dentistry journal

Article
Efficacy of Virtual Preparation Simulators Compared to
Traditional Preparations on Phantom Heads
Lea Stoilov 1,† , Fabian Stephan 1,† , Helmut Stark 1 , Norbert Enkling 2 , Dominik Kraus 1 and Milan Stoilov 1, *

1 Department of Prosthodontics, Preclinical Education and Dental Materials Science, University of Bonn,
53111 Bonn, Germany
2 Department of Reconstructive Dentistry and Gerodontology, School of Dental Medicine, University of Bern,
3012 Bern, Switzerland
* Correspondence: [email protected]; Tel.: +49-228-287-22436
† These authors contributed equally to this work.

Abstract: Background: Virtual simulators are increasingly being introduced in dental education. This
study investigates whether virtual simulators offer comparable or superior educational efficacy when
compared to traditional phantom simulators. Materials and Methods: Participants were randomly
allocated into groups: Virtual Preparation (SIM; n = 30) and Traditional Preparation (FRA; n = 30).
Students were tasked with preparing tooth 36 for a full-cast crown during free practice for four days.
Faculty staff provided feedback to both groups. Examinations were administered and graded by
three examiners (preclinical and clinical consultants and a dental surgery consultant). Additionally, a
survey was conducted to assess each training concept. Results: The FRA group achieved significantly
better grades in the preparation exam evaluations by all three examiners, compared to the SIM group.
Interrater reliability showed only moderate agreement, with the clinical examiner giving better grades
than the other two. The questionnaire results indicate that while participants managed with the
virtual system, they preferred the analog system for exams and patient preparation. Conclusion:
Virtual simulators do not seem to be as good when it comes to practicing for a preparation exam or
clinical preparation, especially for unexperienced students. However, they still appear to be useful as
an additional tool for introducing students to the topic of preparation.

Citation: Stoilov, L.; Stephan, F.; Stark,

Keywords: dental education; digital dentistry; SIMtoCARE; virtual simulation; HVRS
H.; Enkling, N.; Kraus, D.; Stoilov, M.
Efficacy of Virtual Preparation
Simulators Compared to Traditional
Preparations on Phantom Heads. 1. Introduction
Dent. J. 2024, 12, 259. https:// The progress of digital dentistry is increasingly making its way into dental education
doi.org/10.3390/dj12080259 and training, where digital workflows are replacing analog methods. A classic example
Academic Editor: Dorina Lauritano of this is the replacement of conventional impressions and lost-wax casting in practical
prosthodontic courses with intraoral scans and chairside milling of restorations. This shift
Received: 28 July 2024 allows students to familiarize themselves with modern technologies, while ensuring a
Revised: 8 August 2024
standardized quality of work by minimizing variations due to deficient material processing.
Accepted: 13 August 2024
The use of chairside systems, such as the CEREC® system (Dentsply Sirona© , Bensheim,
Published: 14 August 2024
Germany), marked the beginning of the digitization of dental education. In the preclinical
environment, it is employed as a self-assessment tool (PrepCheck® , Dentsply Sirona© , Ben-
sheim, Germany) and provides feedback on students’ preparations. However, conventional
Copyright: © 2024 by the authors.
phantom heads with attachable and detachable models and interchangeable plastic teeth
Licensee MDPI, Basel, Switzerland. are still required. Thus, this concept occupies a transitional position between the traditional
This article is an open access article training approach and an innovative, purely digital approach.
distributed under the terms and Based on experience, dental preparation for crown placement poses a challenging
conditions of the Creative Commons learning task for students in the foundational years of dental education. The learning
Attribution (CC BY) license (https:// process is time-consuming, and the initial results can be frustrating for both students and
creativecommons.org/licenses/by/ instructors. To address this issue, digital evaluation systems, such as PrepCheck® (Dentsply
4.0/). Sirona© , Bensheim, Germany), Compare (Planmeca© Oy, Helsinki, Finland), or Dental

Dent. J. 2024, 12, 259. https://doi.org/10.3390/dj12080259 https://www.mdpi.com/journal/dentistry

Dent. J. 2024, 12, 259 2 of 18

Teacher™ (KaVo© Dental, Biberach, Germany), have been implemented. These systems are
seen as software extensions within the corresponding scanning system, assisting students
in learning preparation techniques and, additionally, practicing digital impressions. In the
context of Computer-Assisted Learning (CAL), these systems can highlight initial rough
errors without contact with the faculty staff [1,2]. Students can learn autonomously or
through self-directed learning, engaging with the faculty staff at a higher skill level in
further inquiries. Park et al. [3] described them as “useful” for bridging the gap between
learning styles and supporting students’ self-assessment. Furthermore, students appreciate
immediate, objective, and, particularly, visual feedback on their deficiencies [4,5]. Rosen-
berg et al. [6] found that computer-assisted training is even superior, or at least equivalent,
to traditional methods. In a previous study by the authors, it was also demonstrated
that these systems appear to be equivalent, with the limitation that they cannot provide
feedback on how to approach tooth preparation, problem-solving, and ergonomics [7].
Although traditional phantom heads still represent the gold standard in training and
have been supplemented by modern self-evaluation systems, they cannot precisely simulate
the patient cases encountered in clinical practice. In addition, anatomical structures such
as a moving tongue can only be inadequately mimicked. Furthermore, dental education
standards expect the teaching of increasingly complex procedures or competencies that
can no longer be adequately taught using phantom heads, and might require the use of
modern digital systems [8].
Virtual systems (Haptic Virtual Reality Simulation, HVRS), such as the “Dente” (SIM-
toCARE, Vreeland, The Netherlands), can now virtually simulate most dental treatments.
This includes practicing simple measures as well as operative or prosthetic treatment
steps. Additionally, implant placement or even local anesthesia can now be practiced.
Furthermore, patient-specific cases can be incorporated after digitalization and practiced.
This is particularly useful for simulating treatment procedures in advance, before they are
performed on real patients. Undergraduate students initially learn operative exercises,
such as preparing cavities and, especially, teeth for receiving full crowns. Students could
gain their first experience in handling the handpiece and dental mirror. All of this occurs in
a more playful environment, one similar to a video game. They are gradually introduced to
dental practice through the virtual systems, starting with simple, less complex exercises for
hand–eye coordination. This approach could offer potential advantages for beginners, as
initial attempts to adequately prepare a tooth are often challenging for both students and
supervising faculty. The load on the faculty staff could be reduced at this level, as students
autonomously perform appropriate exercises and receive virtual feedback. Some studies
support virtual simulators as supplements in the preclinical environment, as students
seem to perform well with a virtual simulator. However, these systems cannot yet replace
phantom heads [9–11].
In universities and dental education, traditional phantom heads with plastic models
and teeth continue to be regarded as the gold standard. They are used both in practical
courses and in corresponding exams or state examinations. However, practice time is often
very limited and restricted to class times, and support is provided by the faculty staff.
Students often criticize this situation and demand the opportunity for free practice time [3].
Both points require additional staffing, which in turn increases costs. The possibility of
practicing autonomously in a dental simulation laboratory that is accessible around the
clock could provide a solution. Students would log in with a personalized identifier,
allowing tracking of which student worked at what time and for how long. HVRS systems
could be used for this purpose and enable free practice. The aspect of sustainability should
also be considered. HVRS systems generate less plastic waste, require no compressed air
and no suction, and do not waste water that subsequently needs to be treated.
This study aims to examine whether HVRS systems can be considered to be equivalent
to phantom heads. Specifically, we investigated their effectiveness in teaching crown
preparation and preparing students in an auto-didactic environment (free practice time) for
a crown preparation exam.
Dent. J. 2024, 12, 259 3 of 18

2. Materials and Methods

The present investigation was conducted at the Department of Prosthetic Dentistry,
Propaedeutics and Materials Science, Center for Dental, Oral, and Maxillofacial Diseases,
at the University Hospital Bonn. A total of 60 dental students (50 female and 10 male)
participated in this voluntary study.
Participants were contacted and recruited using printed flyers and social media. In-
formed consent was obtained from all students prior to the initiation of the study. Ethical
approval was obtained from the ethics committee of the medical faculty of the University
of Bonn (number 159/20).
Inclusion criteria were defined as follows:
- Students studying according to the new licensing regulations for dentists in Germany;
- Students in the 1st to 4th semester (equal skill level regarding tooth preparation);
- Students without preparation experience;
- Students who had not participated in the fixed prosthodontics preclinical course.
Upon registration, participants were randomly assigned a number from “1” to “60”
to ensure anonymous group assignment and evaluation. All participants first received an
introductory lecture to cover theoretical basics in preparation shapes and requirements,
materials science, ergonomics, and the operation of respective analog and digital simulators.
The study’s objective, detailed procedures, and tasks were explained, and any remaining
questions were clarified to ensure all participants had the same level of understanding.
After the introductory lecture, a preliminary exercise was conducted to ensure an
even distribution of initially skilled and less skilled participants within each group. All
participants had to prepare tooth 36, without neighboring teeth, on the ANKA-4V dental
model (Frasaco© , Tettnang, Germany), for a full-cast crown within two hours. Each student
had only one attempt; no repetition of the exercise was allowed if a tooth was improperly
prepared. Each participant was provided with a phantom workstation with accessories,
a high-speed handpiece (Expertmatic Lux E25L, KaVo Dental© , Biberach, Germany), and
the practice tooth. The ANKA-4V dental models, the phantom mask (Frasaco© , Tettnang,
Germany), basic dental instruments (mirror, probe, and tweezers), and the requested
preparation burs were part of the course materials from a previous course and were
brought by the participants. They were given guidelines for ideal preparation and a model
of the ideal preparation. The preparation margin was to be 0.5 mm supragingival with
a preparation angle of 4–6◦ or a convergence angle of 8–12◦ , respectively. The circular
substance removal was defined as 0.5 mm and the occlusal as 1 mm, with an aesthetic
bevel and functional bevel of 45◦ . These specifications also applied to the subsequent free
practice time and the preparation exam at the end of the study.
The prepared teeth were archived in a blinded manner in a box marked with the corre-
sponding student number, allowing for an anonymous evaluation of the tooth preparations
by a preclinical senior physician from the Department of Prosthetic Dentistry, Propaedeutics
and Materials Science at the Center for Dental, Oral, and Maxillofacial Diseases, University
of Bonn. The examiner could choose from the grades “good” = “+”, “satisfactory” = “0”,
and “poor” = “−”. This allowed the assessment of the students’ ability to execute a novel
and complex practical task. Based on this, participants were evenly divided into the Frasaco
group (FRA) (n = 30) and the SIMtoCare group (SIM) (n = 30).
After group assignment, students were given the opportunity to improve their prac-
tical skills through free practice and enhance their preparation of tooth 36 for a full-cast
crown. The FRA group worked with the ANKA-4V dental models (Frasaco© , Tettnang, Ger-
many) and an analog simulation workstation (Figure 1), as described before. The SIM group
performed the same training on the virtual preparation simulator “Dente” (SIMtoCARE,
Vreeland, The Netherlands) (Figure 2). Each group had a total of 32 practice hours over
four working days (8 h per day). On the fifth day, the preparation exam was conducted.
 After group assignment, students were given the opportunity to improve their prac-
tical skills through free practice and enhance their preparation of tooth 36 for a full-cast
tical skills through free practice and enhance their preparation of tooth 36 for a full-cast
crown. The FRA group worked with the ANKA-4V dental models (Frasaco©©, Tettnang,
crown. The FRA group worked with the ANKA-4V dental models (Frasaco , Tettnang,
Germany) and an analog simulation workstation (Figure 1), as described before. The SIM
Germany) and an analog simulation workstation (Figure 1), as described before. The SIM
group performed the same training on the virtual preparation simulator “Dente” (SIMto-
Dent. J. 2024, 12, 259 group performed the same training on the virtual preparation simulator “Dente” (SIMto-
CARE, Vreeland, Netherlands) (Figure 2). Each group had a total of 32 practice hours4 over
of 18
CARE, Vreeland, Netherlands) (Figure 2). Each group had a total of 32 practice hours over
four working days (8 h per day). On the fifth day, the preparation exam was conducted.
four working days (8 h per day). On the fifth day, the preparation exam was conducted.

Figure1.1. Phantom simulation

simulationunit
unitbyby Planmeca©©© (Helsinki,
(Helsinki, Finland) with
with mounted phantom
phantom head
Figure 1.Phantom
Figure Phantom simulation unit byPlanmeca
Planmeca (Helsinki, Finland)
Finland) with mounted
mounted phantomhead
head
and model (Frasaco©©, Tettnang, Germany).
©
and
andmodel
model(Frasaco
(Frasaco ,, Tettnang,
Tettnang,Germany).
Germany).

Figure 2. “Dente” simulator by SIMtoCARE (Vreeland, The Netherlands) with tablet, phantom
Figure2.2.“Dente”
Figure “Dente”simulator
simulator
byby SIMtoCARE
SIMtoCARE (Vreeland,
(Vreeland, The The Netherlands)
Netherlands) with tablet,
with tablet, phantom
phantom head,
head, and handpiece.
head, and handpiece.
and handpiece.

During free practice, students worked under realistic conditions with neighboring
teeth. To ensure equal opportunities, the FRA group had unlimited access to consumables
such as practice teeth, neighboring teeth, and gloves, allowing for an unlimited number of
repetitions. Throughout the practice period, all participants could seek constructive feed-
back and suggestions for improvement from the preclinical course staff as often as needed.
Additionally, participants could always view a plastic model of the master preparation of
tooth 36 to spatially visualize the improvement suggestions.
Dent. J. 2024, 12, 259 5 of 18

2.1. Use of the “Dente” Simulator

At the start of the free practice period, all participants in the SIM group were first
required to log into the “SIMtoCARE” (version number: 3779) learning software, using the
provided tablet, with their assigned username and password. They then needed to select
the “Prosthodontics” module and the “04-Crown” case. A dedicated course was created
in the SIMtoCARE software specifically for this study. Each participant was assigned
to this course, which contained only the “04-Crown” exercise, ensuring that only this
exercise could be selected and trained. The recommended instruments (handpiece, mirror,
and bur) were enabled, and all alternative instruments were hidden to avoid distractions
or deviations.
Upon successful selection, the dental model and the instruments to be used were
displayed in their original sizes on the three-dimensional screen. The user could interact
with the virtual dental model and perform the necessary preparation on tooth 36, including
tasks involving neighboring teeth and the opposing jaw, using the virtual representations
of the instruments in real time. A physical handpiece, a handle on the device to move the
dental mirror, and a physical foot pedal were available. Numerous supporting functions
were also available, including height adjustment of the device, customizable magnification
(1.0–4.5×) of the dental model, and the options to show/hide the opposing jaw, adjust the
light angle, and display the percentage of enamel and dentin removed during preparation.
Finally, the user could upload the result to the teaching staff by swiping right on the tablet
and pressing the “Submit” button.

2.2. Preparation Exam and Evaluation

On the last day of the practice blocks for each group, a final preparation exam was
conducted for all students, regardless of their practice group. All students had to prepare
tooth 36 for a full-cast crown, using neighboring teeth, on the Frasaco model ANKA-4V
(Frasaco© , Tettnang, Germany) within two hours under exam conditions. After the time
expired, teeth 35, 36, and 37 were submitted, marked, and stored in the corresponding
numbered box to ensure an anonymous, blinded evaluation by the teaching staff.
The prepared teeth were evaluated by three senior physicians from the Center for
Dental, Oral, and Maxillofacial Diseases at the University of Bonn, each with at least
15 years of experience in student teaching. The evaluators included two senior physicians
from the Department of Prosthetic Dentistry, Propaedeutics and Materials Science, one
teaching in the preclinical and the other in the clinical study section, who regularly assess
student preparations in their respective sections. The third examiner was a senior physician
in oral surgery, a field in which student preparations are not assessed in dental education,
providing a basis for an objective evaluation by reducing potential subjective influences
such as familiarity effects.
The evaluators independently rated the preparations, conducting the assessments at
different times and locations. They were provided only with the preparation results from
the final exam and the opposing jaw model, along with a uniform evaluation form with
predefined criteria validated in a previous study [7]. The grading criteria included possi-
bility of crown retention, substance removal, preparation angle, bevel, surface roughness,
potential undercuts, preparation margin, and lack of damage to neighboring teeth (Table 1).
The evaluators could grade “Good” = “+”, “Average” = “0”, and “Poor” = “−”. A sum
score was calculated for the final grade, with “+” equaling 5 points, “0” equaling 2.5 points,
and “−” equaling −1 point, corresponding to a grading scale from 1 = “very good” to
5 = “deficient” (German grading scale) (35 to ≤7) (Table 1). For the criterion “No damage
to neighboring teeth”, only “+” or “−” were available, with the examiner required to make
a clear decision. Even minor damage to neighboring teeth was considered an iatrogenic
injury and was marked negatively. The most important evaluation criterion was whether a
crown could be retained on the tooth, with “Yes” or “No” as the options. If this criterion
was rated negatively, 21 points were automatically deducted from the total score, making
“4” (sufficient) the highest achievable grade.
Dent. J. 2024, 12, 259 6 of 18

Table 1. Criteria assessed for evaluation of teeth prepared during the exam. Examiners had the option
to rate with “+” (yes), “−” (no) or “0” (neutral). A total grade from 35–0 points, based on responses
rated 1–5, could be awarded.

Assessed Criterion Score

Is a crown attachable? Yes/No
Circular Occlusal
Substance removal?
+/− or “0” +/− or “0”
Damage to adjacent teeth? +/−
Finish line quality? +/− or “0” +/− or “0”
Preparation angle? (Undercuts? Conicity?) +/− or “0” +/− or “0”
Surface roughness? +/− or “0” +/− or “0”
Grade scale Total grade
35 to 0|1 to 5

2.3. Assessment of the Systems

After the performance assessment, all participants were asked to complete an evalua-
tion form corresponding to their group (FRA or SIM) (Table 2). The evaluation aimed to
determine how intuitive or complicated the operation of each method was and whether the
students felt well-prepared for the final preparation exam through the respective training
methods. Additionally, students were asked if they would be interested in using the re-
spective training system in the future and to grade the system. The students could choose
from grades “1” to “5” for statements A to F (Likert scale), with “1” = “strongly agree,”
“2” = “agree,” “3” = “neither agree nor disagree,” “4” = “disagree,” and “5” = “strongly
disagree.” For statement G, the answers “1” to “5” were assigned weights correspond-
ing to the school grading system: “1” = “very good,” “2” = “good,” “3” = “satisfactory,”
“4” = “sufficient,” and “5” = “poor.” Additionally, participants could write down sugges-
tions for potential improvements in a free-text box.

Table 2. Questions handed out to the participants at the end of the study. Participants had the
opportunity to choose between “1” (strongly agree) and “5” (strongly disagree).

Statement 1 2 3 4 5
“Operating the Dente or Phantom
A
simulator was simple”
“Operating the Dente or the Phantom
B
simulator was complex”
“Practicing on the Dente or the Phantom
C
simulator improved my skills”
“In the phantom course, I would like to continue
D
training with the system I used in this study”
“The training system I used has prepared me well
E
for the preparation exam”
“With the training system and sufficient practice, I
F
feel capable of preparing a tooth on a patient”
G “Please evaluate the training system you used”
H “What would you like to improve?”
Dent. J. 2024, 12, 259 7 of 18

2.4. Statistical Analysis

To calculate the statistically necessary number of participants for the present investiga-
tion, the power analysis previously described in Stoilov et al. [7] was used. The present
authors assumed a type I error probability of 0.05, a standard deviation of 2.3 grades, and
a minimally detectable effect size of 1.5 grades (dRMSSE = 0.25). With a power of 80%, a
sample size of 35 per group was calculated. However, limited access to students led to a
maximum sample size of 30 participants per group (60 participants total). Considering
the maximum available sample size and maintaining the other parameters, a minimally
detectable effect size of 1.5 grades (dRMSSE = 0.4) was calculated for this study (SPSS
Statistics 27, IBM® , Armonk, NY, USA).
For statistical evaluation, the results from the aforementioned evaluation forms were
first descriptively compiled using “Microsoft Excel” (version number: 16.78.3 (23102801))
(Microsoft© Corporation, Redmond, WA, USA). Subsequently, statistical analysis and
visualization of the results in box plot diagrams were conducted using the statistics software
PRISM 10™ (GraphPad© Software, Boston, MA, USA). The significance was tested using
the Mann–Whitney U-test with an assumed significance level of α = 5%. The inter-rater
reliability was determined using the Friedman test, Dunn’s multiple comparison test, and
Fleiss’ Kappa.

3. Results
3.1. Group FRA versus Group SIM
All 60 participants completed the preliminary exercise, the free practice sessions, the
final exam, and the evaluation form. No drop-outs were documented. Table 3 shows the
scores given by the three evaluators and the score distribution within each group (mean,
SD, and median). The preclinical evaluator (Prosthodontics, VK) graded the participants
in the Frasaco group (FRA) with a median score of 2 (“good”; Mean: 2.93 ± 1.26), which
was better than those in the SIMtoCARE group (SIM), who received a median score of
4.5 (“sufficient”; Mean: 4.30 ± 0.85). Similarly, the clinical evaluator (Prosthodontics, KL)
gave comparable grades, with a median score of 2 (“good”; Mean: 2.20 ± 1.24) for the
FRA group and 4 (“sufficient”; Mean: 3.60 ± 1.43) for the SIM group. The oral surgery
evaluator (Surgery, OC) rated both groups one grade lower on average than the other two
raters. He assigned a median score of 3 (“satisfactory”; Mean: 3.0 ± 1.23) for the FRA group
and 5 (“poor”; Mean: 4.2 ± 1.06) for the SIM group. Statistical analysis assumed a normal
distribution of the grades. The evaluation from each examiner showed significantly better
scores in the Frasaco groups (VK: p < 0.0001; KL: p = 0.0003; OC: p = 0.0002) when applying
the Mann–Whitney U test (Table 4 and Figure 3).

Table 3. Tabular representation of the absolute grade frequency, median, mean, and standard
deviation (SD) of the performance evaluations by the three examiners (VK = Preclinical, KL = Clinical,
and OC = Oral Surgery) for the respective participant groups FRA and SIM.

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Median Mean ± SD

VK FRA 1 15 5 3 6 2 2.93 ± 1.26
VK SIM 0 1 4 10 15 4.5 4.30 ± 0.85
KL FRA 10 12 2 4 2 2 2.20 ± 1.24
KL SIM 4 3 5 7 11 4 3.60 ± 1.43
OC FRA 2 11 7 5 5 3 3 ± 1.23
OC SIM 1 1 5 7 16 5 4.20 ± 1.06
Dent. J. 2024, 12, 259 8 of 18

Dent. J. 2024, 12, x FOR PEER REVIEW 8 of 18

Table 4. A tabular representation of the rank statistics (mean rank and rank sum) for the grading of
group FRA and group SIM by all three examiners (VK = Preclinical, KL = Clinical, and OC = Oral
Table 4. A
Surgery), tabular representation
including of the rank
the calculated U-value andstatistics (meanp-value
the associated rank and rank
from thesum) for the grading
Mann–Whitney of
U-test
group
to assessFRA and group
significant SIM by all
differences in three examiners
participant (VK =The
grading. Preclinical, KL(r)
effect size = Clinical,
accordingand
toOC = Oral
Cohen is
Surgery),
also including the calculated U-value and the associated p-value from the Mann–Whitney U-
indicated.
test to assess significant differences in participant grading. The effect size (r) according to Cohen is
also indicated. Rank Statistics Mann–Whitney U-Test
Mean
Rank Rank
Statistics Exact
n Rank Sum U Mann–Whitney U-Test r
(MRang ) p-Value
Mean Rank Exact
VK FRA 30 n 21.75 Rank Sum U r
(MRang) 652.5 187.5
p-Value 0.52
<0.0001
VK SIM
VK FRA 30 30 39.25 21.75 1178 652.5
187.5 <0.0001 0.52
VK SIM 30
KL FRA 30 22.7 39.25 681 1178
216 0.0003 0.46
KL FRA 30
KL SIM 30 38.3 22.7 1149 681
216 0.0003 0.46
KL SIM 30
OC FRA 30 22.55 38.3 676.5 1149
OC FRA 30 22.55 676.5 211.5 0.0002 0.47
OC SIM 30 38.45 1154 211.5 0.0002 0.47
OC SIM 30 38.45 1154

Figure3.3.Box
Figure Boxplot
plotdiagram
diagramofofthe
thegrades
gradesfrom
fromthe
thepreparation
preparation exam
exam evaluated
evaluated bybythethe three
three examin-
examiners
ers (VK = Preclinical Prosthetics, KL = Clinical Prosthetics, and OC = Oral Surgery) for participants
(VK = Preclinical Prosthetics, KL = Clinical Prosthetics, and OC = Oral Surgery) for participants in
in groups FRA and SIM. The “+” symbol indicates the arithmetic mean of the grades. The horizontal
groups FRA and SIM. The “+” symbol indicates the arithmetic mean of the grades. The horizontal red
red line marks the passing threshold. Statistically significant differences between the respective
line marks
groups arethe passingrepresented
visually threshold. Statistically
by asteriskssignificant
“*”, with differences
significancebetween the respective
levels indicated as p groups
< 0.001
are visually represented by asterisks
(“***”), and p < 0.0001 (“****”). “*”, with significance levels indicated as p < 0.001 (“***”), and
p < 0.0001 (“****”).
3.2. Interrater Reliability
3.2. Interrater Reliability
Each examiner independently and blindly evaluated a total of 60 preparations (FRA
Each examiner independently and blindly evaluated a total of 60 preparations (FRA
group, n = 30; SIM group, n = 30). The preclinical evaluator (VK) gave a median score of 4
group, n = 30; SIM group, n = 30). The preclinical evaluator (VK) gave a median score
(“sufficient”; Mean: 3.62 ± 1.26), while the clinical evaluator (KL) gave a median score of
of 4 (“sufficient”; Mean: 3.62 ± 1.26), while the clinical evaluator (KL) gave a median
3 (“satisfactory”;
score Mean: 2.90
of 3 (“satisfactory”; ± 1.50).
Mean: The
2.90 ± oral surgery
1.50). evaluator
The oral surgery assigned a median
evaluator score
assigned a
of 4 (“sufficient”; Mean: 3.60 ± 1.26), which was equivalent to that of the
median score of 4 (“sufficient”; Mean: 3.60 ± 1.26), which was equivalent to that of the VK evaluator
(Table
VK 5). For (Table
evaluator the given
5). grade
For the distribution,
given grade nodistribution,
normal distribution
no normal wasdistribution
assumed. There-was
fore, the Friedman test was used to check for differences in grading.
assumed. Therefore, the Friedman test was used to check for differences in grading. With an assumed
With
significance
an level of α =level
assumed significance 5%, aofsignificant difference difference
α = 5%, a significant (Friedman (Friedman
test statistic:
test32.27; p<
statistic:
0.0001) in grading among the three evaluators (VK mean rank = 2.25; KL
32.27; p < 0.0001) in grading among the three evaluators (VK mean rank = 2.25; KL meanmean rank = 1.54;
OC mean
rank = 1.54;rank
OC =mean
2.21)rank
was =found
2.21) (Figure 4). The
was found calculated
(Figure 4). TheFleiss’ Kappa,
calculated a measure
Fleiss’ Kappa, ofa
inter-rater agreement, showed a moderate agreement, with κ = 0.3 according
measure of inter-rater agreement, showed a moderate agreement, with κ = 0.3 according to Altmanto
(Table 6). The subsequent post-hoc analysis (Dunn’s Multiple Comparison Test) allowed
targeted examination for statistically significant differences between the ratings of two
Dent. J. 2024, 12, 259 9 of 18

Altman (Table 6). The subsequent post-hoc analysis (Dunn’s Multiple Comparison Test)
allowed targeted examination for statistically significant differences between the ratings
of two evaluators. A significantly better rating by the clinical prosthodontics evaluator
(KL) (mean rank = 1.54) compared to the preclinical prosthodontics evaluator (mean
rank = 2.25) and the oral surgery evaluator (mean rank = 2.21) was identified (z = 3.88;
p = 0.0003/z = −3.65; p = 0.0009). This represented a medium effect size, according to
Cohen, with r = 0.35 and r = 0.33, respectively. However, there were no statistically
significant differences between the grades given by the preclinical evaluator (VK) and the
oral surgery evaluator (OC) (z = 0.23; p > 0.9999) (Table 7).

Table 5. Presentation of the absolute grade distribution, median, mean, and standard deviation (SD)
of the performance assessments by the three examiners for all participants.

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Median Mean ± SD

Preclinic (VK) 1 16 9 13 21 4 3.62 ± 1.26
Clinic (KL) 14 15 7 11 13 3 2.90 ± 1.50
Dent. J. 2024, 12, x FOR PEER REVIEW 10 of 18
Oral surgery
3 12 12 12 21 4 3.60 ± 1.29
(OC)

Figure4.4.Box
Figure Boxplot
plotdiagram
diagramillustrating
illustratingthe
thegrade
gradedistributions
distributionsfor
forthe
thepreparation
preparationexam
examasasevaluated
evaluated
by the three examiners. The “+” symbol denotes the arithmetic mean of the grades for each
by the three examiners. The “+” symbol denotes the arithmetic mean of the grades for each examiner.exam-
iner. The horizontal red line represents the passing threshold. Statistically significant differences
The horizontal red line represents the passing threshold. Statistically significant differences between
between groups are indicated by asterisks “*”. The number of asterisks corresponds to the p-value
groups are indicated by asterisks “*”. The number of asterisks corresponds to the p-value significance
significance level: p < 0.001 (“***”).
level: p < 0.001 (“***”).
3.3. Assessment
Table 6. Presentation of the rank statistics (mean rank and rank sum) of the grades assigned by the
All study along
three examiners, participants
with the completed anstatistic
calculated test evaluation formfor
corrected associated with
ties and the their training
associated p-value
system.
from The analysis
the Friedman test toof the questionnaires
assess showed
significant differences in thestatistically significantacross
grading of participants differences for
all groups.
statements
Fleiss’ Kappa A-G. Theincluded.
(κ) is also corresponding evaluation results and score distribution, as well as
the statistical analysis, can be found in Table 8 and Figure 5. No normal distribution was
Rankassumed
Statistics for the given grade distributions, andFriedman
the Mann–Whitney
Test U testFleiss’
was used (α =
Kappa
5%) to check for statistical significance. Friedman
The answersTest to statement “H” focused particularly
Asymptotic
n Mean Rank (MRang ) Rank Sum κ
on technical improvements within the software
Statistic and were, logically,
(Corrected) p-Value asked exclusively to
Preclinic (VK) 60 the SIM2.25group participants.
135 The responses are summarized in Table 9, with their fre-
quency indicated. 32.27 0.0002 0.3
Clinic (KL) 60 1.54 92.5
Participants in the Frasaco group rated the operation of the analog simulation unit
Oral surgery (OC) 60 and the2.21
phantom head as 132.5
more intuitive compared to the SIMtoCARE system (Statement
“A”; “agree” versus “neutral”; p = 0.0209) (Table 8 and Figure 5). At the same time, both
groups found the operation of their respective systems to be not complicated (Statement
“B”; “neutral”; p = 0.0214). Overall, participants from the FRA group more strongly felt
that their skills improved with their system than was the case in the SIM group (Statement
“C”) (p < 0.0001), with the FRA group giving a median score of 1 (“fully agree”). The SIM
Dent. J. 2024, 12, 259 10 of 18

Table 7. Presentation of the test statistics and z-values calculated by Dunn’s Multiple Comparison Test
to evaluate significant differences in grading between the three examiners. Additionally, uncorrected
p-values and Bonferroni-corrected p-values, along with the effect size (r) according to Cohen for
significant differences, are provided.

Dunn’s Multiple Comparison Test

Asymptotic Asymptotic
Test
z-Value p-Value p-Value r
Statistics
(Not Corrected) (Corrected)
VK vs. KL 0.71 3.88 0.0001 0.0003 0.35
VK vs. OC 0.04 0.23 0.8195 >0.9999
KL vs. OC −0.67 −3.65 0.0003 0.0009 0.33

3.3. Assessment
All study participants completed an evaluation form associated with their training
system. The analysis of the questionnaires showed statistically significant differences for
statements A-G. The corresponding evaluation results and score distribution, as well as
the statistical analysis, can be found in Table 8 and Figure 5. No normal distribution was
assumed for the given grade distributions, and the Mann–Whitney U test was used (α = 5%)
to check for statistical significance. The answers to statement “H” focused particularly
on technical improvements within the software and were, logically, asked exclusively
to the SIM group participants. The responses are summarized in Table 9, with their
frequency indicated.

Table 8. Tabular summary of the frequency distribution, median, mean, and standard deviation (SD)
for each statement (A to G) on the evaluation form, reported by participants in both the FRA and SIM
groups.

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Median Mean ± SD

“Strongly “Strongly
“Agree” “Neutral” “Disagree”
Agree” Disagree”
Statement A: FRA 8 11 11 0 0 2 2.10 ± 0.80
Statement A: SIM 1 11 18 0 0 3 2.57 ± 0.57
Statement B: FRA 0 0 6 10 14 4 4.27 ± 0.78
Statement B: SIM 0 1 13 9 7 4 3.73 ± 0.87
Statement C: FRA 26 4 0 0 0 1 1.13 ± 0.35
Statement C: SIM 2 16 8 4 0 2 2.47 ± 0.82
Statement D: FRA 24 5 1 0 0 1 1.23 ± 0.50
Statement D: SIM 1 3 9 7 10 4 3.73 ± 1.14
Statement E: FRA 20 9 1 0 0 1 1.37 ± 0.56
Statement E: SIM 0 10 6 12 2 3 3.20 ± 1.00
Statement F: FRA 7 14 4 4 1 2 2.27 ± 1.08
Statement F: SIM 0 1 6 4 19 5 4.37 ± 0.93
Statement G: FRA 10 19 1 0 0 2 1.70 ± 0.54
Statement G: SIM 0 8 18 4 0 3 2.87 ± 0.63
 “System crashes during use: frozen screen and “holes” in the teeth” 6
“The upper jaw and cheeks must also be displayed to simulate a more realistic situation” 4
“The light is unrealistic” 2
“The display resolution should be higher” 2
Dent. J. 2024, 12, 259 “Finishing the virtual teeth is not possible” 1 11 of 18
“You can zoom in too much” 1

Figure 5.
Figure 5. The
The horizontal
horizontalredreddashed
dashedline visualizes
line visualizesa “neutral” (grade
a “neutral” 3) statement
(grade according
3) statement to theto
according
Likert-type scale. The “+” symbol denotes the arithmetic mean of the grades for each examiner.
the Likert-type scale. The “+” symbol denotes the arithmetic mean of the grades for each examiner.
Mean ± SEM were calculated and the Mann–Whitney U test (* = p < 0.05) was performed. “*”
Mean ± SEM were calculated and the Mann–Whitney U test (* = p < 0.05) was performed. “*” indi-
cates significant statistical differences between the groups. The number of asterisks corresponds to
the p-value significance level: p < 0.050 (“*”) and p < 0.0001 (“****”).

Table 9. Tabular summary of criticisms and suggestions for improvement from the SIM group,
including their absolute frequencies.

Free-Text Responses SIMtoCARE Absolute Frequency

“The virtual model should not be able to rotate 360◦ ” 10
“The speed must be adjustable” 7
“System crashes during use: frozen screen and “holes” in the teeth” 6
“The upper jaw and cheeks must also be displayed to simulate a more realistic situation” 4
“The light is unrealistic” 2
“The display resolution should be higher” 2
“Finishing the virtual teeth is not possible” 1
“You can zoom in too much” 1

Participants in the Frasaco group rated the operation of the analog simulation unit
and the phantom head as more intuitive compared to the SIMtoCARE system (Statement
“A”; “agree” versus “neutral”; p = 0.0209) (Table 8 and Figure 5). At the same time, both
groups found the operation of their respective systems to be not complicated (Statement
“B”; “neutral”; p = 0.0214). Overall, participants from the FRA group more strongly felt
that their skills improved with their system than was the case in the SIM group (Statement
“C”) (p < 0.0001), with the FRA group giving a median score of 1 (“fully agree”). The SIM
group, however, gave a slightly lower score of “2” (“agree”). Interestingly, this contrasts
somewhat with the ratings for statement “D”. Participants in the FRA group agreed that
they wanted to continue practicing with the analog phantom head, while participants in
the SIM group rejected further training with the virtual simulator (“fully agree” versus
“disagree”; p < 0.0001). This opinion was reflected in the responses to statement “E”. Here,
FRA group participants felt better prepared for the final preparation test by using the analog
phantom head (“strongly agree”), compared to the SIM group participants who used the
SIMtoCARE system (“neutral”) (p < 0.0001). Additionally, the confidence to prepare on a
real patient was higher in the FRA group than in the SIM group (Statement “F”) (“agree”
versus “strongly disagree”; p < 0.0001). Overall, both training systems were positively rated
Dent. J. 2024, 12, 259 12 of 18

by the participants (Statement “G”). The analog phantom head received a median score of
“2” (“good”), while the SIMtoCARE system received a median score of “3” (“satisfactory”;
p < 0.0001).

4. Discussion
The education of dental students is a complex process that requires not only the acqui-
sition of theoretical knowledge but also fine motor skills and a high level of hand–foot–eye
coordination. Before invasive clinical procedures can be performed on patients, it is impor-
tant to achieve sufficient competence through intensive use of preclinical practice, [12,13].
Traditionally, these skills are trained and learned using phantom heads and plastic models.
Feedback is provided by the faculty, which is often described as a very subjective assess-
ment of performance [14], leading to dissatisfaction among students [15]. To address this
issue, digital evaluation systems (e.g., PrepCheck, Dental Teacher, and Romexis Compare)
have been introduced in the context of digitalizing dental education. These systems overlay
and compare students’ preparations with instructors’ master preparations, providing objec-
tive feedback [16]. It is even recommended to use these systems for calibrating instructors
and as an adjunct in assessing preparation exams [7]. In a previous study by the authors,
the effectiveness of these systems was investigated [7]. The results showed no significant
difference in the performance of students who received faculty feedback versus feedback
from the preparation assistants. However, students generally positively perceived the use
of these digital systems. The primary function of these systems lies in generating free
practice time, during which no feedback from a tutor or instructor is necessary, allowing
students to learn and improve their skills autonomously [3]. This reduces the workload
and creates more practice time in a phase where it is urgently needed [2].
As the next step in the digitalization of preclinical dental education, haptic virtual
reality simulators (HVRS) are increasingly being adopted [17]. Advances in haptic tech-
nology have changed the perception of virtual reality (VR) and particularly of HVRS. The
haptic experience in the virtual environment (VE) represents a bidirectional flow of infor-
mation between the user and virtual reality, transmitting forces, vibrations, or movements
to the user through a haptic interface and thus simulating tactile and kinesthetic sensa-
tions [18,19]. HVRS fundamentally change the interaction with virtual objects by providing
a realistic sense of touch and feel [20], which is crucial for learning fine dental skills. The
simulation experience is almost entirely transferred to the virtual world, eliminating the
need for plastic teeth or real handpieces. Research in this field has intensified in recent
years, demonstrating the supportive benefits of these systems in training for dental restora-
tive procedures [21–24]. Consequently, more dental schools are implementing these HVR
systems [25,26].
The present study aimed to investigate the effectiveness of virtual simulators (HVRS)
for learning dental preparation (Prosthodontics) during the preclinical phase of dental
education, in comparison to traditional learning using analog phantom heads. For this
purpose, the preparation of tooth 36 for a full-cast crown was performed at an analog
phantom workstation and on the Dente (SIMtoCARE) during a free practice period. A
preparation exam was then conducted to determine the students’ progress.
The performance of students in the FRA group (analog simulation workstation)
was significantly better than that of the SIM group (Dente, SIMtoCARE) (Figure 3). All
three examiners rated the preparations of the FRA group two grades higher on average
(VK: 2 vs. 4.5; KL: 2 vs. 4; OC: 3 vs. 5). Looking at the absolute grade distribution (Table 3),
50% and 53% of the participants in the SIM group received lower grades from examiners
VK and OC, respectively, compared to the analog FRA group, and would have even failed
the preparation exam. The rating from examiner KL was slightly better, but still showed
a high failure rate of 37%. In contrast, the analog FRA group received significantly better
ratings. The grade distribution reversed in this group, with the examiners awarding a grade
of “2” to 50% (VK), 40% (KL), and 37% (OC), attesting to good performance. Ultimately,
33% even achieved a grade of “very good” (“1”) from examiner KL. Based on this data, the
Dent. J. 2024, 12, 259 13 of 18

“Dente” (SIMtoCARE) alone does not seem suitable for preparing inexperienced students
for a preparation exam on the phantom.
In a similar study, Arora et al. [27] also concluded that practice on an analog phantom
head leads to better results than preparation exercises on HVRS. That study used the
Virteasy Simulator (Virteasy Dental© , Changé, France) in order to determine its equivalence
to the phantom head. However, the participants did not have to take a final exam on the
phantom; instead, four preparations were performed and evaluated sequentially. Only in-
experienced second-year students were included, who prepared either only on the Virteasy
or only on the phantom head. Although the initial preparations showed a slight difference
favoring conventional preparation, it was not statistically significant. Interestingly, this
changed significantly for the third and fourth preparations. Participants in the virtual
preparation group contrastingly scored approximately 50/100 points, while the analog
group scored around 80/100 points. This is likely due to the last two preparations being
performed on more complex premolars and molars. Although these results suggest that
HVRS may result in poorer performance in crown preparation training, Arora et al. [27]
confirm the higher effectiveness of virtual simulators. They base this conclusion on the
improved scores observed over time with the use of the simulator. This is also confirmed in
a systematic review by Moussa et al. [24], who report improvement in crown preparation
over time after using HVRS with or without instructor feedback. It appears that HVRS
is more effective for experienced users. This is further evidenced in the study by Wang
et al. [28], which investigated the use of HVRS for metal–ceramic crown preparation. Their
study used the Simodont dental trainer (MOOG© , Nieuw-Vennep, The Netherlands). Both
novices and residents performed preparations, which were then evaluated. Additionally,
the required time and errors in the preparations (i.e., occlusal reduction, undercuts, and
damage to neighboring teeth) were recorded. The results showed that novices took signif-
icantly more time, received poorer evaluations, and made more errors. The detection of
these differences demonstrates the validity of the system. Both groups found working with
the simulator very positive and even preferred virtual training to preparing on plastic teeth.
Murbay et al. [29] also examined the Simodont dental trainer (MOOG© , Nieuw-Vennep,
The Netherlands) and showed that students who entered the study with the Simodont
were able to perform far more satisfactory preparations (in multiple areas), compared to
the group that did not use the simulator, despite having the same level of competence.
Philipp et al. [22] showed opposing results in their study, which had a similar design
to ours and also used the Dente from SIMtoCARE (Vreeland, The Netherlands). They found
no significant difference between the analog (control group) and virtual (test group) groups.
However, the participants were tasked with performing an access cavity for a pulpotomy,
which, although an invasive procedure, is performed on a much smaller area. Therefore,
the complexity of the exercise is lower than the complete preparation of a molar with
neighboring teeth. Furthermore, the participants had already gained preparation experience
on the analog simulator, so unlike in the present study (completely inexperienced students),
the handling of the phantom head for the final exam was familiar and simplified. The
small number of participants (n = 14) also limits its statistical power. Despite the positive
results, Philipp et al. [22] see HVRS more as a bridge between preclinical training on the
phantom and real clinical patients. The authors of the present study share this view and
currently see HVRS as a tool complementary to conventional training. Both approaches
have advantages and disadvantages and can complement each other in their capabilities.
The literature review by Imran et al. [30] and the systematic reviews by Moussa et al. [24]
and Koolivand et al. [31] confirm the positive effect of HVRS and the good conveyance
of psychomotor skills in managing clinical situations. Moussa et al. [24] emphasize the
importance of force-feedback-based 3D simulators compared to 2D-based systems without
force-feedback. They also recommend a combination of instructor feedback and device
feedback. Imran et al. [30] highlight the reduced cost factor, as no technical requirements
for the building (e.g., water supply, drainage, and suction) are necessary, and there is
no need for regular maintenance or buying plastic teeth. However, it should be noted
Dent. J. 2024, 12, 259 14 of 18

that HVRS represents sensitive, highly developed technology that can also malfunction.
Corresponding repairs could be costly and result in the system being unavailable. These
costs could be reduced in the future if HVRS finds wider application.
However, even in the future, the analog phantom head will remain the gold standard
for preparation exams. This is because the simulation of hard tissues, the ergonomics of
working with a simulated patient, the use of a real handpiece with variable speed and actual
water cooling, and the operation of a real treatment unit cannot currently be adequately
represented virtually. Additionally, if a shift to purely virtual training were to occur in the
future, there would still need to be a transition from purely virtual treatment training to real
patient care. The student must then be able to perform a sufficient preparation that does not
endanger the patient, regardless of how well they performed previously in the virtual space
or with virtual patients. For this reason, only a combination of analog and virtual simulation
can currently be recommended, as the student must familiarize themselves with and adapt
to a real treatment environment (the tangible analog phantom patient) at some point, at
the latest, just before treating real patients. In this context, additional aspects become
apparent that are missing in virtual simulation (Dente, SIMtoCARE). Excessive pressure,
insufficient water cooling, and blunt or overly fine instruments (diamonds) ultimately lead
to overheating of the prepared tooth and pose a risk to its vitality. An analog plastic tooth
reacts with charring and the corresponding smell, providing the student with feedback on
this fatal error.
The strength of virtual simulation, on the other hand, lies fundamentally in its ability
to simulate a wide variety of dental procedures with a single system. Considering the
standard portfolio of the Dente (SIMtoCARE), for example, it offers manual dexterity
exercises, restorative procedures such as caries excavation, access cavity preparation, and
pocket depth measurement. Additionally, prosthetic preparation exercises, implantations,
and the administration of block anesthesia are available. Since new cases can theoreti-
cally be added as needed, the possibilities are endless. Particularly in the area of caries
excavation, the practice cases can be designed as interactive exercises in which students
receive direct feedback from the software as to whether all the caries has been removed or if
residual caries remains. It even indicates how much healthy tooth substance was damaged
during the treatment. Compared to the analog phantom, such a situation is generally
difficult to simulate, and if attempted (e.g., using a model with extracted teeth), it requires
supervision by a supervising dentist. This highlights the self-learning aspect of virtual
simulation [32–34]. Jasinevicius et al. [35] demonstrated that students who completed their
preclinical training with a virtual simulator required only 20% of the time that an instructor
needed for personal instruction. It is worth mentioning that virtual systems can import real
individual patient cases following an intraoral scan by, for example, importing the data in
PLY format, and then voxelizing them. This allows for the repeated practice of this individ-
ual situation until a safe and successful approach for future treatment can be implemented.
This capability presents an intriguing option, especially in clinical dental education.
The authors believe that a practice scenario needs to be created in the sense of a
“guided preparation” that shows students a path to safely perform a preparation. This
principle is applied in other fields, such as aviation, particularly with respect to landing.
Pilots receive a predetermined “glideslope” through the Instrument Landing System (ILS),
which ensures that the runway is safely reached and the landing is successful. They receive
constant feedback through the “localizer” about height and distance to the runway and
whether the aircraft is, for instance, too far to the right or left of the runway. Analogous
to this principle, a tooth to be prepared could consist of multiple colored layers. When
the student begins to prepare, they would first expose the tolerance range. Then, they
would see the color of the ideal preparation and can orient themselves to it until they
expose the color of the master preparation. If they grind too deeply, an alert color (e.g.,
red) might indicate excessive substance removal. This way, direct feedback is given during
the preparation process, no human supervision is required, and the whole exercise has a
playful aspect that may enhance the user’s ambition.
Dent. J. 2024, 12, 259 15 of 18

The evaluation of the feedback forms highlights the differences between the two
systems under investigation. Participants’ subjective perceptions of their training methods
were captured using seven statements to be rated (A to G). Additionally, suggestions for
improvement could be provided in an optional free-text format (Statement H).
Initially, participants found working with the Dente (SIMtoCARE) found their system
to be less intuitive, compared to those in the Frasaco group (Statement A). This is further
supported by the results for statement B, “The operation of the Dente or phantom head
was complicated,” which showed a significantly better rating from participants in the FRA
group compared to those in the SIM group. Despite the difference in ratings, the grade
distribution indicates that the perceived complexity of the Dente is not clear-cut. While the
Dente might initially appear less intuitive and more complicated compared to the phantom
head, participants did not perceive it as opaque or particularly complex.
Additionally, participants in the FRA group reported a greater improvement in their
practical skills, compared to responses from those in the SIM group (Statement C). However,
a closer look at the ratings reveals that despite these differences, there is an overall positive
development (60% positive, 27% neutral, 13% negative) in the practical skills of the SIM
group participants as perceived subjectively.
Nonetheless, 76% of the SIM group participants felt that even after adequate practice
with the system, they were not capable of safely preparing a tooth on a patient (Statement
F). In contrast, 70% of the FRA group participants felt confident they could successfully
perform this task in the future. The starkly negative response to Statement D, “I would
like to continue practicing with the system used here in the phantom course”, by the
SIM group (56% rated it 4 or 5, “disagree/strongly disagree”) compared to the positive
response by the FRA group (97% rated it 1 or 2, “strongly agree/agree”) underscores the
differing perspectives and attitudes of the two groups regarding the skills acquired and to
be acquired, as well as their confidence in using the system. This is further emphasized by
the final rating of each system used (Statement G), in which the Dente was rated lower on
average (score “3”) compared to the phantom head (score “2”), albeit not as decisively.
Zafar et al. [11] reached similar conclusions in their study. They investigated the
subjective perceptions of students who performed pulpotomies and crown preparations
using both an HVRS system (Simodont, Nissin Dental© , Kyoto, Japan) and a conventional
dental model. In total, 56% of participants agreed that the HVRS simulator improved their
understanding of pulpotomies and crown preparations. However, participants generally
felt more comfortable using the phantom head with a dental model, compared to the HVRS
simulator. This could be attributed to the participants’ prior familiarity with the analog
system, leading to a bias against the HVRS.
The fundamentally poorer evaluation of the SIMtoCARE system by the students in
this study can be attributed to various factors (Statement H). Primarily, participants felt
that the system did not yet meet the gold standard of the phantom head, which remains
the benchmark for examination situations. The virtual dental models could be rotated
360◦ , allowing users perspectives that did not correspond to the real situation. The lack
of representation of the opposing jaw and the cheeks during preparation, as well as the
ability to zoom in excessively, contributed to the perception that the range of motion of the
handpiece and the visibility of details were less realistic.
Interestingly, Arora et al. [27] view these aspects as advantages of the virtual system,
suggesting that they even contribute to improving students’ skills.
Additionally, some students found the digital lighting and shadow effects unrealistic,
conditions which could distort a realistic working view. Moreover, participants noted
several issues with the SIMtoCARE system’s application. Initially, the rotation speed of
the digital handpiece was fixed at 60,000 RPM, which made finishing the virtual teeth
impossible. A finished surface and precise preparation margin are crucial for a seamless
transition from tooth to crown. Additionally, during system use, there were technical
complications: either the screen froze, or there were deficits in the integrity (“holes”) of the
virtual teeth. In both cases, a system restart was required without saving progress.
Dent. J. 2024, 12, 259 16 of 18

Consequently, users’ trust in the system was significantly undermined, as evidenced

by the negative ratings for Statement D, “I would like to continue practicing with the
system used here in the phantom course”; Statement E, “The practice system used prepared
me well for the preparation examination”; and Statement F, “With the practice method, I see
myself able to safely prepare a tooth on a patient after sufficient practice” by participants in
the SIMtoCARE group.
Wang et al. [28] conducted a similar survey and found contrasting results. They
surveyed both the novice students and dental residents who participated in their study.
Both groups provided consistently positive ratings in favor of the HVRS. They found the
system more user-friendly and efficient compared to conventional methods. Furthermore,
they believed that using the HVRS would improve learning in the course and felt motivated
to continue training with it rather than with plastic teeth. The study highlights that the
so-called novices had already had preparation experience with the phantom and had
completed the phantom course in restorative dentistry. Along with the dental residents,
this study essentially surveyed a more experienced group. This aligns with the observation
that HVRS appears to be more effective and better-accepted among experienced users.
Even among the inexperienced users in our study, the evaluations of both systems
(Statement G) showed only minimal differences. Users rated the HVRS slightly worse (“sat-
isfactory” versus “agree”), though it still received a “satisfactory” rating. It is expected that
with longer-term use and increased experience, overall favorable perception will improve.
In conclusion, it is important to mention that the inter-rater reliability was investigated.
Unlike in Stoilov et al. [7], an additional rater from the surgical field was included to achieve
greater objectivity. However, the results indicate a significant difference in grading, with
only moderate agreement (Fleiss’ Kappa; κ = 0.3). Two of the raters (VK and OC) were more
similar in their evaluations, giving significantly lower grades compared to the rater KL.
This was unexpected, as rater KL is responsible for assessing and grading preparations on
actual patients. In contrast, the other raters are more accustomed to dealing with preclinical
students and might be used to seeing lower-quality preparations. This situation further
emphasizes the need for an objective evaluation system independent of human variability,
one which cannot be affected by fluctuations in daily performance. In this context, the
implementation and testing of evaluation software within the HVRS should be considered
and investigated.

5. Conclusions
Considering the limitations of this study, it can be concluded that haptic feedback
virtual simulators (HVRS) are not currently capable of training inexperienced students for
a preparation exam, compared to the traditional phantom head. Training on the virtual
simulator resulted in significantly lower scores on the preparation exam. Inexperienced
students prefer working with the analog phantom head, even though they initially find the
use of the HVRS manageable and subjectively perceive an improvement in their perfor-
mance. From the authors’ perspective, a combination of both systems is necessary for future
dental education to encompass both virtual and real-world training. For advanced students
who wish to refine their skills in a more intensively simulated environment or engage in
individual practice with patient cases, HVRS offers an efficient and cost-effective option.

Author Contributions: Conceptualization, M.S. and D.K.; methodology, M.S., D.K. and L.S.; software,
F.S. and L.S.; validation, H.S., N.E. and D.K.; formal analysis, M.S.; investigation, L.S. and F.S.;
resources, H.S.; data curation, N.E. and D.K.; writing—original draft preparation, M.S. and L.S.;
writing—review and editing, M.S. and D.K.; visualization, F.S.; supervision, M.S.; project administra-
tion, M.S. and D.K. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Ethical approval was obtained from the Ethics Committee of
the medical faculty of the University of Bonn (number 159/20).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Dent. J. 2024, 12, 259 17 of 18

Data Availability Statement: The original contributions presented in the study are included in
the article.
Conflicts of Interest: The authors declare no conflicts of interest.

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