A Comparative Study of Virtual Reality and Traditional Methods for Surgical Instrument Training

ABSTRACT

Purpose/Objectives

This study aimed to evaluate the effectiveness of virtual reality (VR) training compared to traditional physical model training in improving dental students' ability to recognize oral surgical instruments.

Methods

In 2024, 39 seventh‐semester dental students were randomly assigned to a VR group (n = 19) or a non‐VR group (n = 20). All participants first attended a seminar on surgical instruments. The VR group trained in a custom‐developed interactive scenario using the VR headset, while the non‐VR group used physical instruments. Pre‐ and post‐tests assessed instrument recognition, and students rated their confidence using a visual analog scale. Questionnaire feedback on the VR experience was also collected.

Results

Both groups showed significant improvements from pre‐ to post‐test (p = 0.001 for VR; p < 0.0001 for non‐VR). The non‐VR group outperformed the VR group in the post‐test (median = 8.0 vs. 5.0; p = 0.003) and reported higher confidence levels (mean = 3.85 vs. 3.41; p = 0.004). The VR group showed better recognition of select instruments (Elevator, Langenbeck, Blade Shaft) and reported high levels of satisfaction with the training environment. A significant correlation was observed between video game experience and VR familiarity (R = –0.422, p < 0.001).

Conclusion

VR‐based training enhances student engagement and confidence but was less effective than traditional methods in overall instrument recognition. These findings support using VR as a complementary tool in dental education, particularly in early‐stage surgical training.

1. Introduction

Technological advancements continue to reshape all aspects of life, including dentistry. The integration of innovative tools, such as artificial intelligence in oral radiology, and the use of digital workflows in computer‐aided design and manufacturing, have transformed dental practice and education [1, 2, 3, 4]. In dental education, where hands‐on learning and patient‐student interactions are fundamental, technology plays a transformative role in delivering knowledge, skills, and competencies [5, 6]. In this context, virtual reality (VR) emerges as an important technology, offering an immersive experience within educational scenarios. Nevertheless, it is essential to establish evidence regarding how this new technology contributes to learning, in comparison to traditional methods, in order to optimize learning experiences and strategies, as well as to understand its impact on learning outcomes. Introduced in 1960s and first applied in dentistry in 1990s, VR facilitates a smooth transition from preclinical to clinical settings [7, 8, 9]. It provides the ability to enhance fine motor skills and learning and reduces the need for direct supervision [10, 11, 12, 13]. Beyond educational applications, VR applied to patients has shown potential for reducing dental anxiety and can aid in alleviating postoperative pain [14, 15, 16]. Currently, VR has been primarily used in operative dentistry, prosthodontics, and oral surgery [17]. Despite offering a realistic and immersive learning environment, transferring skills from virtual to real‐world settings might remain challenging due to differences in sensory feedback and patient interaction. These limitations prevent VR from fully replacing traditional hands‐on learning. Furthermore, integrating VR into curricula demands significant planning and resources, and many educators hesitate to adopt new technologies [18]. Financial constraints also hinder widespread implementation [19]. Consequently, VR serves as a supplementary tool in dental education, enhancing rather than replacing the traditional learning model [12, 13, 18, 20, 21, 22, 23, 24].

Today's undergraduate students, predominantly Millennials and Generation Z, are digital natives accustomed to multitasking and engaging with technology [25]. They seek educational approaches that align with the digital age, making VR an ideal bridge [8, 25]. VR provides a realistic, immersive, and interactive 3D environment using devices such as headsets, motion‐tracking systems, and headphones [17, 24]. In dental education, VR has been shown to significantly improve skill acquisition and retention, even in short‐term training [17]. A key benefit of VR is its ability to provide immediate feedback, allowing students to gain confidence and improve skills without compromising safety of dental care [26]. Emerging trends in VR education also incorporate haptic feedback, which simulates tactile sensations, enhancing the realism of the virtual experience [27]. Haptic feedback, for example, can replicate the feel of dental tissues, helping students practice manual skills in a controlled, safe environment. This integration allows students to experience forces and textures as if they were manipulating actual dental instruments, improving motor skills and autonomy [28, 29].

In this sense, VR holds significant potential for application in the learning process of oral surgical instruments. However, there has been no prior research evaluating the effectiveness of VR for this purpose, despite the fact that a thorough understanding of oral surgical instruments is essential in the field of oral surgery. Therefore, this study aims to assess the impact of VR‐based training on undergraduate dental students' ability to recognize oral surgical instruments, comparing it to traditional teaching methods. The null hypothesis is that there would be no difference in undergraduate dental students' ability to recognize oral surgical instruments between those trained using VR‐based methods and those trained using traditional teaching methods.

2. Methods

This study received ethical approval from the Institutional Review Board at Aarhus University(Case Number:2024‐010 ). Thirty‐nine seventh‐semester dental students were recruited during an introductory seminar at the Section for Oral and Maxillofacial Surgery and Oral Pathology, at the Department of Dentistry and Oral Health, Aarhus University (Denmark). Participation was voluntary, and all students provided informed consent. The study methodology spanned over 3 days, beginning with a pre‐exam consisting of 10 pictures of surgical instruments and a blank space to answer. The questionnaire was designed to assess baseline knowledge. Each correct answer was awarded 1 point, resulting in a total possible score ranging from 0 to 10. Students also rated their confidence in each answer using a five‐point visual analog scale (VAS), meaning 0 “not confident” and 5 “highly confident”. Following the pre‐exam, all participants attended a one‐hour oral presentation on oral surgery instruments, where they were encouraged to ask questions. Students were divided into two groups using stratified randomization based on their pre‐exam scores: The VR group and the control group (Non‐VR), using traditional physical instruments.

2.1. VR and Traditional Training

VR training was conducted using an Oculus/Meta Quest 3 VR headset and handheld controllers (Meta Platforms, Inc. Meta Quest 3. Menlo Park, California, USA). The VR scenario was developed by AATE VR (Aarhus, Denmark) through collaboration with author JW and simulates a virtual dental clinic equipped with oral surgery instruments. The VR scenario was developed using Unity 3D with the C# programming language, ensuring compatibility and performance across standard VR systems. No hardware modifications were made. All surgical instruments were modeled and textured in Blender, based on reference photos and physical measurements. The design process followed a participatory approach, beginning with a concept workshop to outline the experience and user flow. This was followed by multiple prototype testing sessions with dental school staff, incorporating their feedback iteratively until the final scenario was approved and deemed ready for educational use.

Each student in the VR group (n = 19) received a brief tutorial to familiarize themselves with the equipment, including tasks like picking up virtual instruments. An instructor supervised the session to ensure safety and assist with technical issues. The VR scenario lasted approximately 5 min and allowed students to interact with the virtual instruments, providing details on each instrument's name and function (Figure 1). The language of instruction could be switched between English and Danishbased on the student's preference. After the session, students completed a questionnaire evaluating their VR experience. Simultaneously, the non‐VR group (n = 20) trained with physical instruments in a separate room. These students had access to the same instruments as those in the VR scenario and could reference the PowerPoint presentation from the seminar. They were given 20 min to complete their training, during which they were not permitted to ask the instructors for help. A follow‐up exam, identical in format and content to the pre‐exam, was administered one week later, just before students began their clinical rotations.

FIGURE 1.

Virtual reality environment for surgical instrument training. Courtesy of AATE VR (Aarhus, Denmark).

2.2. Questionnaire

The questionnaire, adapted from previous studies on VR in dental education, covered four domains: The virtual environment and scenario, hardware usability, educational value, and overall satisfaction [30, 31]. Responses were collected using a 7‐point Likert scale for questions 1–12, a yes/no option for Question 13, and a free‐text field for additional comments.

2.3. Statistical Analysis

Data was analyzed using GraphPad Prism (version 10.0.0 for Windows, GraphPad Software, Boston, Massachusetts USA). Differences between pre‐ and post‐test scores within each group (VR and Non‐VR) were evaluated using the Wilcoxon signed‐rank test, while the Mann‐Whitney U test was applied to compare scores between groups. A significance level of 0.05 was used with a Holm‐Bonferroni correction for multiple testing. Descriptive statistics and Spearman's correlation were used to analyze student feedback from the questionnaires.

3. Results

Data from 39 students were collected. One post‐test was incomplete, resulting in a final sample of 38 participants.

3.1. VR Group Characteristics

Among the 19 students in the VR group, the mean age was 24.06 years (range: 22–28 years), based on data from 18 participants (one participant did not report their age). The majority of participants were female (n = 15).

In terms of VR experience, 13 students were experiencing VR for the first time, while six had prior exposure through gaming. In addition, most participants reported minimal engagement with video games: 14 students indicated they never played, one played daily, and the remaining played occasionally.

3.2. Pre‐ and Post‐ Exam Results

There was no statistically significant difference in baseline scores (median = 3.0, p = 0.926; Figure 2), indicating that both groups began training with similar foundational knowledge.

FIGURE 2.

Differences between pre‐ and post‐exam in both groups.

After the training interventions, both groups showed improvement in post‐exam scores (VR group pre vs. post, p = 0.001, Non‐VR group pre vs. post, p < 0.0001). However, the Non‐VR group significantly outperformed compared to VR group (p = 0.003; Figure 2). The Non‐VR group achieved a median post‐exam score of 8.0, while the VR group had a median score of 5.0.

When the scores for individual instruments were analyzed (Figure 3), the VR group performed better at recognizing the following surgical instruments: the Hylin elevator (p = 0.004), Langenbeck (p = 0.003), and blade shaft (p = 0.003).

FIGURE 3.

Test scores (%) for VR and Non‐VR group, post training, per instrument.

3.3. Student Confidence in Instrument Identification

Confidence levels in identifying surgical instruments increased significantly in both groups (p < 0.001 for each). The students in both the VR and Non‐VR groups started with similar confidence levels (mean Non‐VR: 2.25; mean VR: 2.18) with no statistically significant difference between groups (p = 0.746). After training, the Non‐VR group achieved a higher mean confidence score of 3.85 compared to 3.41 in the VR group (p = 0.004), as shown in Table 1.

TABLE 1.

Pre‐ and post‐exam students’ confidence scores in VR and non‐VR groups.

Tool	Pre‐exam non VR	Post‐exam non VR	p‐value (within group)	Pre‐exam VR	Post‐exam VR	p‐value (within group)	p‐value (between groups, pre‐exam)	p‐value (between groups, post‐exam)
Elevator (Hylin)	2.0	+1.37	p < 0.001 *	1.63	+2.22	p < 0.001 *	p = 0.746 **	p = 0.004 **
Explorer	2.60	+0.87		2.21	+1.94
Surgical Forceps	2.32	+1.55		2.18	+1.82
Langenbeck	2.06	+1.36		1.83	+2.27
Luxator	1.84	+1.58		1.68	+2.27
Needle Holder	2.35	+1.07		2.32	+1.09
Pean	1.60	+1.77		2.28	+0.66
Rougine	3.05	+0.32		2.68	+1.64
Blade Shaft	2.95	+0.47		3.05	+1,15
Excavator	1.68	+.76		1.89	+1,47
Mean Overall	2.25	3.85		2.18	3.41

^*Paired t‐test

^**unpaired t‐test.

In addition, changes in student confidence for identifying each surgical tool in each learning method were also evaluated. The Non‐ and VR‐group showed higher confidence scores between pre‐ and post‐exam, as illustrated in Table 1 (p < 0.0001 for all tools).

When comparing the VR and Non‐VR groups, Table 1 shows that the Non‐VR group demonstrated higher student confidence levels for most instruments compared to the VR group, particularly for the Rougine and Blade shaft. Note that the student confidence for the Pean tool was lower for the Non‐VR group, despite this group having a higher frequency of correct answers for this tool.

3.4. Questionnaire Analysis

The results are summarized in Table 2.

TABLE 2.

Students’ responses from the questionnaire were measured using a 7‐point Likert scale: 1 – Totally Disagree, 2 – Disagree, 3 – Somewhat Disagree, 4 – Neutral, 5 – Somewhat Agree, 6 – Agree, 7 – Totally Agree. The responses are categorized into three subgroups, assessing perspectives on software, hardware, and educational aspects.

Statement	Mean + SD
Software
The instruments are displayed accurately in the system.	5.72 ± 1.27
The VR environment felt immersive and engaging.	6.61 ± 0.60
The haptic feedback enhanced my sense of immersion.	5.00 ± 1.87
Hardware
The VR glasses and controllers made it difficult to complete the training.	5.88 ± 1.27
I could touch virtual objects appropriately.	6.27 ± 0.57
I could track my hands in the VR accurately.	6.33 ± 1.03
I did not experience nausea, headache or dizziness during the VR scenario.	6.00 ± 1.45
It was comfortable to use the VR headset.	6.44 ± 0.92
Education
To what extent do you feel that you have learned something new inside the VR experience?	5.38 ± 1.24
I think this application will be useful for dental students, as it helps them understand and memorize the usage of surgical instruments.	5.94 ± 1.11
I see VR as a necessary tool for teaching in oral surgery.	4.89 ± 1.78
Overall
How well would you rate your experience?	6.33 ± 0.68

Regarding the software, most students agreed that the instruments were accurately presented in the VR scenario (5.72 ± 1.27). They strongly agreed that the VR scenario was immersive (6.61 ± 0.60) and felt that the haptic feedback significantly enhanced the experience (5.00 ± 1.87).

With respect to the hardware, students largely found that the VR headset did not limit their training (5.88 ± 1.27). The majority did not experience any side effects in the VR scenario (6.00 ± 1.45) and reported that the training felt comfortable (6.44 ± 0.92). They also found it easy to track their hands appropriately (6.33 ± 1.03) and to touch objects within the VR environment (6.28 ± 0.57).

Pertaining to educational aspect, most students agreed that they learned something new during the VR training (5.39 ± 1.24). They also believed that VR is a useful tool for oral surgery education (5.94 ± 1.11). However, students only partially agreed that VR is a necessary component of their education (4.89 ± 1.78).

In overall opinions, the overall experience of using VR for surgical instrument training was rated as good (mean = 6.33, SD = 0.68; scale endpoints: 1 = “really bad” to 7 = “really good”). All participants indicated that they would recommend the training experience to others.

While students expressed general satisfaction with the VR training, they also provided valuable feedback for improvement. The most common suggestion was addressing the lack of sharp visual details in the VR environment, which was in accordance with the results related to instrument identification.

3.5. Significant Correlations

Correlation analysis was performed to examine the relationships between VR experience and other variables collected in the questionnaire. Initially, several positive correlations were observed between VR experience and other variables. However, after applying the Holm–Bonferroni correction, the only significant correlation identified was between VR experience and the frequency of playing video games (R = −0.422, p < 0.001). A correlation heat map was generated to visualize the strength and direction of relationships between variables assessed in the VR questionnaire (Figure 4).

FIGURE 4.

The heat map displays Spearmann correlation coefficients between all pairs of variables, with color intensity reflecting the strength of the correlation: positive correlations are shown in shades of red, while negative correlations are shown in shades of blue.

4. Discussion

This study evaluated the effectiveness of VR‐based training compared to traditional methods in improving students' surgical instrument identification skills and confidence. With the increasing integration of VR technology in dental education, it is essential to understand its strengths and limitations, particularly in preparing students for clinical practice. The results revealed significant differences in learning outcomes between the VR and non‐VR groups. Therefore, the null hypothesis stating that there would be no difference in undergraduate dental students' ability to recognize surgical instruments between those trained using VR‐based methods and those trained using traditional teaching methods was rejected.

While both groups showed improvements from pre‐ to post‐exam, the non‐VR group achieved significantly higher post‐exam scores (p = 0.003). Both groups reported increased confidence in identifying surgical instruments after training. However, the VR group's confidence scores were consistent across tools, suggesting that VR training effectively builds task‐specific confidence but may lack the pedagogic efficacy observed with traditional methods.

A potential explanation for this outcome lies in Mayer's Cognitive Theory of Multimedia Learning, which emphasizes that effective learning depends on the management of cognitive load [32]. While VR provides engaging and immersive experience, it also increases extraneous cognitive load, potentially diverting mental resources away from core learning objectives. According to Cognitive Load Theory, working memory can process up to seven novel pieces of information but is more effectively limited to handling 2–4 elements at a time [33]. Moreover, working memory can retain information for only about 20 s unless it is refreshed through repetition [33]. Working memory is essential for learning, but its limited capacity makes it vulnerable to overload, particularly when dealing with complex or unfamiliar concepts—in this case surgical instruments.

Cognitive load is influenced by three types of demands: Intrinsic load (mental effort required by the task), extraneous load (effort imposed by the learning environment), and germane load (effort required to pass new information into long‐term memory) [33, 34, 35]. In the context of VR training, adapting to VR controls and navigating the virtual environment can increase extraneous cognitive load, diverting mental resources away from the primary learning objectives [36]. Although most participants reported no major technical issues, some noted challenges such as screen freezing, blurry instruments, and inadequate hand‐tracking by the controllers, which could add a level of distraction and thus the extraneous load. In addition, the novelty of VR may have increased the intrinsic load, potentially interfering with the retention of instrument knowledge in long‐term memory. Castaneda et al. found that text in VR environments can act as a visual distraction, potentially hindering the learning process [37]. They suggested that incorporating a narrating voice can enhance learning outcomes more effectively than tactile interactions.

The impact of cognitive load was further highlighted in a similar study on VR and mandibular block anesthesia [38]. The study shows that the need to read on‐screen guidelines and to process visual information while administering a mandibular block can fragment learners' focus and increase cognitive workload, consequently resulting in a slower learning curve. To address these challenges, incorporating pre‐training phase and narrating voice together with text in our study could alleviate cognitive load and enhance learning outcomes. In contrast to VR, traditional training allows students to focus fully on the learning without the added cognitive burden of adapting to new technology. The tactile feedback and direct, real‐time supervision provided in traditional methods are essential for skill acquisition in oral surgery. These factors likely contributed to the non‐VR group's better performance. Lastly, while our study showed that VR can boost confidence after intervention—a positive outcome—it also poses the risk of overloading information for beginners who are unfamiliar with the technology.

At baseline, both groups had similar student confidence scores on the VAS scale (mean VR: 2.18, mean non‐VR: 2.25, p = 0.746). After the intervention, while both groups showed an improvement in confidence, the non‐VR group demonstrated significantly higher confidence scores than the VR group (mean VR: 3.41, mean non‐VR: 3.80, p = 0.004). Although the VR group had slightly lower confidence scores post‐intervention, these results confirm that the VR training is as effective as traditional methods in improving confidence. These findings align with previous research, which reported that both extended reality‐based and traditional training methods led to significant increases in self‐confidence in administrating mandibular block anesthesia [39]. Conversely, Pulijala et al. found that VR significantly improved confidence in orthognathic surgery, with VR‐trained participants outperforming the control group [31]. Since most of their participants were already familiar with surgical knowledge, anatomy, and instruments, they assumed that integrating a multisensory learning experience contributed to their increased confidence. Confidence is closely linked to training and experience. In our study, participants were not restricted from accessing external resources before the post‐test, such as classmates’ discussions, PowerPoint presentations, or textbooks. This exposure to supplementary materials may have provided additional knowledge, potentially contributing to increased confidence levels.

As a part of our questionnaire, we asked participants about their prior experience with VR and gaming activities. Although the majority (66.67%) reported having some experience with VR, most (77.78%) indicated that they have never played video games. Familiarity with game mechanics and controllers can make the transition to VR more intuitive for gamers, potentially reducing the cognitive load associated with learning in a VR environment [40]. Previous research suggests that VR‐based training may be better suited for individuals at an intermediate proficiency level rather than beginners [41].

The results of the present study are in line with the findings from Alsufyani et al., where traditional lectures on panoramic radiographic anatomy resulted in higher test scores than a VR‐based anatomical teaching tool [8]. Similarly, Slaidina et al. concluded that VR alone is insufficient for dental training in prosthodontics, which aligns with the results from the present study [21]. In a recent systematic review, Algarni et al. demonstrated that VR can improve motor skills, enhance performance, and boost confidence [11]. Another systematic review concluded that, while VR is regarded as a useful component of dental education, it cannot fully replace conventional learning methods [42].

VR has been identified to provide a higher level of efficacy within certain teaching scenarios in dentistry. Chen et al. found that VR in orthodontics can be superior to PowerPoint Presentations [43]. In their study, they developed a comprehensive virtual learning environment focused on Class II Division 1 using real patient data. Their findings indicated that students not only demonstrated higher engagement and motivation but also perceived VR as a more effective and useful learning tool compared to conventional methods. Likewise, Choi et al. observed that a VR group had significantly higher levels of understanding in tooth removal procedures and greater satisfaction with the observation experience compared to a control group [44]. Furthermore, when students need to perform hands‐on parts of the scenarios (e.g., bone removal or cavity preparation), VR appeared to be more effective than traditional learning methods.

Another study highlighted VR as a useful tool for learning apexification, resulting in a higher exam grade [12]. Moussa et al., in their systematic review, found that the most notable improvements from VR training were observed in cavity wall convergence, pulpal floor preparation, extension of Class I cavity outlines, reduced pulpal exposure, and faster preparation times [17]. However, the acquisition of theoretical knowledge was less pronounced.

Although the findings from the present study provide valuable insights into VR training, such as improved post exam scores, increased student confidence, and positive acceptance and preference from the questionnaire, certain limitations must be acknowledged. The sample size was small, and we only tested novice students. To fully understand VR's potential and consider its wider use in oral surgery education, it should also be tested with more experienced students and clinical instructors. In addition, as noted in the comments section from questionnaire, some instrument details in the VR environment were not clear enough, especially for the Luxator and Elevator. Future work should focus on improving the sharpness and distinctiveness of these tools or adding the option of magnification.

5. Conclusion

The findings indicate that VR, while valuable for building confidence, may not yet match the performance outcomes of traditional methods in surgical instrument identification. These findings suggest that VR is best utilized as a supplementary tool rather than a standalone method. A hybrid approach, combining VR with traditional training, may offer the most comprehensive preparation for clinical practice. As VR technology becomes more mature, it may play an important role in oral surgery education.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data is available on request from the authors.