Stage of manual skill acquisition with Simodont virtual reality simulator for pre-clinical dental training: An interventional matching study

Stage of manual skill acquisition with Simodont virtual reality simulator for pre-clinical dental training: An interventional matching study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Stage of manual skill acquisition with Simodont virtual reality simulator for pre-clinical dental training: An interventional matching study Uziel Jeffet, Nir Uziel, Noga Retzkin Binyamin, Ido Vana, Noa Sadan, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7436627/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Mar, 2026 Read the published version in BMC Medical Education → Version 1 posted 10 You are reading this latest preprint version Abstract Background Recent studies have demonstrated the effectiveness of virtual reality (VR) simulators in dental education. However, these studies primarily focused on the early stages of psychomotor skill acquisition and often did not account for confounding variables when assigning participants to study groups. The present study aims to determine the stage of manual skill acquisition at which VR simulator training is most effective, using a matched interventional study design. Methods A planned crossover study with a matched design was conducted among 70 undergraduate dental students from Tel Aviv University. Matching was performed based on age, gender, dominant hand, spatial perception, and fine motor skills. To evaluate manual performance under both direct vision (Class I cavity preparation) and indirect vision (Class 1 occlusal-proximal [OP] preparation), students were evenly assigned to two groups (Group 1 and Group 2), matched to control for potential confounding factors. Using a crossover approach, each group alternated roles as the experimental or control group for the two phantom-based tasks. The experimental group trained with both the Simodont virtual reality simulator and the conventional phantom simulator, while the control group practiced solely with the conventional simulator on plastic teeth. The experimental group was further subdivided into three subgroups based on the timing of Simodont exposure corresponding to different stages of skill acquisition: cognitive, associative, and autonomous. Results No statistically significant differences were observed between the experimental and control groups in manual performance scores under direct vision (p = 0.461) or indirect vision (p = 0.916). Additionally, no significant differences were found among the three experimental subgroups representing different stages of skill acquisition (p > 0.05). Conclusion The integration of the Simodont simulator during the preclinical year does not appear to enhance dental students’ manual performance under either direct or indirect vision conditions. Virtual reality simulator dental students manual skill Simodont dental education Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Dentists must demonstrate a high level of manual dexterity and proprioceptive awareness to perform dental procedures effectively. Therefore, dental students are required to develop manual skills during the early stages of their dental education. Traditionally, the acquisition of these skills in most dental schools worldwide is based on exercises performed on plastic teeth mounted in a "phantom head simulator"¹. During the pre-clinical year of the dentistry degree, students are introduced to a conventional simulator with a phantom head, which simulates dental procedures on plastic teeth using dental instruments such as turbines and handpieces. However, the conventional simulator presents limitations, including insufficient tactile feedback, prolonged learning curves, and the ability to simulate only simplified tooth structures within the phantom model. Due to the complexity of manual skill acquisition, a considerable proportion of dental students fail pre-clinical courses and are not permitted to progress to the subsequent year, which involves treating patients². Recent technological advances have led to the development of virtual reality simulators, which have been reported to accelerate and improve the acquisition of manual skills in phantom courses³⁻⁴. The most common virtual reality simulator used in dental education is the DentSim computer-assisted simulator, which consists of a simulated patient with a head and dentoform, and two infrared cameras that transmit beams to two computers to generate a three-dimensional (3D) virtual image of the tooth preparation, the preparation process, and performance grading⁵. The newly developed Simodont simulator is based on haptic (touch) technology and includes a force-feedback robotic arm connected to software that creates a realistic experience of oral treatment procedures⁴. The system enables repeated training with tactile feedback for drilling into various tissues, supporting the development of self-assessment skills and reducing dependence on clinical instructors⁶. Although the ultimate goal of virtual reality simulators is to replace conventional phantom training, most studies suggest that these innovations should not be used in isolation. Instead, they should supplement the traditional phantom laboratory due to limitations in task validity assessment and the high cost of initial setup and maintenance⁷⁻⁹. Wei et al. 10 demonstrated that dental students who received additional training with the Simodont simulator showed significantly improved cavity preparation performance compared to students trained exclusively with the conventional phantom simulator. De Boer et al.¹¹ examined the effect of Simodont training on dental students with no prior manual skill experience and found that only students who trained with Simodont were able to pass the manual skills test. Yuan et al.¹² investigated the effectiveness of Simodont training in preclinical students for teaching cavity preparation after the theoretical knowledge of the task had been standardized. They concluded that the Simodont simulator significantly improved cavity preparation performance compared with the conventional phantom simulator alone. All of these studies assessed the impact of Simodont training on cavity preparation performance during the initial cognitive stage of skill acquisition, without considering the more advanced stages that are essential for achieving full skill competence. Furthermore, in these studies, experimental and control groups were assigned randomly without matching specific characteristics (e.g., age, gender, fine motor skill competence, spatial perception, and dominant hand), which could act as confounding factors and potentially affect the internal validity of the findings. According to Ackerman’s theory, skill acquisition consists of three stages¹³: (1) Cognitive stage – the initial phase of learning, in which the learner must understand instructions to perform a given task; (2) Associative stage – the intermediate phase, in which perceptual speed and efficiency are developed to perform the task more quickly and accurately; and (3) Autonomous (automatic) stage – the final phase, in which task performance relies predominantly on psychomotor abilities and less on cognitive processing. A gap exists in the literature regarding the stage of manual skill acquisition in dental students at which additional training with the Simodont simulator is most effective. Recently, the Simodont simulator has been introduced at our University School of Dentistry to enhance preclinical training in cavity preparation, serving as a supplementary tool to the conventional phantom simulator. Therefore, the aim of the present study was to determine whether additional training with the Simodont simulator improves the manual dexterity of preclinical dental students compared to training with the conventional phantom simulator alone, using an interventional study design with matching for potential confounding factors. This study also aimed to identify the stage of manual skill acquisition at which Simodont training is most beneficial. To the best of our knowledge, this is the first study to employ a matched design, therefore we hypothesized that additional Simodont training would not significantly improve cavity preparation performance compared to conventional phantom training alone. Methods Participants: A planned-crossover study with a matched design was conducted during the 2025 academic year among 70 third-year undergraduate dental students. All participants were in their first year of practicing on a phantom head and had not received any prior manual dexterity training for dental procedures using dental instruments. Prior to commencing the study, all participants provided written informed consent, approved by the Ethics Committee (No. 0009807-1), after the principal investigator had explained the study’s aims and procedures. Inclusion criteria consisted of third-year dental students who had signed informed consent and had no previous manual dexterity training. Exclusion criteria included a history of vision-related pathology (e.g., strabismus, amblyopia, anisometropia, glaucoma, or cataract) or dexterity-related disorders (e.g., carpal tunnel syndrome). The entire class volunteered to participate in the study, preventing selection bias. Purdue Pegboard Test: All students underwent a validated assessment at the beginning of the study, prior to commencing the phantom head simulation course. This assessment included the Purdue Pegboard Test under direct vision to evaluate baseline fine motor skills and under indirect vision to assess baseline spatial perception. The Purdue Pegboard Test¹⁴ is a reliable and valid occupational therapy assessment tool (Fig. 1 ). It consists of a board with two vertical columns of holes, and four cups located distally: the right and left cups each contain 25 pins, while the remaining two cups hold washers and collars, respectively. The test comprises four distinct tasks. In the first three tasks, as many pins as possible must be inserted into the board’s holes within 30 seconds; in the final task, the time limit is 60 seconds. The score for each task is determined by the number of pins inserted. The four tasks are as follows: Dominant hand – inserting pins using the dominant hand only. Non-dominant hand – inserting pins using the non-dominant hand only. Both hands – simultaneously inserting one pin with each hand into two adjacent holes. Assembly task – continuously using both hands to assemble four components in sequence: a pin, a washer, a collar, and a second washer. Simodont virtual simulator: The Simodont (NISSIN Dental Products, New York, USA) is a three-dimensional (3D) virtual reality haptic simulator designed for intensive preclinical training of dental students and for the assessment of their manual skills. The system comprises two computers: a graphics PC and a panel PC. It utilizes two separate projectors to generate 3D images, which are viewed through specialized 3D glasses. To replicate a realistic clinical experience, the Simodont incorporates a handpiece gimbal, a hand mirror gimbal, and a horseshoe-shaped finger rest area, with virtual exercises displayed on a high-resolution 3D screen. Research methodology (Fig. 2): Before performing the first task on plastic teeth mounted in a mannequin head, all dental students received theoretical instruction and a live demonstration of the manual task by a clinical instructor. For the assessment of the first phantom task under direct vision (Class I cavity preparation on tooth No. 36, with a depth of 1.5–2.0 mm and a width equal to 1/4 of the intercuspal distance) and the second task under indirect vision (OP preparation on tooth No. 16, with a depth of 1.5–2.0 mm and a minimal distance of 1.5 mm from the distal marginal ridge), the 70 students were matched into two equal groups (Group 1 and Group 2, n = 35 each) to minimize bias from potential confounding factors. Using a crossover design, Groups 1 and 2 alternated roles as the experimental and control groups for these two phantom tasks. For the first phantom task, the Class I preparation, Group 1 (experimental group) trained with both the Simodont simulator and the conventional phantom head simulator for drilling on plastic teeth, while Group 2 (control group) practiced exclusively with the conventional phantom head simulator. Group 1 received an additional 120-minute training session on the Simodont, which simulated a Class I cavity preparation using haptic technology. In the second phase of the crossover design, Group 2 served as the experimental group and Group 1 as the control group for the OP preparation on tooth No. 16. The experimental group in each phase was further subdivided into three subgroups according to the timing of Simodont training relative to the stages of skill acquisition: Group A – Cognitive stage: immediately after receiving theoretical instruction and a demonstration of the task, before beginning practical execution. Group B – Associative stage: after receiving theoretical instruction and demonstration and following initial practice of the procedure. Group C – Autonomous stage: after receiving theoretical instruction and demonstration, and near completion of the practice phase. The students’ manual scores were compared between the control and experimental groups. Three independent instructors graded each task according to standardized criteria, including cavity outline and depth. Scores were given on a continuous scale from 0 to 100, with a passing threshold of 60. Student identification numbers were coded, and the instructors were blinded to both the students’ identities and their group assignments. Feedback questionnaire At the end of the Simodont training, all participants completed a questionnaire designed to gather their opinions regarding the training simulator and its potential applications in the following academic year for acquiring the manual skills required in dentistry (Table 1 ). Table 1 Means, SD and frequency distributions of responses to the feedback questionnaire. The questions were rated on a scale of 1 to 3, 1 for "Disagree", 2 for "Partially agree" and 3 for "Agree". Question Mean ±SD 1 = Disagree 2 = Partially Agree 3 = Agree The image of teeth and dental instruments looked realistic? 2.6 0.53 1(2%) 18 (36%) 31 (62%) The hardness and morphology of anatomical models and instruments felt realistic? 1.8 0.60 15(30%) 30(60%) 5(10%) The practicing on Simodont improved my fine motor skill acquisition? 1.8 0.799 20(40%) 18(36%) 12(24%) Practicing on Simodont improved my self-assessment for evaluation cavity preparation 1.7 0.74 21(42%) 20(40%) 9(18%) Practicing on Simodont increased my confidence for more complicated dental procedure 1.66 0.79 27(54%) 13(26%) 10(20%) Statistics: Assumptions of normality for the study variables were evaluated using Kolmogorov–Smirnov tests. Descriptive statistics were calculated for both groups regarding the independent variables: age, gender, dominant hand, basic fine motor skills, and spatial perception. All statistical analyses were conducted using SPSS software (Version 29.0, IBM Corp., Armonk, NY, USA). Statistical significance was set at p < 0.05. For comparisons between the experimental and control groups, Mann–Whitney tests were applied for age and scores on the Purdue tests under both direct and indirect vision conditions. Chi-square tests were used to analyze the distribution of gender and hand dominance between groups. Kruskal–Wallis tests were employed to compare data among the three sub-groups (cognitive stage, associative stage, and autonomous stage groups). Results Kolmogorov–Smirnov tests indicated that all study variables—students’ scores on the Purdue Pegboard tests under direct and indirect vision, age, and manual grades in the phantom laboratory—were not normally distributed ( p < 0.05). Comparison of study group characteristics This analysis was conducted to evaluate potential confounding effects of independent variables that might influence manual grades, thereby impacting the internal validity of the study. Mann–Whitney tests revealed no statistically significant differences between Group 1 ( n = 35) and Group 2 ( n = 35) for age ( p = 0.432), all 4 tasks of Purdue under direct vision (p > 0.194) and indirect vision (p > 0.173). Chi-square tests showed no significant differences in gender distribution ( p = 1.000) or hand dominance ( p = 1.000) between the groups. Sub-group comparisons – Group 1 Kruskal–Wallis tests comparing the cognitive stage group, associative stage group, and autonomous stage group in Group 1 (Table 2 ) revealed no statistically significant differences in age ( p = 0.322), all 4 tasks of Purdue under direct vision (p > 0.753) and indirect vision (p > 0.713). Chi-square tests indicated no significant differences in gender distribution ( p = 0.813) or hand dominance ( p = 0.997) among the sub-groups. Table 2 Median (P50) and 95% confidence intervals (upper and lower bounds) for age, gender, and Purdue direct and indirect test scores in Group 1. Group 1 N = 35 Characteristic Cognitive stage group (N = 12) Associative stage group (N = 12) Autonomic stage group (N = 11) Total experiment group Age P50 = 25 CI(23.6,26) P50 = 26 CI(24.6,27.3) P50 = 25 CI(24.4,26.4) P50 = 26 CI(24.7,26) Dominant Hand 11 right, 1 left 11 right, 1 left 10 right, 1 left 32 right 3 left Gender F (n = 9), M (n = 3) F (n = 10), M (n = 2) F (n = 8), M (n = 3) F (n = 27), M (n = 8) Purdue dominant hand P50 = 15 CI(13.6,16.5) P50 = 16 CI(14.5,16.6) P50 = 16 CI(14.6,17.1) P50 = 16 CI (14.8,16.1) Purdue non dominant hand P50 = 15 CI(13,15.9) P50 = 15 CI(13.5,15.4) P50 = 15 CI(13.7,16) P50 = 15 CI(13.9,15.2) Purdue both hands P50 = 11 CI(10.5,12.9) P50 = 12 CI(11.2,13) P50 = 12 CI(11.3,12.8) P50 = 12 CI(11.4, 12.5) Purdue assembly P50 = 34 CI(30,41.7) P50 = 36 CI(30.5,38.1) P50 = 36 CI(29.8,41.4) P50 = 36 CI( 32.5, 37.9) Purdue indirect dominant hand P50 = 8 CI( 6.1,9.7) P50 = 8.5 CI(7.7,9.1) P50 = 8 CI(6,9.2) P50 = 8 CI(7.2, 8.7) Purdue indirect non dominant hand P50 = 9 CI(7,10.1) P50 = 8.5 CI(7,8.9) P50 = 8 CI(6.9,9.9) P50 = 9 CI(7.6,9) Purdue indirect both hands P50 = 5.5 CI(4.7,6.6) P50 = 6 CI( 5, 6.5) P50 = 5 CI (4.9,5.8) P50 = 6 CI(5.2,6) Purdue indirect assembly P50 = 18.5 CI(15.7,23.3) P50 = 20 CI( 17.1,21.9) P50 = 18 CI (16.4,21.7) P50 = 19 CI( 17.8,20.9) Preparation tooth 36 P50 = 65.5 CI (58,70.9) P50 = 60 CI (53.6,66.3) P50 = 50 CI (50.6,63.8) P50 = 61 CI( 57.1,64.1) Preparation tooth 16 P50 = 65 CI (56.7,73.2) P50 = 73 CI (62.5,75.9) P50 = 50 CI( 48.1,58.3) P50 = 65 CI (58.5,67) Sub-group comparisons – Group 2 Kruskal–Wallis tests comparing the cognitive stage group, associative stage group, and autonomous stage group in Group 2 (Table 3 ) demonstrated no statistically significant differences for age ( p = 0.469), all 4 tasks of Purdue under direct vision (p > 0.310) and indirect vision (p > 0.375) except for Purdue indirect non-dominant hand, which showed a statistically significant difference ( p = 0.032). Chi-square tests revealed no significant differences in gender distribution ( p = 0.436) or hand dominance ( p = 0.997) between the sub-groups. Table 3 P50 (50 percentile) and 95% Confidence interval (Upper, Lower) of age, gender, four tasks of Purdue direct and indirect tests for group 2. Group 2 N = 35 Characteristic Cognitive stage group (N = 12) Associative stage group (N = 12) Autonomic stage group (N = 11) Total experiment group N = 35 Age P50 = 26 CI(23.8,26.6) P50 = 26 CI(24.5,26.7) P50 = 27 CI(24.8,28) P50 = 26 CI(25,26.4) Dominant Hand 11 right, 1 left 11 right, 1 left 10 right, 1 left 32 right 3 left Gender F(n = 10),M (n = 2) F(n = 10),M (n = 2) F (n = 7), M (n = 4) F(n = 27), M (n = 8) Purdue dominant hand P50 = 16 CI(14.7,17) P50 = 16 CI(14.1,17.1) P50 = 17 CI(15.5,17.3) P50 = 16 CI (15.3,16.6) Purdue non dominant hand P50 = 14.5 CI(13.5,16) P50 = 15 CI(12.5,15.6) P50 = 16 CI(14.6,16.2) P50 = 15 CI( 14,15.4) Purdue both hands P50 = 12 CI(11.6,13) P50 = 13 CI(11.5,13.6) P50 = 12 CI(11.8,13.5) P50 = 12 CI(12,13) Purdue assembly P50 = 34 CI(31.9,38.3) P50 = 36 CI(32.7,39.7) P50 = 34 CI(30.3,37) P50 = 35 CI( 33.1, 36.7) Purdue indirect dominant hand P50 = 7.5 CI(6.4,8.7) P50 = 8.5 CI(7.2,9.4) P50 = 8 CI(6.6,9.5) P50 = 8 CI(7.3,8.6) Purdue indirect non dominant hand P50 = 7 CI(6.2,8) P50 = 9 CI(7.8,10.3) P50 = 8 CI(7.5,9.7) P50 = 8 CI(7.6,8.9) Purdue indirect both hands P50 = 6.5 CI (4.7,8.3) P50 = 6 CI(5.3,7.6) P50 = 6 CI (4.3,6.5) P50 = 6 CI (5.4,6.9) Purdue indirect assembly P50 = 19 CI(15.6,20.8) P50 = 21 CI(17.9,24.2) P50 = 17 CI (15.3,21.5) P50 = 18 CI (17.6,20.8) Preparation tooth 36 P50 = 58.5 CI (51.1,67.8) P50 = 56 CI (52.4, 61.5) P50 = 52.5 CI (51.1,71.4) P50 = 56 CI(55.1,63.1) Preparation tooth 16 P50 = 66.5 CI (56.8,71.1) P50 = 56.5 CI (51.5, 69.9) P50 = 69 CI (55.1,73.2) P50 = 65 CI (58.4,67.3) Comparison of manual grades on plastic tooth No. 36 No significant difference was found between Group 1 (experimental) and Group 2 (control) in the manual performance score for tooth No. 36 ( p = 0.461) (Fig. 3 ). Furthermore, no significant differences were observed among the three subgroups of Group 1 (cognitive, associative, and autonomous stages) with respect to the manual score on tooth No. 36 ( p = 0.207). Comparison of manual grades on plastic tooth No. 16 (OP preparation, indirect vision) No significant difference was found between Group 2 (experimental) and Group 1 (control) for the manual score on tooth No. 16 ( p = 0.916) (Fig. 4 ). Similarly, no significant differences were observed among the three subgroups of Group 2 regarding the manual score on tooth No. 16 ( p = 0.723). Feedback questionnaire At the conclusion of the Simodont training, 71% of the students completed the feedback questionnaire (Table 1 ). The mean response values across all seven questions ranged from 1.6 to 2.6 on the scale used. Notably, the majority of students agreed only with the statement regarding the realism of the images of teeth and dental instruments. For all other questions, most students partially disagreed or disagreed, indicating a perception that the use of Simodont did not substantially aid in acquiring the manual skills required for phantom laboratory practice. Discussion Implementation of virtual reality simulators incorporating force feedback (haptic) technology during the preclinical year of dental education has been well documented 9 – 12 . Although a recent systematic review 15 concluded that the application of virtual reality in dental education improves students' clinical outcomes and self-assessment, the consensus in most studies is that virtual simulators should enhance rather than replace conventional phantom head simulators 16 . Virtual reality simulators have inherent disadvantages, including the absence of a physical finger rest and the inability to perform bimanual coordination required for indirect vision, soft tissue retraction, and light reflection using a dental mirror. Dentists must practice bimanually: one hand performs precise drilling, while the other hand manipulates the dental mirror at exact angles to provide optimal visualization of the small and inverted operative field. Learning this skill is challenging due to the brain’s natural difficulty in simultaneously controlling two new complex motor actions requiring coordination of both hands. Therefore, the Simodont does not accurately simulate the dentist’s real working posture. Our study demonstrated no significant effectiveness of the virtual simulator in improving manual skills for dental procedures under both direct and indirect vision. To our knowledge, this is the first study employing matched design controlling for confounding factors, especially manual dexterity and spatial perception that could influence dental students' manual performance scores. Lugassy et al 17 concluded that manual skill in dentistry, a key competence, partially reflects innate ability. Hattori et al. 18 reported lower scores for dental students using the Simodont compared to conventional simulators, attributing the difference to variability in students’ depth perception abilities. Murbay et al. 19 evaluated the impact of integrating the Simodont simulator into a preclinical operative dentistry course. Thirty-two students were randomized into two groups: one trained with Simodont and the other without. Their findings showed significantly improved clinical performance in the Simodont group. Wei et al. 10 also explored Simodont’s effectiveness in teaching access and coronal cavity preparation in preclinical training, demonstrating greater consistency in task performance among students trained with Simodont compared to traditional methods. In contrast, our larger study with 70 matched students found no significant differences between control and experimental groups on manual performance under direct and indirect vision, highlighting the importance of controlling for confounders such as age, gender, dominant hand, fine motor skills, and spatial perception. While virtual reality simulators appear to enhance student performance and self-confidence, they cannot currently replace conventional phantom head simulators. Studies suggest that virtual reality is most effective during the early cognitive stage of preclinical dental training 20 . Bakr et al.²¹ recommended a gradual introduction of virtual simulators starting from the first year, progressing through cariology exercises in the second year, and adjunct crown preparation training in the third year alongside phantom simulators. Our study found no significant differences in performance among the cognitive, associative, or autonomous stages of motor skill acquisition. The feedback questionnaire in this study revealed that students only agreed that the images of teeth and dental instruments appeared realistic; however, they did not feel that the virtual simulator enhanced their manual performance. This perception may be related to the simulator’s limited ability to accurately replicate tactile sensations of enamel, dentin, and bone, as well as practical drawbacks such as high initial cost, the need for instructor guidance prior to training, and requirements for precise calibration. Limitations Due to limited availability of the simulator, training time was restricted to two hours per student. Future research should investigate the benefits of extended training durations to maximize the educational value of virtual simulation. Conclusion The use of the Simodont simulator during the preclinical year may not improve dental students’ manual performance under direct or indirect vision. Although virtual reality simulators represent promising educational tools, they currently cannot replace conventional phantom head simulators in dental training. Declarations Acknowledgements Not applicable. Author contributions Conceptualization, U.J. and D.L.; methodology, D.L., N.U and U.J.; software, N.R.B. and I.V.; validation, D.L. and U.J.; formal analysis, D.L.; investigation, U.J. and I.V.; resources, D.L.; data curation, D.L.; writing—original draft preparation, D.L. and U.J.; writing—review and editing, N.S., Y.S., T.B., and S.L.; visualization, U.J.; supervision, D.L.; project administration, U.J; funding acquisition, U.J and D.L. All authors have read and agreed to the published version of the manuscript. Funding This research received no external funding. Data availability The data presented in this study are available on request from the corresponding author. Dr Diva Lugassy, mail: [email protected] . Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of Tel Aviv University (protocol code No. 0009807-1). Prior to commencing the study, all participants provided written informed consent, approved by the Ethics Committee (No. 0009807-1), after the principal investigator had explained the study’s aims and procedures Consent for publication All authors have read and agreed to the published version of the manuscript. Competing interests The authors declare no competing interests References Suvinen TI, Messer LB, Franco E. Clinical simulation in teaching preclinical dentistry. Eur J Dent Educ. 1998; 2: 25-32. Causby R, Reed L, Mcdonell M, Hillier S. Use of objective psychomotor tests in health professionals. Perceptual and Motor Skills: Motor Skills and Ergonomics. Percep and Motor Skills. 2014; 118: 765-804. Johnson L, Thomas G, Dow S, Stanford C. An initial evaluation of the Iowa dental surgical simulators. J Dent Educ. 2000; 64: 847-853. Bakker D, Lagerweij M, Wesselink P, Vervoorn M. Transfer of manual dexterity skills acquired on the simodont, a dental haptic trainer with a virtual environment, to reality. A pilot study. Bio Algor Med Sys. 2010; 11: 21-24. Rose JT, Buchanan JA, Sarrett DC. The DentSim system. J Dent Educ. 1999; 63: 421-423. Lok-Sze Leung A, Yeung C, Chu S, Wong AWY, Yu OY. Use of computer simulation in dental training with special reference to Simodont. Dentistry J. 2021; 9,125. Quinn F, Keogh P, Mcdonald A, Hussey D. A pilot study comparing the effectiveness of conventional training and virtual reality simulation in the skill acquisition of junior dental students. Eur J Dent Educ. 2003; 7: 13-19. Urbankova A, Hadavi F, Lichtenthal RM, Leblanc VR. Effect of different types of dental simulation training on students' performance in operative dentistry. J Dent Educ. 2004; 68: 245-246. Bark MM, Massey WL, Alexander H. Evaluation of simodont haptic 3D virtual reality dental training simulator. Inter J Dent Clinic. 2013; 5: 1-6. Wei Y, Peng Z. Application of Simodont virtual simulation system for preclinical teaching of access and coronal cavity preparation. Plos One. 2024; 1-13. De Boer IR, Lagerweij MD, De Vries MW, Wesselink PR, Vervoorn JM. The effect of force feedback in a virtual learning environment on the performance and satisfaction of dental students. Simul Healthc. 2017; 12: 83-90. Yuan CY, Wang XY, Dong YM, Gao XJ. Effect of digital virtual simulation system for preclinical teaching of access and coronal cavity preparation. Zhonghun Kou Qiang. 2021; 56, 479-484. Ackerman PL. Determinants of individual differences during skill acquisition: cognitive ability and information processing. J Exper Psych. 1988; 117: 288-318. Mathiowertz V, Rogers SL, Keval MD, Donahoe L, Rennele C. The purdue pegboards: Norms for 14 to 19 year olds. Amer J Occup Ther. 1986;40: 174-179 Moussa R, Alghazaly A, Althagafi N, Eshky R, Borzangy S. Effectiveness of Virtual Reality and Interactive Simulators on Dental Education Outcomes: Systematic Review. Eur J Dent. 2022;16:14-31. doi: 10.1055/s-0041-1731837 Leung AL, Yeung C, Chu S, Wong AW, Yu OY, Chu CH. Use of Computer Simulation in Dental Training with Special Reference to Simodont. Dent J. 2021 21;9:125. doi: 10.3390/dj9110125 Lugassy D, Levanon Y, Pilo R, Shely A, Rosen G, Meirowitch A, Brosh, T. Predicting the clinical performance of dental students with a manual dexterity test. Plos One 2018; 13:https://doi.org/10.1371/journal.pone.0193980. Hattori A, Tonami KI, Tsuruta J, Hideshima M, Kimura Y, Nitta H, Araki K. Effect of the haptic 3D virtual reality dental training simulator on assessment of tooth preparation. J Dent Scien. 2022; 17: 514-520. Murbay S, Neelakantan P, Chang JWW, Yeung S. Evaluation of the introduction of a dental virtual simulator on the performance of undergraduate dental students in the pre- clinical operative dentistry course. Eur J Dent Educ. 2019; 00: 1-15. Kolivand H, Shooreshi MM, Safari-Faramani R, Borji M, Mansory MS, Moradpoor H, Bahrami M, Azizi SM. Comparison of the effectiveness of virtual reality based education and conventional teaching methods in dental education: a systematic review. BMC Med Educ. 2024; 24,8. Bakr MM, Idris G, Ankily MA. The potential integration of Simodont dental trainer in different stages of the dental curriculum. Saudi Dent J. 2034; 36: 1449-1455. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Mar, 2026 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 03 Nov, 2025 Reviews received at journal 11 Oct, 2025 Reviews received at journal 08 Oct, 2025 Reviewers agreed at journal 08 Oct, 2025 Reviewers agreed at journal 06 Oct, 2025 Reviewers invited by journal 06 Oct, 2025 Editor invited by journal 09 Sep, 2025 Editor assigned by journal 09 Sep, 2025 Submission checks completed at journal 09 Sep, 2025 First submitted to journal 22 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7436627","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":528148466,"identity":"c2411d02-18e5-493f-a2b0-b051d04d1281","order_by":0,"name":"Uziel Jeffet","email":"","orcid":"","institution":"Tel-Aviv University","correspondingAuthor":false,"prefix":"","firstName":"Uziel","middleName":"","lastName":"Jeffet","suffix":""},{"id":528148467,"identity":"454bf849-41dc-4ffa-b998-f1aa5250d29c","order_by":1,"name":"Nir Uziel","email":"","orcid":"","institution":"Tel-Aviv 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12:23:21","extension":"html","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":95933,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7436627/v1/9a6b83c04ea5d19071c5241c.html"},{"id":93773660,"identity":"f1fbffbd-92bf-4f8a-9521-ce924175c88e","added_by":"auto","created_at":"2025-10-17 12:23:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":132195,"visible":true,"origin":"","legend":"\u003cp\u003ePurdue pegboard test under direct and indirect vision.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7436627/v1/c1241b647fee76976cc7e0db.png"},{"id":93775436,"identity":"5b2922c1-28ae-4f9b-a3ee-bab77d88710c","added_by":"auto","created_at":"2025-10-17 12:31:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2456569,"visible":true,"origin":"","legend":"\u003cp\u003eCourse of study.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7436627/v1/55db412d78539b300b10616a.png"},{"id":93773672,"identity":"1213c6ad-bdbf-477d-8d91-a754026313bb","added_by":"auto","created_at":"2025-10-17 12:23:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":730190,"visible":true,"origin":"","legend":"\u003cp\u003eBox plot of Group 1 (experiment) and Group 2 (control) in relation to manual score on preparation tooth no 36\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7436627/v1/db7e8dee58c104e83a0e8a44.png"},{"id":93775440,"identity":"771a5ab3-69f1-4e94-826d-1ce116f99425","added_by":"auto","created_at":"2025-10-17 12:31:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":734145,"visible":true,"origin":"","legend":"\u003cp\u003eBox plot of Group 1 (control) and Group 2 (experiment) in relation to manual score on preparation tooth no 16.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7436627/v1/53d05cba8a2d0013d3a31e94.png"},{"id":104250767,"identity":"9dee5771-ecc3-4fca-b231-2754138dfe57","added_by":"auto","created_at":"2026-03-09 16:08:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4835803,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7436627/v1/c1577290-fdd3-4694-81d0-af934e6b8be3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Stage of manual skill acquisition with Simodont virtual reality simulator for pre-clinical dental training: An interventional matching study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDentists must demonstrate a high level of manual dexterity and proprioceptive awareness to perform dental procedures effectively. Therefore, dental students are required to develop manual skills during the early stages of their dental education. Traditionally, the acquisition of these skills in most dental schools worldwide is based on exercises performed on plastic teeth mounted in a \"phantom head simulator\"\u0026sup1;. During the pre-clinical year of the dentistry degree, students are introduced to a conventional simulator with a phantom head, which simulates dental procedures on plastic teeth using dental instruments such as turbines and handpieces. However, the conventional simulator presents limitations, including insufficient tactile feedback, prolonged learning curves, and the ability to simulate only simplified tooth structures within the phantom model.\u003c/p\u003e\u003cp\u003eDue to the complexity of manual skill acquisition, a considerable proportion of dental students fail pre-clinical courses and are not permitted to progress to the subsequent year, which involves treating patients\u0026sup2;. Recent technological advances have led to the development of virtual reality simulators, which have been reported to accelerate and improve the acquisition of manual skills in phantom courses\u0026sup3;⁻⁴.\u003c/p\u003e\u003cp\u003eThe most common virtual reality simulator used in dental education is the DentSim computer-assisted simulator, which consists of a simulated patient with a head and dentoform, and two infrared cameras that transmit beams to two computers to generate a three-dimensional (3D) virtual image of the tooth preparation, the preparation process, and performance grading⁵. The newly developed Simodont simulator is based on haptic (touch) technology and includes a force-feedback robotic arm connected to software that creates a realistic experience of oral treatment procedures⁴. The system enables repeated training with tactile feedback for drilling into various tissues, supporting the development of self-assessment skills and reducing dependence on clinical instructors⁶. Although the ultimate goal of virtual reality simulators is to replace conventional phantom training, most studies suggest that these innovations should not be used in isolation. Instead, they should supplement the traditional phantom laboratory due to limitations in task validity assessment and the high cost of initial setup and maintenance⁷⁻⁹.\u003c/p\u003e\u003cp\u003eWei et al.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e demonstrated that dental students who received additional training with the Simodont simulator showed significantly improved cavity preparation performance compared to students trained exclusively with the conventional phantom simulator. De Boer et al.\u0026sup1;\u0026sup1; examined the effect of Simodont training on dental students with no prior manual skill experience and found that only students who trained with Simodont were able to pass the manual skills test. Yuan et al.\u0026sup1;\u0026sup2; investigated the effectiveness of Simodont training in preclinical students for teaching cavity preparation after the theoretical knowledge of the task had been standardized. They concluded that the Simodont simulator significantly improved cavity preparation performance compared with the conventional phantom simulator alone.\u003c/p\u003e\u003cp\u003eAll of these studies assessed the impact of Simodont training on cavity preparation performance during the initial cognitive stage of skill acquisition, without considering the more advanced stages that are essential for achieving full skill competence. Furthermore, in these studies, experimental and control groups were assigned randomly without matching specific characteristics (e.g., age, gender, fine motor skill competence, spatial perception, and dominant hand), which could act as confounding factors and potentially affect the internal validity of the findings.\u003c/p\u003e\u003cp\u003eAccording to Ackerman\u0026rsquo;s theory, skill acquisition consists of three stages\u0026sup1;\u0026sup3;: (1) Cognitive stage \u0026ndash; the initial phase of learning, in which the learner must understand instructions to perform a given task; (2) Associative stage \u0026ndash; the intermediate phase, in which perceptual speed and efficiency are developed to perform the task more quickly and accurately; and (3) Autonomous (automatic) stage \u0026ndash; the final phase, in which task performance relies predominantly on psychomotor abilities and less on cognitive processing.\u003c/p\u003e\u003cp\u003eA gap exists in the literature regarding the stage of manual skill acquisition in dental students at which additional training with the Simodont simulator is most effective.\u003c/p\u003e\u003cp\u003eRecently, the Simodont simulator has been introduced at our University School of Dentistry to enhance preclinical training in cavity preparation, serving as a supplementary tool to the conventional phantom simulator. Therefore, the aim of the present study was to determine whether additional training with the Simodont simulator improves the manual dexterity of preclinical dental students compared to training with the conventional phantom simulator alone, using an interventional study design with matching for potential confounding factors. This study also aimed to identify the stage of manual skill acquisition at which Simodont training is most beneficial. To the best of our knowledge, this is the first study to employ a matched design, therefore we hypothesized that additional Simodont training would not significantly improve cavity preparation performance compared to conventional phantom training alone.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants:\u003c/h2\u003e\u003cp\u003eA planned-crossover study with a matched design was conducted during the 2025 academic year among 70 third-year undergraduate dental students. All participants were in their first year of practicing on a phantom head and had not received any prior manual dexterity training for dental procedures using dental instruments.\u003c/p\u003e\u003cp\u003ePrior to commencing the study, all participants provided written informed consent, approved by the Ethics Committee (No. 0009807-1), after the principal investigator had explained the study\u0026rsquo;s aims and procedures.\u003c/p\u003e\u003cp\u003eInclusion criteria consisted of third-year dental students who had signed informed consent and had no previous manual dexterity training. Exclusion criteria included a history of vision-related pathology (e.g., strabismus, amblyopia, anisometropia, glaucoma, or cataract) or dexterity-related disorders (e.g., carpal tunnel syndrome). The entire class volunteered to participate in the study, preventing selection bias.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePurdue Pegboard Test:\u003c/h3\u003e\n\u003cp\u003eAll students underwent a validated assessment at the beginning of the study, prior to commencing the phantom head simulation course. This assessment included the Purdue Pegboard Test under direct vision to evaluate baseline fine motor skills and under indirect vision to assess baseline spatial perception.\u003c/p\u003e\u003cp\u003eThe Purdue Pegboard Test\u0026sup1;⁴ is a reliable and valid occupational therapy assessment tool (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). It consists of a board with two vertical columns of holes, and four cups located distally: the right and left cups each contain 25 pins, while the remaining two cups hold washers and collars, respectively. The test comprises four distinct tasks. In the first three tasks, as many pins as possible must be inserted into the board\u0026rsquo;s holes within 30 seconds; in the final task, the time limit is 60 seconds. The score for each task is determined by the number of pins inserted. The four tasks are as follows:\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDominant hand \u0026ndash; inserting pins using the dominant hand only.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eNon-dominant hand \u0026ndash; inserting pins using the non-dominant hand only.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eBoth hands \u0026ndash; simultaneously inserting one pin with each hand into two adjacent holes.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAssembly task \u0026ndash; continuously using both hands to assemble four components in sequence: a pin, a washer, a collar, and a second washer.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\n\u003ch3\u003eSimodont virtual simulator:\u003c/h3\u003e\n\u003cp\u003eThe Simodont (NISSIN Dental Products, New York, USA) is a three-dimensional (3D) virtual reality haptic simulator designed for intensive preclinical training of dental students and for the assessment of their manual skills. The system comprises two computers: a graphics PC and a panel PC. It utilizes two separate projectors to generate 3D images, which are viewed through specialized 3D glasses. To replicate a realistic clinical experience, the Simodont incorporates a handpiece gimbal, a hand mirror gimbal, and a horseshoe-shaped finger rest area, with virtual exercises displayed on a high-resolution 3D screen.\u003c/p\u003e\n\u003ch3\u003eResearch methodology (Fig. 2):\u003c/h3\u003e\n\u003cp\u003e\u003c/p\u003e\u003cp\u003eBefore performing the first task on plastic teeth mounted in a mannequin head, all dental students received theoretical instruction and a live demonstration of the manual task by a clinical instructor. For the assessment of the first phantom task under direct vision (Class I cavity preparation on tooth No. 36, with a depth of 1.5\u0026ndash;2.0 mm and a width equal to 1/4 of the intercuspal distance) and the second task under indirect vision (OP preparation on tooth No. 16, with a depth of 1.5\u0026ndash;2.0 mm and a minimal distance of 1.5 mm from the distal marginal ridge), the 70 students were matched into two equal groups (Group 1 and Group 2, n\u0026thinsp;=\u0026thinsp;35 each) to minimize bias from potential confounding factors. Using a crossover design, Groups 1 and 2 alternated roles as the experimental and control groups for these two phantom tasks.\u003c/p\u003e\u003cp\u003eFor the first phantom task, the Class I preparation, Group 1 (experimental group) trained with both the Simodont simulator and the conventional phantom head simulator for drilling on plastic teeth, while Group 2 (control group) practiced exclusively with the conventional phantom head simulator. Group 1 received an additional 120-minute training session on the Simodont, which simulated a Class I cavity preparation using haptic technology.\u003c/p\u003e\u003cp\u003eIn the second phase of the crossover design, Group 2 served as the experimental group and Group 1 as the control group for the OP preparation on tooth No. 16.\u003c/p\u003e\u003cp\u003eThe experimental group in each phase was further subdivided into three subgroups according to the timing of Simodont training relative to the stages of skill acquisition:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eGroup A \u0026ndash; Cognitive stage: immediately after receiving theoretical instruction and a demonstration of the task, before beginning practical execution.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eGroup B \u0026ndash; Associative stage: after receiving theoretical instruction and demonstration and following initial practice of the procedure.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eGroup C \u0026ndash; Autonomous stage: after receiving theoretical instruction and demonstration, and near completion of the practice phase.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe students\u0026rsquo; manual scores were compared between the control and experimental groups. Three independent instructors graded each task according to standardized criteria, including cavity outline and depth. Scores were given on a continuous scale from 0 to 100, with a passing threshold of 60. Student identification numbers were coded, and the instructors were blinded to both the students\u0026rsquo; identities and their group assignments.\u003c/p\u003e\n\u003ch3\u003eFeedback questionnaire\u003c/h3\u003e\n\u003cp\u003eAt the end of the Simodont training, all participants completed a questionnaire designed to gather their opinions regarding the training simulator and its potential applications in the following academic year for acquiring the manual skills required in dentistry (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMeans, SD and frequency distributions of responses to the feedback questionnaire. The questions were rated on a scale of 1 to 3, 1 for \"Disagree\", 2 for \"Partially agree\" and 3 for \"Agree\".\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuestion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026plusmn;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u0026thinsp;=\u0026thinsp;Disagree\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partially Agree\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u0026thinsp;=\u0026thinsp;Agree\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe image of teeth and dental instruments looked realistic?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1(2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18 (36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e31 (62%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe hardness and morphology of anatomical models and instruments felt realistic?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15(30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30(60%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5(10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe practicing on Simodont improved my fine motor skill acquisition?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.799\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20(40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18(36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12(24%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePracticing on Simodont improved my self-assessment for evaluation cavity preparation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21(42%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20(40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9(18%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePracticing on Simodont increased my confidence for more complicated dental procedure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27(54%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13(26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10(20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistics:\u003c/h2\u003e\u003cp\u003eAssumptions of normality for the study variables were evaluated using Kolmogorov\u0026ndash;Smirnov tests.\u003c/p\u003e\u003cp\u003eDescriptive statistics were calculated for both groups regarding the independent variables: age, gender, dominant hand, basic fine motor skills, and spatial perception.\u003c/p\u003e\u003cp\u003eAll statistical analyses were conducted using SPSS software (Version 29.0, IBM Corp., Armonk, NY, USA). Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003eFor comparisons between the experimental and control groups, Mann\u0026ndash;Whitney tests were applied for age and scores on the Purdue tests under both direct and indirect vision conditions. Chi-square tests were used to analyze the distribution of gender and hand dominance between groups. Kruskal\u0026ndash;Wallis tests were employed to compare data among the three sub-groups (cognitive stage, associative stage, and autonomous stage groups).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eKolmogorov\u0026ndash;Smirnov tests indicated that all study variables\u0026mdash;students\u0026rsquo; scores on the Purdue Pegboard tests under direct and indirect vision, age, and manual grades in the phantom laboratory\u0026mdash;were not normally distributed (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003ch3\u003eComparison of study group characteristics\u003c/h3\u003e\n\u003cp\u003eThis analysis was conducted to evaluate potential confounding effects of independent variables that might influence manual grades, thereby impacting the internal validity of the study.\u003c/p\u003e\u003cp\u003eMann\u0026ndash;Whitney tests revealed no statistically significant differences between Group 1 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;35) and Group 2 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;35) for age (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.432), all 4 tasks of Purdue under direct vision (p\u0026thinsp;\u0026gt;\u0026thinsp;0.194) and indirect vision (p\u0026thinsp;\u0026gt;\u0026thinsp;0.173). Chi-square tests showed no significant differences in gender distribution (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000) or hand dominance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000) between the groups.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eSub-group comparisons \u0026ndash; Group 1\u003c/h2\u003e\u003cp\u003eKruskal\u0026ndash;Wallis tests comparing the cognitive stage group, associative stage group, and autonomous stage group in Group 1 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) revealed no statistically significant differences in age (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.322), all 4 tasks of Purdue under direct vision (p\u0026thinsp;\u0026gt;\u0026thinsp;0.753) and indirect vision (p\u0026thinsp;\u0026gt;\u0026thinsp;0.713). Chi-square tests indicated no significant differences in gender distribution (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.813) or hand dominance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.997) among the sub-groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMedian (P50) and 95% confidence intervals (upper and lower bounds) for age, gender, and Purdue direct and indirect test scores in Group 1.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eGroup 1\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCognitive stage group (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAssociative stage group (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAutonomic stage group (N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal experiment group\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;25\u003c/p\u003e\u003cp\u003eCI(23.6,26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e\u003cp\u003eCI(24.6,27.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;25\u003c/p\u003e\u003cp\u003eCI(24.4,26.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e\u003cp\u003eCI(24.7,26)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDominant Hand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 right, 1 left\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 right, 1 left\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 right, 1 left\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32 right 3 left\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF (n\u0026thinsp;=\u0026thinsp;9), M (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eF (n\u0026thinsp;=\u0026thinsp;10), M (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eF (n\u0026thinsp;=\u0026thinsp;8), M (n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eF (n\u0026thinsp;=\u0026thinsp;27), M (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue dominant hand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\u003cp\u003eCI(13.6,16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;16\u003c/p\u003e\u003cp\u003eCI(14.5,16.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;16\u003c/p\u003e\u003cp\u003eCI(14.6,17.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;16\u003c/p\u003e\u003cp\u003eCI (14.8,16.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue non dominant hand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\u003cp\u003eCI(13,15.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\u003cp\u003eCI(13.5,15.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\u003cp\u003eCI(13.7,16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\u003cp\u003eCI(13.9,15.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue both hands\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;11\u003c/p\u003e\u003cp\u003eCI(10.5,12.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e\u003cp\u003eCI(11.2,13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e\u003cp\u003eCI(11.3,12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e\u003cp\u003eCI(11.4, 12.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue assembly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;34\u003c/p\u003e\u003cp\u003eCI(30,41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;36\u003c/p\u003e\u003cp\u003eCI(30.5,38.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;36\u003c/p\u003e\u003cp\u003eCI(29.8,41.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;36\u003c/p\u003e\u003cp\u003eCI( 32.5, 37.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue indirect dominant hand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e\u003cp\u003eCI( 6.1,9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8.5\u003c/p\u003e\u003cp\u003eCI(7.7,9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e\u003cp\u003eCI(6,9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e\u003cp\u003eCI(7.2, 8.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue indirect non dominant hand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e\u003cp\u003eCI(7,10.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8.5\u003c/p\u003e\u003cp\u003eCI(7,8.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e\u003cp\u003eCI(6.9,9.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e\u003cp\u003eCI(7.6,9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue indirect both hands\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;5.5\u003c/p\u003e\u003cp\u003eCI(4.7,6.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e\u003cp\u003eCI( 5, 6.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e\u003cp\u003eCI (4.9,5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e\u003cp\u003eCI(5.2,6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue indirect assembly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;18.5\u003c/p\u003e\u003cp\u003eCI(15.7,23.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;20\u003c/p\u003e\u003cp\u003eCI( 17.1,21.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e\u003cp\u003eCI (16.4,21.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;19\u003c/p\u003e\u003cp\u003eCI( 17.8,20.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreparation tooth 36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;65.5\u003c/p\u003e\u003cp\u003eCI (58,70.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;60\u003c/p\u003e\u003cp\u003eCI (53.6,66.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e\u003cp\u003eCI (50.6,63.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;61\u003c/p\u003e\u003cp\u003eCI( 57.1,64.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreparation tooth 16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;65\u003c/p\u003e\u003cp\u003eCI (56.7,73.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;73\u003c/p\u003e\u003cp\u003eCI (62.5,75.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e\u003cp\u003eCI( 48.1,58.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;65\u003c/p\u003e\u003cp\u003eCI (58.5,67)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eSub-group comparisons \u0026ndash; Group 2\u003c/h2\u003e\u003cp\u003eKruskal\u0026ndash;Wallis tests comparing the cognitive stage group, associative stage group, and autonomous stage group in Group 2 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) demonstrated no statistically significant differences for age (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.469), all 4 tasks of Purdue under direct vision (p\u0026thinsp;\u0026gt;\u0026thinsp;0.310) and indirect vision (p\u0026thinsp;\u0026gt;\u0026thinsp;0.375) except for Purdue indirect non-dominant hand, which showed a statistically significant difference (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.032). Chi-square tests revealed no significant differences in gender distribution (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.436) or hand dominance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.997) between the sub-groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eP50 (50 percentile) and 95% Confidence interval (Upper, Lower) of age, gender, four tasks of Purdue direct and indirect tests for group 2.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eGroup 2\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCognitive stage group (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAssociative stage group (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAutonomic stage group (N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal experiment group N\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e\u003cp\u003eCI(23.8,26.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e\u003cp\u003eCI(24.5,26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;27\u003c/p\u003e\u003cp\u003eCI(24.8,28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e\u003cp\u003eCI(25,26.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDominant Hand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 right, 1 left\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 right, 1 left\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 right, 1 left\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e32 right 3 left\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF(n\u0026thinsp;=\u0026thinsp;10),M (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eF(n\u0026thinsp;=\u0026thinsp;10),M (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eF (n\u0026thinsp;=\u0026thinsp;7), M (n\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eF(n\u0026thinsp;=\u0026thinsp;27), M (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue dominant hand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;16\u003c/p\u003e\u003cp\u003eCI(14.7,17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;16\u003c/p\u003e\u003cp\u003eCI(14.1,17.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;17\u003c/p\u003e\u003cp\u003eCI(15.5,17.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;16\u003c/p\u003e\u003cp\u003eCI (15.3,16.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue non dominant hand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;14.5\u003c/p\u003e\u003cp\u003eCI(13.5,16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\u003cp\u003eCI(12.5,15.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;16\u003c/p\u003e\u003cp\u003eCI(14.6,16.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\u003cp\u003eCI( 14,15.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue both hands\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e\u003cp\u003eCI(11.6,13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;13\u003c/p\u003e\u003cp\u003eCI(11.5,13.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e\u003cp\u003eCI(11.8,13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e\u003cp\u003eCI(12,13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue assembly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;34\u003c/p\u003e\u003cp\u003eCI(31.9,38.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;36\u003c/p\u003e\u003cp\u003eCI(32.7,39.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;34\u003c/p\u003e\u003cp\u003eCI(30.3,37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;35\u003c/p\u003e\u003cp\u003eCI( 33.1, 36.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue indirect dominant hand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;7.5\u003c/p\u003e\u003cp\u003eCI(6.4,8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8.5\u003c/p\u003e\u003cp\u003eCI(7.2,9.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e\u003cp\u003eCI(6.6,9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e\u003cp\u003eCI(7.3,8.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue indirect non dominant hand\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;7\u003c/p\u003e\u003cp\u003eCI(6.2,8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;9\u003c/p\u003e\u003cp\u003eCI(7.8,10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e\u003cp\u003eCI(7.5,9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e\u003cp\u003eCI(7.6,8.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue indirect both hands\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;6.5\u003c/p\u003e\u003cp\u003eCI (4.7,8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e\u003cp\u003eCI(5.3,7.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e\u003cp\u003eCI (4.3,6.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;6\u003c/p\u003e\u003cp\u003eCI (5.4,6.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePurdue indirect assembly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;19\u003c/p\u003e\u003cp\u003eCI(15.6,20.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e\u003cp\u003eCI(17.9,24.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;17\u003c/p\u003e\u003cp\u003eCI (15.3,21.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;18\u003c/p\u003e\u003cp\u003eCI (17.6,20.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreparation tooth 36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;58.5\u003c/p\u003e\u003cp\u003eCI (51.1,67.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;56\u003c/p\u003e\u003cp\u003eCI (52.4, 61.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;52.5\u003c/p\u003e\u003cp\u003eCI (51.1,71.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;56\u003c/p\u003e\u003cp\u003eCI(55.1,63.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreparation tooth 16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;66.5\u003c/p\u003e\u003cp\u003eCI (56.8,71.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;56.5\u003c/p\u003e\u003cp\u003eCI (51.5, 69.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;69\u003c/p\u003e\u003cp\u003eCI (55.1,73.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP50\u0026thinsp;=\u0026thinsp;65\u003c/p\u003e\u003cp\u003eCI (58.4,67.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eComparison of manual grades on plastic tooth No. 36\u003c/h2\u003e\u003cp\u003eNo significant difference was found between Group 1 (experimental) and Group 2 (control) in the manual performance score for tooth No. 36 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.461) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Furthermore, no significant differences were observed among the three subgroups of Group 1 (cognitive, associative, and autonomous stages) with respect to the manual score on tooth No. 36 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.207).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eComparison of manual grades on plastic tooth No. 16 (OP preparation, indirect vision)\u003c/h2\u003e\u003cp\u003eNo significant difference was found between Group 2 (experimental) and Group 1 (control) for the manual score on tooth No. 16 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.916) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Similarly, no significant differences were observed among the three subgroups of Group 2 regarding the manual score on tooth No. 16 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.723).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eFeedback questionnaire\u003c/h2\u003e\u003cp\u003eAt the conclusion of the Simodont training, 71% of the students completed the feedback questionnaire (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The mean response values across all seven questions ranged from 1.6 to 2.6 on the scale used. Notably, the majority of students agreed only with the statement regarding the realism of the images of teeth and dental instruments. For all other questions, most students partially disagreed or disagreed, indicating a perception that the use of Simodont did not substantially aid in acquiring the manual skills required for phantom laboratory practice.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eImplementation of virtual reality simulators incorporating force feedback (haptic) technology during the preclinical year of dental education has been well documented\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Although a recent systematic review\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e concluded that the application of virtual reality in dental education improves students' clinical outcomes and self-assessment, the consensus in most studies is that virtual simulators should enhance rather than replace conventional phantom head simulators\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eVirtual reality simulators have inherent disadvantages, including the absence of a physical finger rest and the inability to perform bimanual coordination required for indirect vision, soft tissue retraction, and light reflection using a dental mirror. Dentists must practice bimanually: one hand performs precise drilling, while the other hand manipulates the dental mirror at exact angles to provide optimal visualization of the small and inverted operative field. Learning this skill is challenging due to the brain\u0026rsquo;s natural difficulty in simultaneously controlling two new complex motor actions requiring coordination of both hands. Therefore, the Simodont does not accurately simulate the dentist\u0026rsquo;s real working posture.\u003c/p\u003e\u003cp\u003eOur study demonstrated no significant effectiveness of the virtual simulator in improving manual skills for dental procedures under both direct and indirect vision. To our knowledge, this is the first study employing matched design controlling for confounding factors, especially manual dexterity and spatial perception that could influence dental students' manual performance scores. Lugassy et al\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e concluded that manual skill in dentistry, a key competence, partially reflects innate ability. Hattori et al.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e reported lower scores for dental students using the Simodont compared to conventional simulators, attributing the difference to variability in students\u0026rsquo; depth perception abilities.\u003c/p\u003e\u003cp\u003eMurbay et al.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e evaluated the impact of integrating the Simodont simulator into a preclinical operative dentistry course. Thirty-two students were randomized into two groups: one trained with Simodont and the other without. Their findings showed significantly improved clinical performance in the Simodont group. Wei et al.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e also explored Simodont\u0026rsquo;s effectiveness in teaching access and coronal cavity preparation in preclinical training, demonstrating greater consistency in task performance among students trained with Simodont compared to traditional methods. In contrast, our larger study with 70 matched students found no significant differences between control and experimental groups on manual performance under direct and indirect vision, highlighting the importance of controlling for confounders such as age, gender, dominant hand, fine motor skills, and spatial perception.\u003c/p\u003e\u003cp\u003eWhile virtual reality simulators appear to enhance student performance and self-confidence, they cannot currently replace conventional phantom head simulators. Studies suggest that virtual reality is most effective during the early cognitive stage of preclinical dental training\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Bakr et al.\u0026sup2;\u0026sup1; recommended a gradual introduction of virtual simulators starting from the first year, progressing through cariology exercises in the second year, and adjunct crown preparation training in the third year alongside phantom simulators. Our study found no significant differences in performance among the cognitive, associative, or autonomous stages of motor skill acquisition.\u003c/p\u003e\u003cp\u003eThe feedback questionnaire in this study revealed that students only agreed that the images of teeth and dental instruments appeared realistic; however, they did not feel that the virtual simulator enhanced their manual performance. This perception may be related to the simulator\u0026rsquo;s limited ability to accurately replicate tactile sensations of enamel, dentin, and bone, as well as practical drawbacks such as high initial cost, the need for instructor guidance prior to training, and requirements for precise calibration.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eDue to limited availability of the simulator, training time was restricted to two hours per student. Future research should investigate the benefits of extended training durations to maximize the educational value of virtual simulation.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe use of the Simodont simulator during the preclinical year may not improve dental students\u0026rsquo; manual performance under direct or indirect vision. Although virtual reality simulators represent promising educational tools, they currently cannot replace conventional phantom head simulators in dental training.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eAcknowledgements\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eNot applicable.\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eAuthor contributions\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eConceptualization, U.J. and D.L.; methodology, D.L., N.U and U.J.; software, N.R.B. and I.V.; validation, D.L. and U.J.; formal analysis, D.L.; investigation, U.J. and I.V.; resources, D.L.; data curation, D.L.; writing\u0026mdash;original draft preparation, D.L. and U.J.; writing\u0026mdash;review and editing, N.S., Y.S., T.B., and S.L.; visualization, U.J.; supervision, D.L.; project administration, U.J; funding acquisition, U.J and D.L. All authors have read and agreed to the published version of the manuscript.\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eFunding\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eThis research received no external funding.\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eData availability\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eThe data presented in this study are available on request from the corresponding author. Dr Diva Lugassy, mail: [email protected]. Ethics approval and consent to participate\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eThis study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of Tel Aviv University (protocol code No. 0009807-1). Prior to commencing the study, all participants provided written informed consent, approved by the Ethics Committee (No. 0009807-1), after the principal investigator had explained the study\u0026rsquo;s aims and procedures\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eConsent for publication\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eAll authors have read and agreed to the published version of the manuscript. Competing interests\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eThe authors declare no competing interests\u003c/span\u003e\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSuvinen TI, Messer LB, Franco E. Clinical simulation in teaching preclinical dentistry. Eur J Dent Educ. 1998; 2: 25-32. \u003c/li\u003e\n\u003cli\u003eCausby R, Reed L, Mcdonell M, Hillier S. Use of objective psychomotor tests in health professionals. Perceptual and Motor Skills: Motor Skills and Ergonomics. Percep and Motor Skills. 2014; 118: 765-804. \u003c/li\u003e\n\u003cli\u003eJohnson L, Thomas G, Dow S, Stanford C. An initial evaluation of the Iowa dental surgical simulators. J Dent Educ. 2000; 64: 847-853.\u003c/li\u003e\n\u003cli\u003eBakker D, Lagerweij M, Wesselink P, Vervoorn M. Transfer of manual dexterity skills acquired on the simodont, a dental haptic trainer with a virtual environment, to reality. A pilot study. Bio Algor Med Sys. 2010; 11: 21-24.\u003c/li\u003e\n\u003cli\u003eRose JT, Buchanan JA, Sarrett DC. The DentSim system. J Dent Educ. 1999; 63: 421-423.\u003c/li\u003e\n\u003cli\u003eLok-Sze Leung A, Yeung C, Chu S, Wong AWY, Yu OY. Use of computer simulation in dental training with special reference to Simodont. Dentistry J. 2021; 9,125.\u003c/li\u003e\n\u003cli\u003eQuinn F, Keogh P, Mcdonald A, Hussey D. A pilot study comparing the effectiveness of conventional training and virtual reality simulation in the skill acquisition of junior dental students. Eur J Dent Educ. 2003; 7: 13-19.\u003c/li\u003e\n\u003cli\u003eUrbankova A, Hadavi F, Lichtenthal RM, Leblanc VR. Effect of different types of dental simulation training on students\u0026apos; performance in operative dentistry. J Dent Educ. 2004; 68: 245-246.\u003c/li\u003e\n\u003cli\u003eBark MM, Massey WL, Alexander H. Evaluation of simodont haptic 3D virtual reality dental training simulator. Inter J Dent Clinic. 2013; 5: 1-6.\u003c/li\u003e\n\u003cli\u003eWei Y, Peng Z. Application of Simodont virtual simulation system for preclinical teaching of access and coronal cavity preparation. Plos One. 2024; 1-13.\u003c/li\u003e\n\u003cli\u003eDe Boer IR, Lagerweij MD, De Vries MW, Wesselink PR, Vervoorn JM. The effect of force feedback in a virtual learning environment on the performance and satisfaction of dental students. Simul Healthc. 2017; 12: 83-90.\u003c/li\u003e\n\u003cli\u003eYuan CY, Wang XY, Dong YM, Gao XJ. Effect of digital virtual simulation system for preclinical teaching of access and coronal cavity preparation. Zhonghun Kou Qiang. 2021; 56, 479-484.\u003c/li\u003e\n\u003cli\u003eAckerman PL. Determinants of individual differences during skill acquisition: cognitive ability and information processing. J Exper Psych. 1988; 117: 288-318. \u003c/li\u003e\n\u003cli\u003eMathiowertz V, Rogers SL, Keval MD, Donahoe L, Rennele C. The purdue pegboards: Norms for 14 to 19 year olds. Amer J Occup Ther. 1986;40: 174-179\u003c/li\u003e\n\u003cli\u003eMoussa R, Alghazaly A, Althagafi N, Eshky R, Borzangy S. Effectiveness of Virtual Reality and Interactive Simulators on Dental Education Outcomes: Systematic Review. Eur J Dent. 2022;16:14-31. doi: 10.1055/s-0041-1731837\u003c/li\u003e\n\u003cli\u003eLeung AL, Yeung C, Chu S, Wong AW, Yu OY, Chu CH. Use of Computer Simulation in Dental Training with Special Reference to Simodont. Dent J. 2021 21;9:125. doi: 10.3390/dj9110125 \u003c/li\u003e\n\u003cli\u003eLugassy D, Levanon Y, Pilo R, Shely A, Rosen G, Meirowitch A, Brosh, T. Predicting the clinical performance of dental students with a manual dexterity test. Plos One 2018; 13:https://doi.org/10.1371/journal.pone.0193980.\u003c/li\u003e\n\u003cli\u003eHattori A, Tonami KI, Tsuruta J, Hideshima M, Kimura Y, Nitta H, Araki K. Effect of the haptic 3D virtual reality dental training simulator on assessment of tooth preparation. J Dent Scien. 2022; 17: 514-520.\u003c/li\u003e\n\u003cli\u003eMurbay S, Neelakantan P, Chang JWW, Yeung S. Evaluation of the introduction of a dental virtual simulator on the performance of undergraduate dental students in the pre- clinical operative dentistry course. Eur J Dent Educ. 2019; 00: 1-15.\u003c/li\u003e\n\u003cli\u003eKolivand H, Shooreshi MM, Safari-Faramani R, Borji M, Mansory MS, Moradpoor H, Bahrami M, Azizi SM. Comparison of the effectiveness of virtual reality based education and conventional teaching methods in dental education: a systematic review. BMC Med Educ. 2024; 24,8.\u003c/li\u003e\n\u003cli\u003eBakr MM, Idris G, Ankily MA. The potential integration of Simodont dental trainer in different stages of the dental curriculum. Saudi Dent J. 2034; 36: 1449-1455.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Virtual reality simulator, dental students, manual skill, Simodont, dental education","lastPublishedDoi":"10.21203/rs.3.rs-7436627/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7436627/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eRecent studies have demonstrated the effectiveness of virtual reality (VR) simulators in dental education. However, these studies primarily focused on the early stages of psychomotor skill acquisition and often did not account for confounding variables when assigning participants to study groups. The present study aims to determine the stage of manual skill acquisition at which VR simulator training is most effective, using a matched interventional study design.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA planned crossover study with a matched design was conducted among 70 undergraduate dental students from Tel Aviv University. Matching was performed based on age, gender, dominant hand, spatial perception, and fine motor skills. To evaluate manual performance under both direct vision (Class I cavity preparation) and indirect vision (Class 1 occlusal-proximal [OP] preparation), students were evenly assigned to two groups (Group 1 and Group 2), matched to control for potential confounding factors. Using a crossover approach, each group alternated roles as the experimental or control group for the two phantom-based tasks. The experimental group trained with both the Simodont virtual reality simulator and the conventional phantom simulator, while the control group practiced solely with the conventional simulator on plastic teeth. The experimental group was further subdivided into three subgroups based on the timing of Simodont exposure corresponding to different stages of skill acquisition: cognitive, associative, and autonomous.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNo statistically significant differences were observed between the experimental and control groups in manual performance scores under direct vision (p\u0026thinsp;=\u0026thinsp;0.461) or indirect vision (p\u0026thinsp;=\u0026thinsp;0.916). Additionally, no significant differences were found among the three experimental subgroups representing different stages of skill acquisition (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe integration of the Simodont simulator during the preclinical year does not appear to enhance dental students\u0026rsquo; manual performance under either direct or indirect vision conditions.\u003c/p\u003e","manuscriptTitle":"Stage of manual skill acquisition with Simodont virtual reality simulator for pre-clinical dental training: An interventional matching study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 12:23:12","doi":"10.21203/rs.3.rs-7436627/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-03T06:52:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-11T16:59:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-09T03:36:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126970950961532895611661648292975115345","date":"2025-10-09T02:44:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313400335989081147185871540015898143131","date":"2025-10-06T07:34:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-06T06:31:37+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-09T12:23:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-09T05:05:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-09T05:04:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-08-22T17:25:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf92d4d1-e4c9-4491-9b77-61776dbead99","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:04:26+00:00","versionOfRecord":{"articleIdentity":"rs-7436627","link":"https://doi.org/10.1186/s12909-026-08917-1","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2026-03-02 15:58:05","publishedOnDateReadable":"March 2nd, 2026"},"versionCreatedAt":"2025-10-17 12:23:12","video":"","vorDoi":"10.1186/s12909-026-08917-1","vorDoiUrl":"https://doi.org/10.1186/s12909-026-08917-1","workflowStages":[]},"version":"v1","identity":"rs-7436627","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7436627","identity":"rs-7436627","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}