Integrating first-person smart glasses video into oral and maxillofacial surgery education: a mixed-methods study on student learning and experience

Abstract

Background

Video-based and wearable technologies have the potential to enhance the learning experience by increasing visual access in clinical education, however these technological methods have limited evidence about the effects of observation awareness and learning experience of the interns in the dental clinical internship setting. The aim of this study was to evaluate how different clinical observation modalities used during implant surgery training affect students’ observational awareness, visibility of the surgical field, and overall learning experience in oral and maxillofacial surgery education.

Methods

A total of 95 participants from fifth-year dental students were included in the study and separated into three groups as traditional observation group, live video streaming group and hybrid observation (traditional observation + live video streaming) group. Following the observation, a questionnaire comprising qualitative and quantitative data was administered to the groups. Data were collected using a structured questionnaire and open-ended questions that assessed students’ observational awareness, learning experiences, and overall perceptions. Quantitative data were analyzed using Kruskal-Wallis and Dunn test (p < 0.05), while qualitative data were collected through semi-structured interviews and analyzed using inductive content analysis.

Results

Significant differences were found among the observation groups in terms of observational awareness, visibility of the surgical field, and perceived educational experience (p < 0.001). The hybrid observation group demonstrated significantly higher scores in following procedural steps, recognizing instrument usage, professional development, and clinical awareness compared with the traditional observation group (p < 0.001). Although no significant differences were found in most knowledge-based items, the hybrid group showed a higher correct response rate regarding radiological evaluation. Traditional observation group facilitated awareness of the clinical environment and professional interaction but remained limited in visual access, whereas live video observation improved visual clarity while providing a more limited contextual clinical experience. The qualitative findings indicated that the hybrid observation model provides a comprehensive learning experience by combining enhanced visual access with an awareness of the clinical context.

Conclusions

A hybrid observation model that combines traditional observation with live video streaming via smart glasses and provides a first-person perspective was associated with increased observational awareness, better visibility of the surgical field, and a more positive perception of the educational experience among dental students. While live video support enhances visual clarity, integrating video-assisted observation with direct clinical experience provides a more comprehensive and contextually rich learning experience. Hybrid observation environments may serve as a useful complementary educational approach for surgical training in dental education.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09896-z.

Introduction

Traditional face-to-face lessons remain an indispensable component of dental education for knowledge transfer [1]. The digital tools which are integrated in emerging technologies in dental education enhance the capacity of teaching and have emerged as a promising alternative approach. Technological innovations in education and teaching, together with increased student access to electronic resources, have increased the importance of different teaching methods [2, 3]. Especially voice and video records, virtual reality and methods such as haptic technologies have become an indispensable part of practical skill training in medical and dental education in recent years [4]. These developments facilitate the adoption of new approaches that support and enrich educational models.

In practical dental education, video-based training aims to provide students’ competencies in a standardized and efficient manner. This training method is used as an effective tool to improve and enhance the conventional education and to promote long-term retention [5]. Benefits of this training model are specified in terms of teaching practical competencies and their transfer to clinical practice [6, 7]. One of the major limitations of live monitoring in clinical training is that intraoral procedures cannot be viewed by all students from the same perspective and with adequate clarity [8]. Reports addressing the effectiveness and perception of video lectures as a learning tool in health education are promising [9]. Studies have shown that medical students achieve similar test results following both live lectures and video-based instruction; while some students prefer live lectures, others favor video-based learning because it allows them to progress at their own pace and review the content as needed [10, 11]. Existing studies also reveal certain challenges of video-based educational methods as perceived by students. Students may report being restricted to a single point of view, being unable to observe the working position of the dentist while performing the procedure, being unable to observe the reactions of the patient and experiencing distraction during video viewing. This issue results from passive observation of the educational material, highlighting the disadvantages of this non-interactive, one-way learning model [12, 13]. One of the most significant disadvantages of the traditional educational model is that, due to limited physical space, students are restricted to viewing intraoral procedures from the perspective of an experienced instructor [7]. This subject becomes more pronounced, particularly in operating room–based procedures such as Oral and Maxillofacial Surgery and may prevent students from clearly observing the surgical field [14]. Therefore educators are seeking new methods and technologies to enable students to observe the surgical field more equitably, more clearly and from a closer perspective.

One of the latest technological developments is the use of wearable smart devices [14]. The emergence of hands-free, wearable, interactive technologies such as smart glasses has encouraged researchers to further investigate their potential roles in clinical education [15]. In dental education, smart glasses contribute to improved clinical care by emphasising both distance learning and clinical practice. Integration of smart glasses in dentistry offers several advantages. They significantly enhance the dentists’ workflow by enabling hands-free access to core knowledge, optimizing the clinical processes, and saving time. In dental education, smart glasses provide significant benefits by capturing the clinical procedures from the practitioner’s point of view and offering valuable learning experience for students [14].

Most existing research focuses on the preclinical training period while studies evaluating clinical training environments remain insufficient. This inadequacy prevents a full understanding of the potential of video-supported methods during the critical internship period, in which dental students develop their clinical skills on real patients. Therefore, this study aimed to investigate the effects of three different methods used in dental clinical internship training [traditional internship observation, live video monitoring of the surgical procedure via a monitor in the classroom, and a hybrid educational method (the combination of traditional observation and live video monitoring of the surgical procedure)] on students’ knowledge level, clinical awareness, observation skills, and overall learning experience. It is anticipated that the data obtained from this study will contribute to the development of student-centered, multi-observer–based teaching approaches in clinical surgical education, the standardization of hybrid educational models, and the establishment of a scientific basis for future clinical training protocols. The present study evaluated hybrid observation as a multifactorial educational environment integrating direct clinical observation and first-person video-assisted visualization.

The following hypotheses were tested in this study:

[1] Different surgical observation methods may be associated with differences in students’ observational awareness, visibility of the surgical field, and educational experience.

[2] The hybrid observation model, which combines direct clinical observation with first-person video-assisted visualization, may offer a more comprehensive observational and contextual learning experience than conventional observation methods.

Methods

Ethical approval and study design

This study received ethical approval from the Non-Interventional Clinical Research Ethics Committee of Uşak University Faculty of Medicine, (decision no. 28), issued at its meeting on September 11, 2025. The study was conducted in accordance with the relevant ethical principles and regulations set forth in the Declaration of Helsinki. This study adopted a sequential explanatory mixed-methods educational design with group allocation. Students were assigned to observation groups during the quantitative phase, and qualitative data were subsequently collected from same participants to further explain and contextualize the quantitative findings [16]. The primary outcome of this study was students’ observational and educational experiences related to observing surgical procedures, specifically visibility of the surgical field, the ability to follow the steps of the procedure, and perceived educational benefits.

Sample size

The sample size of the study was calculated using G*Power 3.1.9.7 software. The calculation was based on an omnibus comparison among three independent observation groups in the quantitative phase of the study (3 group, ANOVA) [1, 17]. Type I error rate of α = 0.05 was adopted. In the power analysis, for a three-group comparison (Cohen’s f = 0.4), the parameters were set at α = 0.05 and power = 0.80. According to analysis conducted for three groups, the required total sample size was calculated as 84. This method was preferred to ensure that the study achieves adequate statistical power.

Participants

This study included 95 students (47 male and 48 female participants), with an average age of 23.1 ± 0.9, who were 5th-year students at Uşak University Faculty of Dentistry and fully completed the questionnaire. Students were informed about the study on September 15, 2025, before starting their surgical internship. The clinical observation sessions and questionnaire administration were completed on September 16, 2025. The questionnaires were administered immediately after the observation sessions on the same day.

Inclusion criteria for the study are as follows:

• Fifth-year dental students at Uşak University Faculty of Dentistry.

• Students who had not yet started their Oral and Maxillofacial Surgery internship during the study period.

• Students who voluntarily agreed to participate in the study.

Exclusion criteria for the study are as follows:

• Students who declined to participate in the study.

• Students who were absent on the observation day.

• Students who had prior implant surgery observation experience outside the standard undergraduate curriculum.

• Students who did not complete the questionnaire in full.

• Students who were unable to observe both the surgical procedure and the monitor simultaneously.

• Students with a limited field of vision.

• Students with visual impairments.

Participant allocation and observation groups

During the study period, eligible fifth-year dental students who had not yet begun their Oral and Maxillofacial Surgery rotation were invited to participate in the study. Therefore, no separate sampling procedure was applied, and eligible individuals (n = 95) were included in the study (Fig. 1). Randomization was used solely to assign participants to observation groups; it was not used for participant selection. Group allocation was performed by a researcher not involved in data collection or questionnaire administration using Randomizer.org. The allocation sequence was generated prior to the observation sessions, and students were informed of their assigned groups immediately before the educational intervention. Due to the educational nature of the intervention, blinding of participants was not possible. To minimize potential carryover between groups, students assigned to different observation methods were placed in separate classrooms before and during the observation sessions. Additionally, participants were not informed about the characteristics of the alternative observation methods prior to participation. To further reduce the likelihood of information exchange between groups, all observation sessions and survey administrations were completed on the same day.

Fig. 1.

Flowchart of the research process

Fifth-year students of Uşak University Faculty of Dentistry were initially grouped to ensure an equal sample size in each group. However, considering the exclusion criteria, variations occurred in the sample sizes of the groups. The statistician confirmed that the minimal differences in sample sizes between the groups would not affect the statistical analyses. According to the resulting list, the students were assigned to “Traditional Observation”, “Live Video Streaming” and “Hybrid Observation” groups, respectively. Randomization process was conducted by a neutral researcher who was not involved in the data collection process. Group allocation was concealed until the observation day, and students were not informed about alternative observation methods to minimize performance bias. Representative sample illustrations and images of the study groups are presented in Figs. 2 and 3. The definitions of the study groups are as follows.

Fig. 2.

Illustration of the study sites and observation methods [(A) Traditional observation group, B Live video observation group, C Hybrid observation group]

Fig. 3.

Observation models used in the study [(A) Traditional observation group (Group 1), in which students observed the surgery inside the operating room; B Live video observation group (Group 2), in which students observed the surgery in real time via a live video feed; C Hybrid observation group (Group 3), in which students observed the surgery inside the operating room with simultaneous monitor support; D Monitor view used for live video–supported observation in the hybrid group]

Traditional observation group (group 1)

The students observed the surgical procedures in the operating room in person, and followed the process under the guidance of a lecturer. No video recording or live video streaming support was provided during the surgical procedures. This method represents a traditional operating room-based observation widely used in dental clinical education.

Live video streaming group (group 2)

Students in this group followed the surgical procedures via live video streaming on a monitor located in the classroom, separate from the operating room. Students did not have physical access to the operating room.

Hybrid observation group (group 3)

Students in this group followed the surgical procedures both through traditional in-person observation and live video streaming on a monitor located in the operating room.

Video recording and live streaming system

The video recordings used in the study were obtained using Ray-Ban Meta Wayfarer smart glasses (Ray-Ban, EssilorLuxottica, Milan, Italy). Ray-Ban Meta smart glasses were preferred due to their lightweight design, first-person perspective camera alignment, suitability for use in sterile environments and real-time wireless transmission capability without the need for additional equipment. These smart glasses feature a 3024 × 4032 pixel camera resolution, a 4-hour charging time, dual speakers, 5 microphones (Fig. 4). They can be controlled via touch or voice and feature Wi-Fi-based live video streaming capabilities. Images were recorded from the first-person (trainer) surgical specialist’s perspective, and the camera was positioned within the surgeon’s natural line of sight to ensure a clear view of the patient’s oral tissues.

Fig. 4.

Ray-Ban Meta Wayfarer smart glasses used for video recording

Live video streaming was carried out through a closed broadcasting system accessible only to the observation groups. For this purpose, a private, password-protected account was created on the Instagram platform and throughout the study. The account was managed exclusively by the research team, with access restricted to relevant student groups for a limited time. Data privacy was maintained throughout the broadcast, and patients’ facial areas and identifying information were not visible at any stage. The footage obtained during the broadcast was not downloaded, archived or shared with third parties; they were used solely for simultaneous educational purposes. Following completion of the study, the account was permanently deactivated, and no digital broadcast content was stored.

Live video streaming and video viewing were carried out using tablets. The tablets used in both the hybrid group and the live video group were standard devices with a 10.4-inch screen size and a resolution of 2000 × 1200 pixels. The tablets were placed in the operating room and in the Faculty of Dentistry student study room. In both the hybrid and live video groups, equal distance between the students and the tablets was taken into consideration. During transmission, video quality, colour contrast, and synchronization were monitored by a member of the research team and no technical malfunctions were observed. This equipment and transmission system were selected to enhance the quality of educational observation of surgical procedures and enable students to evaluate the procedures from multiple perspectives (Fig. 5).

Fig. 5.

Monitor view used for real-time video-supported observation during the surgical procedure

Data collection tools and procedure

This study was conducted among undergraduate students studying at Uşak University Faculty of Dentistry who participated in the Oral and Maxillofacial Surgery observation internship during the 2025–2026 academic year.

The surgical procedures performed in the posterior jaw region (molar implant surgery) were evaluated within the scope of the research. Implant surgeries performed in the molar region were included in this study because access to this area is difficult and the field of vision is limited, which can negatively affect students’ visual learning experience. However, the aim was to ensure that the training provided was of equal standards by conducting the study in similar regions. Depending on the clinical indication, procedures could be performed on the right or left side in the same patient. The total number of patients included was 7. The study included standardized single-tooth implant surgeries performed in the posterior maxillary and mandibular regions according to clinical indication. Cases included one or bilateral single-tooth implant procedures, multiple single-tooth implant placements on the same side, or single-tooth implant procedures in different jaws in the same patient. Each observation session included five students. It was ensured that all student groups were given similar visibility and that there were no differences in direct visual access. Additionally, students were asked for their approval regarding this matter. All surgical procedures were carried out by a surgical same specialist in accordance with faculty standard protocols. The patients were informed that participation in the study was voluntary and that video recording would not affect the operation or the duration of it. In addition, students were informed that completion the questionnaire was voluntary and that their responses would not affect their academic status or individual performance.

In this study, a custom designed survey form was used to collect both quantitative and qualitative data. Questionnaire form was refined by the study team and a statistical consultant after reviewing comparable studies in literature. The draft of the questionnaire was submitted for expert review to assess its alignment with the study objectives, scope, clarity of statements, and content validity and was finalized following the necessary revisions based on the feedback received. The first section (Section A) of the questionnaire (Appendix-1), consists of four questions related to the surgical area, the procedure performed, the anesthesia method used, and the radiological evaluation, designed to measure students’ knowledge and awareness of the procedure during observation. The quality of observation and its educational contribution were assessed using thirteen Likert-type items of the second section (Section B, C, and D) of the questionnaire. The third section of the questionnaire (Section E) consists of an open-ended question that allows participants to evaluate their general views and experiences regarding the observation method in detail. The initial draft of the questionnaire was reviewed by four experts with experience in oral and maxillofacial surgery education and biostatistics to assess the clarity, appropriateness, and comprehensibility of the items. Based on the experts’ recommendations, some changes were made to improve the wording and structure of the questionnaire. The final version of the questionnaire was developed after consensus was reached among the experts. The reliability of the questionnaire was assessed through a pilot study, who were not included in the final study sample, conducted with 30 students [18] and Cronbach’s alpha coefficient was calculated as 0.953, which indicates excellent reliability.

Statistical analysis

The process of analyzing quantitative data

Quantitative data were analyzed using R version 4.6 (R Core Team) [19]. Descriptive statistics were presented as frequencies (n) and percentages (%) for categorical variables, and as medians, means (M), and standard deviations (SD) for Likert-type items.

Differences among the three observation methods (traditional, live-stream, and hybrid) were evaluated using the following statistical procedures. For the four knowledge questions (Q1–Q4), group × response contingency tables were constructed based on correct/incorrect classifications. Because expected cell frequencies were below 5, Fisher’s Exact Test with Monte Carlo simulation (B = 20,000) was applied, and Pearson’s chi-square test with Monte Carlo simulation (B = 10,000) was performed for reference purposes. Effect sizes were reported using Cramer’s V with corresponding 95% confidence intervals (CIs). For Q3 and Q4, pairwise group comparisons were further evaluated using odds ratios (ORs) with 95% CIs. For the remaining Likert-type items (Q5–Q17), both Pearson’s χ²/Fisher’s Exact tests (Monte Carlo simulation) and the Kruskal–Wallis test for independent samples were conducted. The effect size for the Kruskal–Wallis test was calculated as η². For items showing significant Kruskal–Wallis results, pairwise group comparisons were performed using Dunn’s post hoc test with Holm correction.

In addition, section-based Kruskal–Wallis analyses were conducted using total scores calculated for each of the four questionnaire sections. To control for multiple comparisons, Bonferroni, Holm, and Benjamini–Hochberg false discovery rate (FDR) corrections were applied to the Likert-type items, with a Bonferroni-adjusted significance threshold of α = 0.0038.

Internal consistency reliability was assessed for each Likert-type section and for the overall scale using Cronbach’s alpha coefficients. A p-value < 0.05 was considered statistically significant for all analyses.

The process of analyzing qualitative data

In this study, the Standards for Reporting Qualitative Research (SRQR, Appendix-2) were followed to enhance the methodological rigor, transparency, and credibility of the qualitative results [20, 21], enabling readers to apply or transfer the results to their own situations, contexts, time, and populations [22, 23]. This study was conducted using a phenomenological qualitative research design in order to explore dental students’ perceptions and learning experiences related to surgical observation in depth. Phenomenology is an approach that aims to elucidate individuals’ experiences, perceptions, and the meanings they attribute to a particular phenomenon [24]. For this reason, it was chosen as an appropriate method to understand students’ experiences with different surgical observation methods.

The study sample consisted of students who participated in implant surgery trainings held at a faculty of dentistry and experienced three different surgical observation methods. In the qualitative data collection process, a purposive sampling strategy was used to reveal how students’ perceptions of their viewing experiences were shaped within the context of different levels of knowledge. Criterion sampling, a type of purposive sampling methods was used. The criteria included participation in the relevant surgical observation and voluntary provision of feedback regarding the experience. Within this context, based on the responses to the knowledge assessment questions administered after the surgical observation process, students with the highest and lowest levels of knowledge were identified in each observation group. Participants were selected to represent approximately two-thirds of each observation group (Group 1: n = 23, Group 2: n = 19, Group 3: n = 21). The aim is to represent the diversity of experiences within the group while maintaining qualitative data depth and ensuring data saturation. Thus, the aim was for the qualitative data to reflect not only average experiences but also experiential diversity and extremes. In total, three groups were evaluated according to the surgical observation methods.

In-depth interviews, one of the fundamental methods of qualitative research, are most frequently used in healthcare settings and represent one of the most established qualitative data collection methods. Such in-depth interviews are typically semi-structured, based on a small number of preplanned open-ended questions, and follow a progression-based line of inquiry. The strength of in-depth interviews lies in their ability to analyze the research topic in depth and in detail from participants’ perspectives [25]. The data were collected through a semi-structured interview form developed by researchers. In-depth interview questions were designed in a non-directive and open-ended manner to enable students to comparatively evaluate their experiences with different observation methods. The same questions were asked of all participants, and were asked to respond based on their own experiences with the observation method they had undergone. In-depth interviews were conducted after obtaining participants’ written informed consent, and were audio recorded. Interviews continued until thematic saturation was achieved, meaning no substantially new themes emerged from additional interviews.

Questions

• How would you generally describe the surgical observation method you experienced? What were the most important aspects of this experience for you in terms of its contributions to your learning and professional development?

• How did your level of visibility of the surgical field affect your ability to understand and follow the surgical procedure?

• During this observation process, which aspects do you think you gained the most insight into? (e.g., use of surgical instruments, doctor–patient communication, ergonomics)

• What are the strengths and limitations of the observation method you experienced?

• Is there anything else you’d like to add regarding your experience observing the surgery?

At the end of the in-depth interviews, participants were asked whether they had any additional comments. During the in-depth interviews, the concept of data saturation, which is commonly used in qualitative research on oral health [26, 27] and has been extensively studied in the research community [28], was applied. Participants were asked to reflect on their answers during the interviews until data saturation was achieved or no new information was obtained. The data collection process was terminated when new themes or concepts began to recur during the interviews, and additional interviews failed to make a meaningful contribution to the existing themes. This approach ensured that each group adequately reflected the diversity of experiences within the group. Interviews lasted an average of 30 min. All audio recordings were transcribed word for word after the interviews and prepared for qualitative analysis.

The data obtained were analyzed using the content analysis method. The analysis process began with researchers becoming familiar with the data by repeatedly reading all interview transcripts. Following this stage, meaningful statement units relevant to the research purpose were identified from the participants’ statements and these units were coded. The coding and theme creation processes were carried out using MAXQDA Analytics Pro (version 24.4.1) software to ensure the systematic organization of the data. MAXQDA software was chosen because it allows for the systematic coding of qualitative data, visual and analytical comparison of themes, and transparent monitoring of the analysis process. The analysis process was conducted using an inductive approach, with themes derived directly from participant statements without relying on a predetermined framework. Frequency values were used to more transparently reveal the dominance and distribution of the themes. However, these frequencies are not intended for quantitative generalization; they only aim to show the relative importance of themes and their level of visibility within the data. This approach is consistent with the descriptive quantification framework recommended in qualitative research.

The coding process was conducted independently by two researchers in order to enhance the reliability of the qualitative analysis process. Researchers independently reviewed the interview transcripts, identified meaningful units of meaning, and generated preliminary codes. Following the independent coding process, the codes were compared, and areas of disagreement were discussed and resolved. Inter-coder agreement was assessed using Cohen’s kappa coefficient, with a kappa value (κ = 0.79) indicating good agreement. The interviews were conducted by researchers experienced in oral and maxillofacial surgery education who were not involved in the academic assessment of the participating students. To minimize potential researcher bias, a neutral and non-directive interview approach was adopted during data collection. Reflexive discussions were conducted throughout the coding and analysis process, and independent coding by two researchers followed by consensus meetings helped reduce subjective interpretation and enhance analytic rigor. In order to ensure the rigor of qualitative research, the principles of credibility, dependability and confirmability suggested by Lincoln and Guba [29] were taken into consideration. The methodological rigor of the study was addressed in accordance with the reliability criteria suggested in qualitative research. Transferability was strengthened by detailed reporting of the research context, sample characteristics, and data collection process. Dependability and confirmability were supported by systematically conducting the analysis process, clearly defining the coding steps, and reaching a consensus among researchers [30]. This process is consistent with current literature recommendations for increasing methodological rigor in qualitative research [24, 31].

Quantitative results

Descriptive characteristics of the participants

A total of 95 fifth-year dental students participated in the study. Participants were distributed across three observation groups: traditional observation (n = 35; 36.8%), live video streaming observation (n = 29; 30.5%), and hybrid observation (n = 31; 32.6%) (Table 1).

Table 1.

Distribution of Participants According to Observation Method

Observation Group	n	%
Group 1	35	36.8
Group 2	29	30.5
Group 3	31	32.6
Total	95	100.0

[Group 1 (Traditional observation), Group 2 (Live video streaming observation), Group 3 (Hybrid observation)]

Comparison of knowledge questions (Section A: Q1–Q4)

No statistically significant differences were observed among the groups regarding knowledge of the anatomical region operated on (Q1), the name of the surgical procedure performed (Q2), or the anesthesia method used (Q3) (Fisher’s Exact Test, all p > 0.05; Cramer’s V indicated small effect sizes). For the correct identification of the preoperative radiological assessment (Q4), a significant difference was observed between groups at the unadjusted level (Fisher’s Exact Test, p = 0.041, Cramer’s V = 0.27, 95% CI [0.00, 0.46]); however, this difference did not remain significant after correction for multiple comparisons (Holm-adjusted p = 0.165; FDR-adjusted p = 0.164) (Table 2).

Table 2.

Correct Response Rates and Between-Group Comparisons for Knowledge Questions (Q1–Q4)

Item	Subject	Group 1%ᵃ	Group 2%ᵃ	Group 3%ᵃ	χ² (df = 2)	Fisher p	pFDR	Cramer’s V [%95 GA]	Effect
Q1	Anatomical Region	94.3	100.0	100.0	3.50	0.328	0.328	0.19 [0.00, 0.37]	Small
Q2	Surgical Procedure	94.3	100.0	100.0	3.50	0.328	0.328	0.19 [0.00, 0.37]	Small
Q3	Anesthesia Method	82.9	96.6	96.8	5.47	0.111	0.227	0.24 [0.00, 0.42]	Small
Q4	Preoperative Radiological Assessment	77.1	93.1	96.8	7.08	0.041	0.164	0.27 [0.00, 0.46]	Small

Because the expected cell frequencies were below 5, Fisher’s Exact Test with Monte Carlo simulation (B = 20,000) was used; χ² values are provided for reference purposes. The 95% confidence intervals (CIs) for Cramer’s V were calculated using the bootstrap method. pFDR = Benjamini–Hochberg false discovery rate correction. CI = confidence interval. ᵃPercentage of participants providing the correct response [Group 1 (Traditional observation: n = 35), Group 2 (Live video streaming observation: n = 29), Group 3 (Hybrid observation: n = 31)]

Additionally, the Kruskal–Wallis test conducted on the total Section A score revealed a significant difference among the groups (H [2] = 14.37, p < 0.001, η² = 0.13, indicating a medium effect size). However, no individual item remained statistically significant after adjustment for multiple comparisons.

Pairwise odds ratio analyses showed that students in the hybrid observation group were approximately 8.65 times more likely to correctly identify the preoperative radiological assessment (Q4) than those in the traditional observation group (OR = 8.65, 95% CI [1.05, 406.43], p = 0.030). In contrast, the difference between Group 1 and Group 2 was not statistically significant (OR = 3.92, 95% CI [0.69, 41.27], p = 0.097) (Table 2). The wide confidence intervals reflect the limited sample size.

Comparison of likert-type items (Sections B, C, and D: Q5–Q17)

Statistically significant differences were observed among the groups for all thirteen Likert-type items (Kruskal–Wallis H [2] range = 23.12–60.62, all Holm-adjusted p-values < 0.001). The calculated η² values ranged from 0.23 to 0.64, indicating large effect sizes for all items according to Cohen’s criteria (1988) [32]. Across all items, the hybrid observation group demonstrated the highest mean ranks, whereas the traditional observation group consistently showed the lowest mean ranks (Table 3).

Table 3.

Descriptive Statistics and Kruskal–Wallis Test Results for Likert-Type Items (Q5–Q17)

Item	Group 1 M (SD)	Group 2 M (SD)	Group 3 M (SD)	H (df = 2)	pHolm	η²	Effect
Q5.Hand positioning/technique	2.60 (0.81)	4.00 (0.46)	4.45 (0.51)	59.40	< 0.001	0.62	Large
Q6. Sequence of instrument use	3.03 (0.98)	3.93 (0.59)	4.42 (0.62)	34.48	< 0.001	0.35	Large
Q7.Ease of maintaining attention	2.54 (1.07)	3.86 (0.44)	4.65 (0.49)	60.62	< 0.001	0.64	Large
Q8.Clear observation of procedural steps	2.23 (1.00)	3.90 (0.49)	4.45 (0.57)	59.93	< 0.001	0.63	Large
Q9.Surgeon–patient communication	3.91 (0.74)	4.07 (0.59)	4.68 (0.48)	24.63	< 0.001	0.25	Large
Q10. Surgical planning	2.37 (0.94)	3.76 (0.74)	4.32 (0.70)	51.30	< 0.001	0.54	Large
Q11.Complication management	2.40 (1.12)	3.66 (0.94)	4.32 (0.65)	40.86	< 0.001	0.42	Large
Q12.Surgeon’s explanations	3.31 (0.90)	3.93 (0.46)	4.68 (0.54)	44.90	< 0.001	0.47	Large
Q13.Integration of theory and practice	2.80 (0.76)	3.90 (0.49)	4.58 (0.56)	57.18	< 0.001	0.60	Large
Q14.Clinical observation skills	2.89 (0.93)	3.93 (0.75)	4.58 (0.56)	46.84	< 0.001	0.49	Large
Q15.Contribution to professional development	3.09 (0.74)	4.21 (0.56)	4.58 (0.56)	49.45	< 0.001	0.52	Large
Q16.Decision-making under stress	3.14 (0.85)	4.10 (0.56)	4.32 (0.60)	35.30	< 0 0.001	0.36	Large
Q17. Patient behavior/stress	3.46 (0.89)	4.10 (0.49)	4.39 (0.72)	23.12	< 0.001	0.23	Large

Likert scale: 1 = Strongly Disagree to 5 = Strongly Agree. [Group 1 (Traditional observation: n = 35), Group 2 (Live video streaming observation: n = 29), Group 3 (Hybrid observation: n = 31)]. H = Kruskal–Wallis test statistic. η² = Kruskal–Wallis effect size (epsilon-squared estimate). pHolm = Holm–Bonferroni adjusted p-value. Effect size classifications were based on Cohen’s (1988) criteria

Pairwise group comparisons (dunn post-hoc test with holm correction)

Results of the Holm-adjusted Dunn post-hoc analyses indicated that the hybrid observation group scored significantly higher than the traditional observation group on all thirteen Likert-type items (all adjusted p-values < 0.001). The live-stream observation group scored significantly higher than the traditional observation group on all items except Q9 (surgeon–patient communication), for which no significant difference was observed (adjusted p = 0.504). Comparisons between the hybrid and live-stream groups revealed significant differences favoring the hybrid group on nine items. No significant differences were found between these two groups for Q15 (contribution to professional development), Q16 (decision-making under stress), and Q17 (patient behavior/stress), whereas Q9 showed a significant advantage for the hybrid group (Table 4).

Table 4.

Summary of Pairwise Comparisons for Likert-Type Items (Dunn–Holm Post-hoc Tests)

Item	Group 1 – Group 2	Group 1 – Group 3	Group 2 – Group 3
Q5	z = 5.16, padj < 0.001	z = 7.46, padj < 0.001	z = 2.11, padj = 0.035
Q6	z = 3.28, padj = 0.002	z = 5.83, padj < 0.001	z = 2.38, padj = 0.017
Q7	z = 3.95, padj < 0.001	z = 7.78, padj < 0.001	z = 3.58, padj < 0.001
Q8	z = 4.97, padj < 0.001	z = 7.56, padj < 0.001	z = 2.38, padj = 0.017
Q9	z = 0.67, padj = 0.504 (ns)	z = 4.67, padj < 0.001	z = 3.81, padj < 0.001
Q10	z = 4.59, padj < 0.001	z = 7.00, padj < 0.001	z = 2.22, padj = 0.026
Q11	z = 3.80, padj < 0.001	z = 6.31, padj < 0.001	z = 2.33, padj = 0.020
Q12	z = 2.40, padj = 0.017	z = 6.66, padj < 0.001	z = 4.03, padj < 0.001
Q13	z = 4.22, padj < 0.001	z = 7.51, padj < 0.001	z = 3.07, padj = 0.002
Q14	z = 3.76, padj < 0.001	z = 6.81, padj < 0.001	z = 2.85, padj = 0.004
Q15	z = 4.75, padj < 0.001	z = 6.79, padj < 0.001	z = 1.87, padj = 0.061 (ns)
Q16	z = 4.32, padj < 0.001	z = 5.61, padj < 0.001	z = 1.16, padj = 0.244 (ns)
Q17	z = 2.76, padj = 0.012	z = 4.77, padj < 0.001	z = 1.87, padj = 0.062 (ns)

Dunn post-hoc comparisons were adjusted using the Holm–Bonferroni procedure. Positive z-values indicate that the second group had a higher mean rank than the first group. ns = non-significant (adjusted p > 0.05). [Group 1 (Traditional observation), Group 2 (Live video streaming observation), Group 3 (Hybrid observation)]

Comparison of section total scores

Kruskal–Wallis tests conducted on the aggregated scores of the three Likert-based subscales revealed significant between-group differences with large effect sizes across all sections: Observation Quality (Section B), H(2) = 69.47, p < 0.001, η² = 0.73; Surgical Process and Learning Contribution (Section C), H(2) = 65.17, p < 0.001, η² = 0.69; and Emotional/Clinical Observation (Section D), H(2) = 33.68, p < 0.001, η² = 0.34. A significant difference with a large effect size was also observed for the total score of the thirteen-item Likert scale, H(2) = 68.05, p < 0.001, η² = 0.72 (Table 5). Effect size classifications were based on Cohen’s (1988) criteria [32]. (Table 5).

Table 5.

Kruskal–Wallis Comparisons for Section Total Scores

Sections	Items	H (df = 2)	pHolm	η²	Effect
A. Knowledge and Awareness	Q1–Q4	14.37	< 0.001	0.13	Medium
B. Observation Quality	Q5–Q9	69.47	< 0.001	0.73	Large
C. Surgical Process and Learning Contribution	Q10–Q15	65.17	< 0.001	0.69	Large
D. Emotional/Clinical Observation	Q16–Q17	33.68	< 0.001	0.34	Large
Total Likert Scale	Q5–Q17	68.05	< 0.001	0.72	Large

pHolm = Holm–Bonferroni adjusted p-value. Effect size classifications were based on Cohen’s (1988) criteria

Scale internal consistency

Cronbach’s alpha coefficients indicated high internal consistency for all subscales and for the overall Likert-type scale. The Observation Quality subscale (Section B) yielded a Cronbach’s α of 0.89, indicating good reliability. The Surgical Process and Learning Contribution subscale (Section C) demonstrated excellent internal consistency with α = 0.92. The Emotional/Clinical Observation subscale (Section D) produced an α value of 0.85, reflecting good reliability. For the complete 13-item Likert scale (Q5–Q17), Cronbach’s α was 0.95, indicating excellent internal consistency according to the criteria proposed by Nunnally and Bernstein (1994) (Table 6) [33].

Table 6.

Cronbach’s Alpha Coefficients for the Scale and Subscales

Section	Items	k	n	Cronbach α	Interpretation
B. Observation Quality	Q5, Q6, Q7, Q8, Q9	5	95	0.89	Good
C. Surgical Process and Learning Contribution	Q10, Q11, Q12, Q13, Q14, Q15	6	95	0.92	Excellent
D.Emotional/Clinical Observation	Q16, Q17	2	95	0.85	Good
Total Likert Scale	Q5–Q17	13	95	0.95	Excellent

k = number of items. Interpretation criteria: α ≥ 0.90 = excellent; 0.80 ≤ α < 0.90 = good; 0.70 ≤ α < 0.80 = acceptable Nunnally & Bernstein, [33]

Qualitative Results

In this study, dental students’ perceptions of their surgical observation were analyzed using content analysis, and three main themes along with sub-codes associated with these themes were identified. The themes were analyzed comparatively according to surgical observation methods [group 1, group 2 and group 3]. Table 7 presents the main themes, associated sub-codes, and their frequency distributions, with each theme supported by direct student quotations. Thematic analysis was performed by coding meaningful statements and expressions related to the educational observation experience. Coding frequencies represent the number of coded segments identified during analysis rather than the number of individual participants, as a single participant could contribute multiple statements to the same code or theme. Frequencies represent the number of coded expressions/segments identified during thematic analysis rather than the number of individual participants.

Table 7.

Frequency of coded expressions/themes identified during thematic analysis

Theme	Code	Group 1 (f)	Group 2 (f)	Group 3 (f)
Theme 1: Visual access and clarity of the surgical field	Limited field of view	28	6	4
	Inability to see details	25	7	5
	Increased clarity with monitor/camera	3	21	34
Theme 2: Learning experience and educational contribution	Educational and productive experience	19	24	37
	Reinforcement of theoretical knowledge	14	22	29
	Ability to follow the steps of the process	12	20	33
Theme 3: Clinical Setting and Professional Awareness	Surgeon and patient communication	26	9	31
	Surgeon positioning and instrument use	23	8	28
	The professional contribution of the clinical atmosphere	21	7	30

Frequencies (f) represent the number of times the relevant code was mentioned at least once in participant statements and are not intended for quantitative generalization; they are presented to reflect the relative dominance of the themes

The qualitative findings revealed that different methods of observing surgical procedures affect the students’ learning experiences through different mechanisms. While observing from operating room contributed to experiencing the clinical atmosphere and observing professional interactions, it remained limited in terms of visual access. The live video streaming method enhanced visual clarity, however it partially limited the clinical setting experience. In contrast, the monitor supported observation method in operating room emerged as the most comprehensive learning experience by offering visual access, learning effectiveness and clinical awareness together. When these themes are considered together, it becomes evident that the methods of observing the surgical procedures shape students’ learning experiences not only at the level of information transfer; but also through interrelated mechanisms such as visual access, cognitive processing and clinical contextual awareness.

Discussion

This study is one of the few to evaluate the blended observation method supported by live video in dental clinical education. Consistent with the first hypothesis, the findings indicate that different surgical observation methods are associated with differences in students’ ability to view the surgical field, observational awareness, and perceived educational experience. Although statistically significant differences in knowledge-based outcomes were limited to the item related to preoperative radiological assessment, the findings support differences in observational and experiential learning outcomes rather than general knowledge acquisition. Consistent with the second hypothesis, the hybrid observation method was associated with more positive observation and educational experiences, particularly regarding following procedure steps, observing technical details, and developing clinical awareness. Overall, the hybrid observation group received the most positive evaluations across various observation and experiential domains.

First-person video-assisted hybrid observation approaches may contribute positively to dental education, teaching, and clinical practice, serving as an innovative alternative both the educational and practical aspects of dentistry [30]. A previous study reported that smart glasses may improve medical students’ acquisition of various surgical skills in surgical education [34]. The Ray-Ban Meta smart glasses used in this study provided high resolution, providing real-time image transmission from the surgeon’s first-person perspective, allowing students to observe the surgical process directly from the practitioner’s viewpoint. The integration of the camera with the natural head position provided a high level of alignment between trainer’s field of view and the images observed by students on the monitors; thus the limitations frequently reported in traditional observation such as loss of viewing angle, crowding and physical positioning constraints were largely reduced. The live streaming capability supported real-time learning and appeared to facilitate understanding of complex surgical steps particularly in facilitating the understanding of the complex surgical steps.

This study has demonstrated that, in situations where the physical constraints of the operating room limit students’ visual access and observational experience, the blended observation method is associated with more positive observational and experiential learning outcomes. These findings support the growing body of evidence suggesting that the integration of technology can enhance the quality of learning in digital dentistry education [2]. The findings suggest that the hybrid observation method was associated with improved observational awareness and perceived educational experience and understanding the critical steps of the surgical procedure. Qutieshat et al. [13] reported that blended learning enhances dental students’ clinical performance and satisfaction levels. This learning process, supported by both visual and auditory inputs, suggests that hybrid observation method may contribute to cognitive engagement and observational learning as well as affective learning.

In this study, the findings related to attitude questions also indicate that the hybrid observation method offers advantages in terms of the learning experience. Students rated the hybrid observation method significantly higher than other observation methods in terms of instructiveness of the surgeon’s explanations, linking the theoretical knowledge with practice, and contribution of professional development. This finding is consistent with literature indicating that video supported observation enhances students’ cognitive engagement and sustained attention [7]. A study reported that video supported hybrid observation methods in veterinary surgical education strengthen the clinical awareness of students [35]. Similarly, consistent with our findings, Al-Elq et al. [36] reported that hybrid video approaches in medical education enhance students’ practical learning skills. In addition, our study also revealed the main difference between video-based observation method alone and hybrid observation method. Although students in live streaming group followed the overall flow of the surgical procedure, students in the hybrid observation group reported higher satisfaction with reviewing the visual and contextual aspects of the procedure. The opportunity to directly observe the surgeon’s communication, patients’ reactions and complication management enabled students to develop a more holistic perspective on the clinical process. This finding supports the studies emphasizing that active observation and multisensory learning play an important role in clinical skills development [12, 37]. Although traditional observation and live streaming methods contribute to students’ learning processes, the hybrid observation method received higher scores in terms of clearly observing the surgical field, better understanding of procedural steps, and increasing clinical awareness.

A previous study reported that the model that includes live demonstrations and formative assessment improved students’ orthodontics skills [38]. Similarly, another study reported that the flipped classroom approach combined with case based learning improved students’ clinical decision-making and analytical thinking skills [39]. These findings support that the hybrid observation method is a model that promotes active participation in clinical learning and strengthens practice skills. While Ramlogan et al. [4] reported that video demonstrations in periodontology education did not significantly contribute to the students’ tests results, our study showed that the hybrid observation method was associated with differences in knowledge-related responses and learning attitudes. This difference may be attributed to the method used in our study, which integrates the live transmission and observation in the operating room. Previous studies have also reported that video based and hybrid education practices support both cognitive and behavioral learning processes [7, 40]. Particularly, in surgical disciplines, when students cannot directly participate in observation due to limited physical space or infection control protocols, the hybrid observation method can ensure educational equality while preserving quality of education. In addition, the hybrid observation method can be easily implemented with low-cost hardware (e.g., Ray-Ban Meta Wayfarer smart glasses), which may offer a practical solution for dental faculties.

Qualitative findings suggest that the learning outcomes of surgical operation observation cannot be reduced to a single factor; on the contrary they are shaped by the simultaneous interaction of visual access, cognitive integration, and clinical contextual experience. The process of operating room observation enables students to experience the clinical environment and understand surgeon-patient- assistant interactions, thereby supporting professional socialization and contextual learning. However, limited visual access restricted the cognitive processing. Live interaction demonstrations of clinical procedures have traditionally been quite effective in dental education. However, the integration of demonstrations has increasingly been adopted to improve teaching methods [8]. The limited effectiveness of using video demonstrations alone in the teaching of clinical skills, may stem from reduced student interaction and participation in this mode. Interaction and participation are crucial for enhancing student’s understandings and increasing their self-confidence [8]. To mitigate this limitation, the hybrid observation method strengthens students’ both cognitive and contextual learning processes by integrating visual access with clinical environment experience. In addition, students reported that the hybrid observation method provided significant advantages, particularly by enhancing the visual access, facilitating understanding of procedural steps, and maintaining attention during the lesson. These results indicate that the hybrid observation model appeared to provide the most comprehensive learning experience among the evaluated observation methods for enhancing both cognitive learning and the quality of clinical observation. Similar to previous study, the current study also demonstrated satisfaction with the use of videos used in dental education [41]. Consistent with findings in the literature indicating that video-supported and hybrid models increase student motivation, focus, and clinical awareness [38, 42], the results of this study suggest that the hybrid approach contributes not only to cognitive learning but also to affective and behavioral learning processes.

This study has some limitations. Due to the educational nature of the intervention, participant blinding was not feasible; therefore, students were aware of the observation modality to which they were assigned, which may have influenced subjective questionnaire responses and perceptions regarding the educational experience. The study was conducted at a single center, and students’ learning experiences were evaluated over a short period. Long-term clinical learning outcomes, objective performance measures, and potential effects on real patient practice were not assessed. In addition, only a specific surgical procedure was evaluated, limiting the generalizability of the findings to procedures with different levels of surgical complexity. Because qualitative data collection was based on voluntary participation, some perspectives may not have been represented. Differences in technical infrastructure and equipment may also influence the applicability of the technology-based hybrid observation model in other institutions. Future studies should include multicenter designs, different surgical procedures, longer follow-up periods, and objective clinical performance metrics.

Conclusion

This study demonstrates that the hybrid observation model, combining direct observation with live video streaming, positively contributes to dental students’ surgical education and may complement traditional teaching methods. The findings suggest improved observational awareness, learning experience, and perceived educational benefit under this hybrid approach, supported by enhanced visual access through first-person video technology. The hybrid observation was associated with more favorable educational perceptions. Further studies with larger samples are needed to evaluate long-term learning outcomes and clinical skill acquisition.

Abbreviations

SD

Standard deviation

SPSS

Statistical Package for the Social Sciences

SRQR

Standards for Reporting Qualitative Research

Authors’ contributions

Muhammed Fatih Çiçek and Muhammet Fidan designed the study. Muhammed Fatih Çiçek and Muhammet Fidan conducted the methodology. Ahmet Caymaz, Muhammet Demirkaya, Muhammed Mustafa Sağer, Alperen Şamil Karabek, Defne Dayan and Çağla Saygın collected the data. Muhammed Fatih Çiçek and Muhammet Fidan analyzed the data. Muhammed Fatih Çiçek drafted the manuscript. All authors reviewed and approved the final manuscript.

Funding

This research received no external funding.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study received ethical approval from the Non-Interventional Clinical Research Ethics Committee of Uşak University Faculty of Medicine, (decision no. 28), issued at its meeting on September 11, 2025. Written informed consent was obtained from all participants prior to participation in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.