
in our life.
Copyright ª 2018, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

Conflicts of interest: All authors declare no conflicts of interests.

* Corresponding author. 100, Shih-Chuan 1st Road, Kaohsiung, 80708, Taiwan.
E-mail address: chuchh@kmu.edu.tw (C.-C. Hung).

https://doi.org/10.1016/j.kjms.2018.01.009
1607-551X/Copyright ª 2018, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

244
Introduction
With the increase in the elderly population and the
economic growth, the concept of oral health gradually
increased, and dental and dental health care issues are
increasingly important. Due to the high incidence and
prevalence of today’s global oral diseases, the global
market for oral medical equipment in 2016 was $ 23.99
billion up to 4.0% from 2015, and the market was expected
to reach $ 29.09 billion by 2020.2015e2020 growth rate was
up to 4.7%, coupled with the incidence of the poor than
other socio-economic groups. The oral disease has become
an important public health problem, and promote the
global oral medical market continues to grow.
In addition, according to World Health Organization
statistics show that more than 60% of school-age children
worldwide and nearly 100% of adults have dental caries
status, and 35e44 years of adult population, nearly 20%
suffering from severe teeth disease, follow-up will lead to
the possibility of missing teeth. As for the 65e74 year old
population, the total tooth loss rate is as high as nearly 30%
[1]. With the increase in the number of elderly population
and the increasingly aging society, coupled with the majority
of elderly people in the treatment rate is generally low. It will
lead to long-term sustained increase in oral medical needs.
Nowadays, there are a lot of skills about the progresses
in the computer-based technologies such as augmented
reality (AR) and virtual reality (VR). In the two kinds of
reality, AR is the first application began to widely use. AR,
in which 3D virtual objects are integrated into a 3D real
environment in real time. AR is to “virtualize” the virtual
image into the real space, creating a completely virtual
space around the user’s eyes to replace the real space. To
make the users see a world which have a real environment
and generated by the computer graphics over a real scene
[2]. And the VR offered the users a real, inside virtual 3D
model [3e5]. According to the display, to build a three-
dimensional, seemingly true virtual world in the user’s
eyes. Recently, VR also designed head mount display with
special glasses to cover the user’s surrounding vision to
achieve the interaction situation.
With the increasing demand for dental implants, the
dentist-related faculties or post-graduated year (PGY) pro-
fessional competencies, clinical training and experience
accumulation are more important, and these technologies
are directly reflected in the school’s education. Through the
complete education and training with realistic exercises and
assessments, in order to training a dentist. Therefore,
whether it is on the education side or the clinical side,
increasingly mature technology development developed by
the auxiliary products will become more and more important
role in the surgery and education training process.
The history of dentistry
The history of dentistry is almost as long as the history of
human civilization. The progress of science and technology,
the application of technology used in the dental became
more and more mature. From the initial, using pliers to
remove the tooth, wire to lock loose teeth, and the dental
appliance and dental bridge. To the beginning of the 17th and
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T.-K. Huang et al.
18th century, using the tooth filling [6], gradually developed
to the initial bone as a denture concept to replace the loose
teeth. To use the tooth sets of metal wire and fixed appliance
techniques to correct the tooth position [7]. Until today,
dental expertise is currently used to prevent and treat
common oral diseases, namely dental caries and periodontal
disease, and the field also includes common repair, extrac-
tion, implant, root canal therapy and calculus removal.
Nowadays, dentists in the United States and European
countries must pass both written and technical examina-
tions before obtaining a license. Dentistry in Japan
and China also has fully implemented the above mentioned
examination policies. In view of this, enough practice,
professional knowledge in medical and dental colleges. The
better way of learning is without question a developing
trend for global dental education. Learning educational
equipment and method built around such technology will be
a must-have for dental universities around the world.
Informative technological advances in
dentistry
With the advanced development of Information Technology
(IT), dental solutions lead by computer and internet tech-
nologies have made significant progress all over the world.
Digital dental solutions will be the trend for the profes-
sional dental field in the future. The rapid development of
digital dental solutions has been applied in both the clinical
dental field as well as the dental education field. This trend
will gradually challenge both traditional dental clinical
practices and dental education learning methods.
With the medical image of the increasingly mature can
help physicians to identify the patient’s affected area and
to make a different cure. The new technology which
assisted the doctor has gradually been mature. The Image-
guided therapy (IGT) [8,9] and Image-guided interventions
(IGI) technology development [10e15], the image recogni-
tion and location of tracking system [16], coupled with
computer computing [17], combined computed tomogra-
phy, position tracker, display and PC to achieve tracking
location and surgical instruments immediately. By calcu-
lating the position of the medical images and surgical tools
[13], to provide more accurate accuracy in the surgical
position or learning lesson Recently, the current of article
about the nerve surgery published in PubMed more than
1400 [18]. In the nerve surgery also combined with the
above technology to achieve the effect of surgical real-
time. And because good image clarity will affect the
overall system of precision [19], medical imaging such as CT
technology advances, with a good tracking system also
reduces the risk of surgery and mistakes [12].
Educational applications of dentistry
Dr. John M. Harris opened the world’s first dental school in
Bridge, and helped establish the dental establishment as a
health career [13]. The school was opened on February 21,
1828 and is now the Harris Dental Museum [10]. Studies
have shown that graduates who graduated from different
countries [11] or different dental schools may have

AR and VR applied in dentistry
different clinical decisions for the same clinical condition
[12]. This means that in each country or school has its own
teaching and scoring methods. The primary issue about VR
and AR that to achieve the standard score way can be
standardized to facilitate student learning and practicing.
Now there are several systems and devices using VR and
AR [Table 1] [20], through the tracking system to achieve
handpiece and the screen synchronization, the character-
istics of the system equipment and comparison as
follows:Which DentSim is a complete system that in-
corporates VR and AR with its system included ergonomic
postures, instant feedback, exam simulation; direct trans-
fer of data to programmer and the system can be used in
the campus [20,21]. According to the system with VR and
AR not only integrate systems for learning and teaching
from an organizational perspective but also training skills
and improve the hand-eye coordinate [20,22]. The results
that system can improve the users correct the posture and
skills. And some prove showed that lots of the information
technology about VR and AR can train the users and make
them familiar with the system, skill and the lesson [23,24].
A system with VR and AR would become an educational tool
to make the students learn by themselves and some reports
proved that it can decrease faculty time by fivefold when
compared to traditional preclinical teaching methods
[25e27].
A complete VR and AR system in the hardware, there are
the teeth model, handpiece with the motor, different
brand of the burs and the air and water in-and-out. In the
software, it included the simple registration to make the
position of the instruments in the system and the real-time
tracking with correct accuracy. And it could offer different
lessons to let the students learn. A different lesson included
cavity preparation, crown and bridge and access prepara-
tion. According to different lessons may make the students
and PGY practice and be familiar with different symptoms.
Which another system, CDS-100, designed by the EPED
Inc. Computerized Dental Simulators is dental training sys-
tems applied with new technology such as VR and AR. This
technology provides the best computer training system for
dental students and PGY dentists in need of self-training.
Some advantages are as followed:Optical positioning system
provides 3D real-time accurate feedback of optimal teeth’s
angle, depth, and abundant software lessons (Operative
Dentistry, Endodontics, Crown and Bridge and Pedodontics)
provided students easy self-learning and practicing with
digital guide and simulations. Courses & Lessons can be
customized and designed as well as upgraded for specific
projects. Abundant accessories included the system, such as
tooth model, teeth, different brand burs, manikin chair,
Table 1 Comparison of dental simulators modified from: Elby Roy 2017.
PerioSim
Ergonomic postures No
Instant feedback No
Exam simulation Yes
Direct transfer of data to convenor/tutor Not
Teeth used Animated
Right and left operation Available
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245
shadow-less lamp and the posture evaluation system. And
the brand of the tooth, tooth model also can be used in the
system. According to another system, the Implant Real-time
Imaging System (IRIS), the doctors also can be offered the
complete education and experience about the implantology
and clinical treatment. Objective Structured Clinical Exam-
ination (OSCE) incorporated into the operative dentistry
software curriculum. With a Computerized-Objective Eval-
uation System, teachers can set up and highlight the score
percentage with easy way. Teachers can evaluate students’
learning status through digital reports to further strengthen
students’ learning objectives. Evaluation reports with figures
and descriptions offer easy self-learning and comparison
studies to improve clinical practice and precision. And ac-
cording the record, students can review the progress and find
the mistake to improve the skills. In the lesson, broadcasting
function provides teachers a way to easily present and
demonstrate to observing students via remote connect.
Broadcasts can be done in real-time or at the student’s
convenience. Broadcast and playback features provide an
effective solution to solve the imbalance ratio between
teachers and students, as well as provide an educational
tool for college assessment and improvement rankings.
Through the digital dental simulators and clinical environ-
ment, it is easy for students’ to self-practice, allowing them
to gain crucial clinical experience and precision.
Another system, Moog Simodont Dental Trainer, is also a
training system for dental schools. The system can help
students progress faster and realize the progress, also can
offer the teacher plan students work efficiently and track
the students’ progress. The system target is that training
the students’ skill such as removing tooth decay, preparing
crowns with different dental burrs. Customized cases can
be created and students’ work traced and evaluated by
software and teachers. Moog Simodont Dental Trainer
combines Moog’s expertise in haptic technology and ACTA’s
(Academic Center for Dentistry in Amsterdam) experience
in dental education to help students practice more
efficiently and learn faster.
These three systems have their features, like Moog,
according to competence oriented with immediate feed-
back, no water lines, plastic teeth and no burr consump-
tion. And such as CDS-100 and DentSim, by the visible
device, the users can see and use the real handpiece and
teeth to learn and compare the visual and the reality teeth.
Such like CDS-100 has a OSCE and objective evaluation
(Fig. 1). The real-time observation in the visual and real
teeth, customized and abundant lesson, high accuracy and
evaluation are a good and standardized tool for the all
students and PGY.
CDS DentSim IDEA Simodont
Yes Yes No Yes
Yes Yes Yes Yes
Yes Yes No Yes
Yes Yes Yes Yes
Animated Plastic teeth Animated Animated
Yes Available Available Available

246
Figure 1. Difference between Augmented reality (AR) and Virtual reality (VR).
Clinical application of dentistry
With the development of dental technology, the system
combined the surgical instruments, tracking system, med-
ical images and computer became to the real-time navi-
gation technology [28]. The tracking system has a different
component to composed, and according to the work of
component distinguish different types, such as electro-
magnetic and optical tracking system [29e31]. At first, the
navigation system is not mature enough to exceed
the stereolithographic surgical guide of the accuracy. The
method of the surgical guide expressed high precision than
the navigation system [32]. The position or place of the
registration is important for the accuracy of the navigation
system. The wrong place would produce the larger error. So
according to the intended use of the navigation system,
there are the different ways of registration [33]. Although
the navigation played an important role but also the high
quality medical images would make the clear information in
the patient. High quality medical images would increase
the rate of the surgery [19]. There are some reasons to
affect the accuracy of the navigation system, such as in-
tegrated component, medical images accuracy, surgical
tracking unit, registration accuracy and targeting. Many
reasons because of the progress of the visual reality, they
became to be overcome [28]. Currently, the navigation
system became mature, the acculturate accuracy
expressed better expression than the surgical guide [34].
There is a mature system, IGI (DenX Advanced Dental sys-
tem), showed good expression in the dental surgery
[28,35,36]. It played an important role in the dental
implant technology. Especially, it is necessary to ensure the
success rate and decrease the risk of dental implants.
Traditional dental implants must be local anesthesia, and
the scalpel flap treatment. It needs to wait for 3e4 months
after surgery until the wound healing in order to install
dentures, and because the dental inconvenient, resulting in
occlusion dysfunction occurs. After the navigation system
and the advanced development in the surgical instruments,
it can be through the pre-surgical plan to adjust and plan a
precise placement of the implant, not only greatly shorten
the operation time because of the small wound or even the
flapless surgery [35], but also accurately predict and avoid
the nerve. By the way, there are some cases about inves-
tigating the patient using the navigation system, the situ-
ation of the wound and the implant position. As the report,
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T.-K. Huang et al.
after one year, the situation of the recovery is good [37].
Another system, Iris-100 (Implant Real-time Imaging sys-
tem), designed by the EPED Inc., also can achieve the same
function like IGI. According to CT images, Iris-100 can make
the images dynamic to control the situation in real-time in
the implant region. The Iris-100 system monitored the
drills’ depth and angle to achieve the best effect in the
lowest risk. By the CT images, doctors can do the pre-
surgical planning which can lead the drills’ position in the
surgery. Abundant customized hand piece and drills, tissue
punch also combined and applied in the navigation to
achieve the special surgical case and flapless surgery.
Navigation system is the best assistant tool, by the process
of guiding system, you can clearly distinguish the location
of the implant, and the direction and depth. To reduce the
pain of patients due to surgery, although the computer
navigation may not be 100% accurate, there is need to
professional physicians on-site real-time monitoring,
through a wealth of experience, and the risk of the surgery
would decrease.
VR and AR combined the tracking system in
real-time in the surgery
The skill of the visual reality became mature, and more and
more VR and AR showed on the educational and surgical
field. The development of reality devices allow the user
to combine the medical information, medical data and
incorporate these data visualized. It can provide more clear
information and make the users improve safety and lower
risk [38]. Although the visual reality and augmented reality
in the dental field is not enough common, in other field
developed much better, such as the neurosurgery and cra-
nial surgery [39]. The users can use the Head Mount Display
(HMD) display to see the medical information and images
combined to the surgery [40]. And it can decrease the
surgical risk much better than the common visual reality.
Summary
The AR or VR simulators with direct feedback and objective
evaluation function may become an important tool in the
future of dental OSCE. The development of the VR or AR is a
good tool for our society. Not only applied to the education,
but also developed in the clinical treatment. We believe

AR and VR applied in dentistry
that in the future the VR and AR training and lesson can
spread and apply to the every department of dentistry to
make the student and PGY train their skill by themselves.
And because of the complete education and training, in the
surgery would decrease the risk and create the safety sur-
gical environment. And in the surgery, the visible can
combined the accurate medical images, tracking system,
targeting, registration and computed even the HMD system
or AR, to help the physicians execute the surgery.
Depending on the physicians’ experience and the complete
hardware and software, it would build a trustable relation
between the patients and doctors.
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