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 Table of Contents  
Year : 2021  |  Volume : 12  |  Issue : 3  |  Page : 161-167

“When virtuality merges with reality:” Application of virtual reality and augmented reality in dentistry - A literature review

1 Post graduate student, Department of Pedodontics and Preventive Dentistry, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India
2 Intern, Department of Pedodontics and Preventive Dentistry, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India
3 Professor and HOD, Department of Pedodontics and Preventive Dentistry, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India
4 Professor, Department of Pedodontics and Preventive Dentistry, Dr. R. Ahmed Dental College and Hospital, Kolkata, West Bengal, India

Date of Submission31-Jan-2021
Date of Decision18-Jun-2021
Date of Acceptance05-Jul-2021
Date of Web Publication17-Sep-2021

Correspondence Address:
Dr. Khushboo Rana
114, A.J.C, Bose Road, Dr. R. Ahmed Dental College and Hospital, Kolkata - 700 041, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_9_21

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The term “virtuality” has been quoted as “real but not actual, ideal but not abstract” by Marcel Proust. Visual-based reality is gaining popularity in dentistry because of its use in dealing with image-guided and robot-assisted surgery. It has provided a new approach for improving the treatments and delivering education in dentistry. The major throwback was the use of images registration by endoscope camera devices in the form of a video which can be presented on a monitor where the operator is able to observe the site inside the patient. The technologies of modern science have amazed and also fascinate our vision regarding working with patients. This literature review provides only a glance at the future of intelligence science.

Keywords: Artificial intelligence, augmented reality in applied dentistry, modern dentistry, virtual reality

How to cite this article:
Rana K, Sharma B, Sarkar S, Choudhary SR. “When virtuality merges with reality:” Application of virtual reality and augmented reality in dentistry - A literature review. SRM J Res Dent Sci 2021;12:161-7

How to cite this URL:
Rana K, Sharma B, Sarkar S, Choudhary SR. “When virtuality merges with reality:” Application of virtual reality and augmented reality in dentistry - A literature review. SRM J Res Dent Sci [serial online] 2021 [cited 2023 Jan 28];12:161-7. Available from:

  Introduction Top

Dentistry has evolved tremendously with the advancement in the way of diagnosing, ease in performing procedures, advanced treatment, and very importantly preservation of oral health to become, what is today known as “Modern Dentistry.” Dentistry is no exception to the remarkable influences of digital revolution seen in the form of computer-aided design/computer-aided manufacturing assisted crown bridges, caries diagnosing methods such as digital radiography, digital fibreoptic, optical coherence, tomography, laser fluorescence, digital assisted treatment planning for implant surgery/restoration. After all, dentistry is one of those branches of medicine that largely incorporates technological systemization, which is constantly evolving and changing to best suit patients' needs.[1]

Another such technological development is “Interactive Visual Based Technology,” which includes virtual reality (VR), augmented reality (AR), and mixed reality (MR). VR deals with 3D graphical objects or real-like images; whereas AR is watching these virtual objects in the real or live environment; a new world is formed by merging real and virtual worlds called MR.[2]

VR is making a great impact in dentistry due to its vast applications as well as with the advancement in computer systems. It has become an influential tool in dental education because of innovations that enable the dental practitioner to virtually interact with patients. This can be possible using holographic images viewed through VR headset hence enhance the experience of both students and practitioners.[3] The application of this technology is emerging as a breakthrough for the treatment of patients with phobia, especially in pediatric dentistry.[4] Furthermore, several VR programs have been developed to simulate different surgical procedures.[5]

Further, the advent of haptic technology has made it possible to have an immersive feel while learning in a virtual environment, which has steepened the learning curve and also improved patient safety.[6] AR is an enhanced version of reality created by the use of technology to overlay digital information on an image of an object being viewed through a device, which means superimposition of computer-generated working scenario on existing reality to enhance the sensory perception by interacting with it. The scope of indication of AR is diverse, which includes dental education using feedback technology, radiology, orthodontic bracket positioning, prosthetics augmentation, management of dental phobia, endodontic surgery, and very importantly in oral and maxillofacial surgery while performing minimally invasive procedures.[7],[8]

This article aims to review the basic science behind visual-based technology and its various application in dentistry.

  What is Virtual Reality and Augmented Reality? Top

The term “Virtuality” has been quoted as “real but not actual, ideal but not abstract” by Marcel Proust. The term “virtual reality” was coined by Jaron Lainer in 1989. According to Fuchs and bishops, it is “real-time interactive graphics with 3D models, combined with a display technology that gives the user an immersion in the model world and direct manipulation.” It commonly consists of a head-mounted display (HMD), which helps to perceive the virtual world.[9]

Hence, the technology of VR also called Virtual Environment, which was coined by Milgram, entirely engrosses users into an artificial world without visualizing the real world whereas AR technology adds up the feel of reality by superimposing virtual objects upon the real scene in real-time. This advanced technology, i.e. AR in a broader way can be contexed MR, which is a multi-axis spectrum of areas that contain VR, AR, telepresence, and other related technologies[10] [Figure 1].
Figure 1: Hypothetical image showing difference in virtual reality and augmented reality

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Telepresence can be characterized as a human/machine framework in which the human administrator gets adequate data about the teleoperator and the task environment, displayed in an adequately regular way, that the administrator feels present at the far-off site. AR can be viewed as an innovation in the middle of VR and telepresence. While in VR, the environment is totally manufactured and in telepresence, it is totally genuine, in AR the client sees this present reality augmented with virtual items.[11]

Hence, AR is not simply limited to a specific sort of display innovation, for example, HMD nor to the feeling of sight. It can possibly be applied to all the senses; smell, contact, and hearing too. It can likewise be utilized to expand the client's missing sense by tangible replacement, for example, augmenting the sight of a blind user.[11]

The AR technology consists of devices such as displays, input devices, tracking, and computer. The three major types of displays used in AR: HMD, handheld displays, and spatial displays. These days some AR systems are utilizing Contact lenses and newer innovations like virtual retina displays (display of the device is scanned directly onto the retina of viewer eyes).

The various display technologies are:

  1. Monitor based
  2. HMD
  3. Video see-through
  4. Optical see-through [Figure 2].
Figure 2: Schematic diagram representing various display technologies: (a) monitor based (b) optical see – through head mounted display (c) video see-through head mounted display

Click here to view

Input devices are of various types[12],[13] and tracking devices comprise digital cameras and other optical sensors, accelerometers, solid-state compasses, global positioning system (GPS), wireless sensors, etc.

Visual-based reality is gaining popularity in dentistry because of its use in dealing with image-guided and robot-assisted surgery. Bichlmeier et al. acquainted AR framework to view through the real skin onto virtual life systems utilizing continuous representation. The new advancement even thinking of building the real-time three-dimensional (3D) magnetic resonance imaging (MRI) that can be placed directly over the patient body part to make the diagnosis easy and efficient. It would be interesting to see while doing the diagnosis of a patient; all the history and reports start to display over HMD.[14]

  Use of Virtual Reality and Augmented Reality in Dental Education Top

Learning health-related subjects during dental clinics includes the investigation of broad material. Over the years, teachers have been trying to implement various methods to garner the students' interest and help to make learning easier. New innovation-based methodologies have arisen lately through the improvement of a wide scope of computer-based apparatuses and frameworks. These include: “intelligent tutoring systems,” medical simulation, VR techniques.[15]

The “Phantom head simulators” have been a classical device for dental education for a long time because of their countless benefits such as learning by proper handling of handpiece and mirror, allowing the possibility of finger rest. The modern phantom head consists of a water spray to add realism but it cannot be considered ideal because of the disadvantages i.e. it becomes difficult to develop fine motor skills on artificial teeth, cost of handpiece, its maintenance, and dental burs also becomes expensive. The various developments and modifications in simulator technique have led to the advent of computer-based simulation of 3D images and the environment in the form of “Virtual Reality” that improve the learning by increasing the interaction in real and physical ways with the objects. Different frameworks such as dentsim (first test system presented) give the 3D visuals in life-sized model-based learning, with the priority of improving manual dexterity in light of the possibility of a finger rest, water spray, and a dental handpiece.[16]

Other similar systems are virtual dental patient, VR Dental Training System Iowa Dental Surgical Simulator, PerioSim, HapTEL, VirDenT, Moog Simodont Dental Trainer, and The Forsslund System.[17],[18] Later systems, mainly developed through advanced technology using “haptics,” kinaesthetic communication, or 3D touch. The word “Haptics” comes from the Greek: (haptikos), meaning “tactile, pertaining to the sense of touch,” Haptic technology was first developed in the form of game controllers, joysticks, and steering wheels. This technology has given the provision of the sense of touch while applying force, vibration, or motion over the virtual objects. So, when the virtual objects are touched they seem real and tangible. For example, perception of force delivery while cutting the tooth during tooth preparation, by controlling the foot control of the handpiece in a virtual simulation, or significant perception of soft tissue gums while doing the prosthetic procedures. The haptic technology consists of software that calculates the forces required to feel the object by the user and also a hardware device (tools) through which such forces can be transmitted to the user to feel, for example, joysticks, haptic gloves, point source, and specific task design. In dental education, simulations are available for procedures such as the extraction of teeth, practicing the various injections technique, and placement of brackets. E-learning through AR recreation can enhance the ability by using visual and haptic prompts.[19]

Points of interest of utilizing virtual simulators over 2D simulators are; consistently practice a similar tooth preparation without the requirement for management and with simultaneous computer input before executing over the patient in a clinical setting, powerful motor skills ability advancement, consciousness of when and how a blunder was made (information on execution) is a higher priority than the end-product itself (result information), review the chronicle of execution to discover the mistakes, can work on as per own time. Simulators likewise maintain a strategic distance from the requirement for water lines and suction, thus the danger of water-borne sicknesses, for example, Legionella is eliminated. There are a few disadvantages as well, such as just depending on the utilization of items with computer-produced pictures lose basic psychomotor abilities, for example, right handpiece grasp, pose, and related finger rest. Despite advancement in the area, the lack of exposure to the range of procedures available on mannequins, delay performance because of the time lag between output and input, and last very importantly is the technology acceptance critics have to be considered.[20]

The incorporation of serious games or video games is one of the effective means of enhancing the skills and learning in medical science. An investigation was done by Kroon et al. in 2010 with respect to medical students' mentality toward computer games and different innovations in clinical schooling. Among 200 medical students, it has been discovered that 98% upheld that innovation to improve their learning and 95% thought new media innovation could be better incorporated or utilized in educational program.[20]

  Use of Virtual Reality and Augmented Reality in Oral and Maxillofacial Surgery Top

VR system can be used as an important training tool for the dental trainee to practice the surgical procedure with the advantage of handling the surgical instruments by creating the real-like surgical field. A study done by Pulijala et al. using VR including “multimedia combination with 360-degree videos,” “stereoscopic camera” and 3D interaction in training the orthognathic surgery, got strong agreement over the face and content validity of VR surgery.[21] Thus, improving the operative skills among trainees. In spite of being a new and advanced technology, VR is restricted to education (training) such as studying the anatomy of oral and maxillofacial surgery, training the student for giving anesthesia in virtual models, and preoperative planning.

While VR technology is used almost exclusively for preoperative planning and training, with the help of AR we can view digital images and preoperative planning data such as information from computed tomography\MRI or other visual data like the position of implants, drill on the correct spatial position over the surface of the patient. According to Ferrari et al., in 2009; Freschi et al. in 2009.[22],[23] AR has given a positive understanding about the arrangement of direct view of how virtual substance, by and large, got through clinical imaging, is located inside a real scene to the learner. This is especially significant with regards to oral and maxillofacial medical procedures, where the extraordinary anatomical intricacy has invigorated the improvement of such development gadgets. This technique is both protected and productive for the fact that the specialist doesn't have to take his eyes off the patient field to take a look at the picture showed on computer.[21]

“Surgical navigation” originated in a desire to perform the safer and less invasive procedure. The word “navigation in surgery” means knowing proper anatomical orientation such as predicting the position of the implant while placing in bone, before attempting the incision, positioning the jaw in proper anatomical location using this technology during orthognathic surgery, apart from that an important measuring tool (act as 3D measuring system) for doing precise surgery. The major application of navigation devices in “oral and maxillofacial surgery” is in orthognathic surgery, tumor excision, temporomandibular joint movement analysis, foreign body removal, osteotomy, minimally invasive biopsy, prosthetic surgery (augmentation), endodontic surgery, and dental implantation. The computer-assisted medical procedure was one of the significant legacies prior to digital dentistry, which fundamentally comprises of a gadget that tracks the careful instrument whose position and direction are mapped to the virtual space utilizing picture registration process. The spatial connection between the instrument and the careful site is pictured utilizing computer design methods. Similar to a car or mobile phone's GPS, continuous surgical data are also displayed and updated on a surgical monitor[21] [Figure 3]. In this strategy, the surgeon utilizes the pointer to build up a connection with preusable picture information and the surgical field, yet it is hard to arrange the pictures, subsequently, AR framework was created, which projects the pictures straightforwardly on the surgical site and depends on monocular projection in the working microscope, head-up displays, projection on to reason constructed semi-clear screens put between the working scene and the surgeon, or by projection into the binocular optics of a followed surgical microscope.[24] The basic workflow of image-based navigation is explained in [Figure 4].
Figure 3: Hypothetical representation of surgical navigation, showing the resemblance of each of its basic component with global positioning system (1) Localizer (main controlling devices for integration, replication and virtual reproduction of anatomical structure) work as satellite. (2) A surgical probe which sends signals through infrared diodes or pointers mimics the global positioning system system in vehicles, as it emits track waves. (3). A computerized tomography database, for identification of abnormalities and also evaluation of outcomes after surgery, similar to road map depicted in global positioning system system for route navigation

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Figure 4: Flowchart showing: (a) Basic workflow of image base navigation in surgery. (b) workflow of virtual system navigation

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The assortment of information from the patient preoperative pictures (computed tomography, MRI, magnetic resonance angiography, and others), anatomic models, intraoperative pictures (x-beams, ultrasound, video endoscope, and magnifying instrument), and position and shape data, and facilitate hear-able or visual frameworks with usable directing frameworks.[25]

The instances of AR framework application are in; tracing of point, lines, and planes can be moved from stereolithographic skull model on facial skeleton during osteotomies systems; cephalometric drawings, splints, and diagnostic imaging information to the patient. With regards to oncology, the specialist can draw the tumor borders physically as an overlay utilizing VR framework programming apparatuses onto the processed tomographic informational index.[26]

Many studies have been done showing the efficiencies of virtual surgical planning during maxilla and mandible reconstruction. An examination done by Badiali et al. in 2014 utilizing recently planned, localizer-free, head-mounted framework including AR as a guide to maxillofacial bone surgery.[27] This framework is configured to display virtual planning overlaying the details of a real patient. Reported positive outcomes, recommended that it is fitting to continue in vivo testing to evaluate the careful precision under genuine clinical condition. A case report by Pellegrino et al. presenting 2 cases of implant surgery using dynamic surgical navigation has appreciated the use of AR technology as it ultimately reduces the procedure timing and makes the positioning effective. But at the same time having some limitations such as simultaneously paying attention to the patient as well as the output from the navigation system display.[28] Lin et al. demonstrated that deviation of implants from the planning can be significantly diminished with the coordination of surgical templates and AR frameworks.[29]

As referenced VR route is considered as a 2D route framework the specialists need to redirect their eyes off the site to take a look at the screen while attempting to keep head-eye coordination and on account of the AR route, they need full profundity insight, massive trackers, furthermore convoluted image registration. One of the modifications including an autostereoscopic 3D image overlying system using a translucent mirror has been developed in 2014 by Wang et al., which has resolved the issue of depth perception.[30] Tran et al. directed examinations on a human volunteer to show the exactness and plausibility of their projection-based AR.[31] Another limitation of such systems is, sensory overflow and visual understanding. Hence, new system known as context-aware AR was introduced in dentistry, in one of the studies done by Kati et al. This programmed data filtering assists with keeping away from sensory over-burden while holding important data.[32]

  Virtual Reality\Augmented Reality in Dental Phobia Top

Dental procedures often evoke pain, anxiety, and distress. This feeling will not only create discomfort to the child but also be associated with adverse consequences such as an attempt to escape, poor recovery, eating, and sleeping disturbances, thus, leading to avoidance of dental treatment, especially in a pediatric patient.

VR could help overcome this problem without the need of medication.[33] Visual-based environment's multi-tactile innovation causes the individual to be completely drenched in the stimulated world. The child wears a head-mounted helmet, that gives a sound system visual picture, consequently making a feeling of profundity and space a sort of hallucination in a different world. Change of visual picture in headset is done by movement tracker that measures the situation of the head. In this manner, the child can feel, glance around and travel through the environment. Principle of VR distraction can be explained by Gate control theory by Melzack and Wall,[34] limited attention theory by McCaul and Malott[35] and multiple resources by Wickens,[36] which states the resources in different sensory system function independently.

A systemic review and meta-analysis done by Eijlers et al.[37] concluded the effectiveness of such an approach is more in the younger patient than in elder, which maybe due to the presence of a higher level of anxiety before the medical procedure. Das et al.[38] revealed that more established youngsters considered the VR method as a basic game accordingly younger kids have more effect than more older kids. In addition, in 2006 Patterson et al.[39] examined people by consolidating the impacts of VR distraction and hypnosis during thermal pain. Results show that the more achievement of distraction with VR immersion in child. The only participant with a high range of suggestibility (response to suggestion) reduces pain using the posthypnotic suggestion combining with VR distraction. Similarly, Asl Aminabadi et al.[40] in 2012, did a study among 120 healthy children aged 4–6 years finding the effect of VR distraction on pain and tension during dental treatment, and discovered VR eyeglass can effectively diminish pain insight and state uneasiness. Whereas, some of the contradictory of using it as a distraction device explained by Dahlquist et al.[41] showed that the use of such devices is more effective in older children than younger this must be due to the use of larger size devices, thus it was inconvenient for the younger child.

Another innovative technology of “Serious video games” also called applied games is an approach to improve the education for physical and social sciences, occupational choice in training, planning, problem-solving in different industries, army and government work, and now in the medical field. In pediatric dentistry, it will become a distraction tool for anxious patient's behavior management and as the dentist games for kids, showing the dental procedure over in-animates and thus motivating the child.[20]

  Other Clinical Application of Ar Vr in Dentistry Top

Martins Santos et al. in 2016[42] researched the visualization and interaction tool of AR in mobile devices using 3D volumetric images from the patient real tomographs. They proposed the software to view tomographic images in the form of 3D volumetric model in the mobile devices, advocating that this approach helps to visualize different directions and also facilitates the precise location of anatomical structures and abnormalities, such as supernumerary teeth, bone fractures, and asymmetries. Therefore, 3D volumetric models of radiographic images may help in enhancing both teaching and learning methods and also the understanding of the anatomical structures, and ease diagnosis.

VR- and AR-based artificial intelligence has a high prospect in prosthodontics, since it is the future of dentistry in the form of dental robots and designing other craniofacial prosthetics. Until now, it has been used in computer-aided milling, smile designing, and also aesthetic planning according to facial recognition using AR. The dental robots are thought to be utilized sooner for the manufacture of removable partial dental replacement, complete dental replacement, and embed prosthesis. The immense examinations have been done in Canada on CRS robots for complete dental replacement tooth plans. Other such frameworks that are under preliminary, MOTOMAN UP6 robot, 50 DOF multimanipulator tooth–arrangement robot system, 84 DOF multimanipulator tooth-plan robot, and smaller than expected cartesian robot for prosthodontic framework. Also utilizing the 3D virtual models can be utilized in acquiring occlusal mapping.[43]

Another innovation is “Virtual articulator” in operative and prosthodontics is a simulation of a mechanical articulator that requires the digital 3D representation of jaw and patient-specific data on the jaw movements.

The utilization of innovation additionally has a few impediments. The expense of the framework is as yet costly. In the future with broad use and economic alternatives, the expense can be decreased. With more investigation and advancements, the limitations shall decrease.

  Conclusion Top

A novel innovation in dentistry in the form VR, AR, and MR is a complex and sophisticated device with a powerful tool that creates high visualization. This is the next step in dental education and has created a new definition of learning and understanding things. It will turn out to be all the more impressive and keen innovation in the impending years; the specialist might have the option to see the delicate and hard tissue inside the patient body to design a fruitful strategy. Along these lines, the field of AR is well-informed, and there is a positive pattern in its application, yet its utilization is still in the beginning phases in the field of dentistry and it is not broadly received in clinical practice.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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