In a classroom at the Health Education Campus of Case Western Reserve University and Cleveland Clinic, a small group of second-year School of Dental Medicine students stand in a circle around a digital cadaver. Together, they dissect the virtual three-dimensional body—removing layers of skin, muscle and bones.
Each student is wearing a Microsoft HoloLens mixed-reality headset, which superimposes holographic content onto otherwise empty classroom space. Transparent visors blend their digital and analog fields of view as the group traces tracts of cranial nerves central to the day’s lesson in neurology.
“I was blown away by how crisp the images are, how we’re able to isolate certain structures and understand the spatial relationship of anatomical structures,” said Tanner Hauptman, a second-year dental student, of the experience last fall. “That first time, we all looked at each other and thought it was so cool. We were taken aback.”
The mixed-reality software Hauptman described is known as HoloAnatomy. Developed by Case Western Reserve’s Interactive Commons—which employs visualization technologies to enhance research and teaching—the software suite was the first third-party application for
the Microsoft device. In 2019, the software became the primary means of anatomy education at the university’s School of Medicine.
In fall 2022, the School of Dental Medicine became the first of its kind in the country to use the technology.
“Everyone has different learning styles,” said Caitlyn Ryan, a second-year dental student. “As a visual learner, I find mixed reality helps me bring together concepts learned in many different ways for a better overall understanding.”
Same anatomy, new technology
Second-year dental student Rachel Elkowitz comes from a family of dentists. In fact, her grandfather, George Elkowitz, and uncle, Lloyd Elkowitz, both graduated from the dental school in 1960 before practicing in Brooklyn and Long Island.
“I’m learning the same materials they did—but our educations are so different,” said Elkowitz. “Anatomically, people are the same as then, but technology is allowing my class to learn about the body in a more detailed way.”
Learning sessions employing mixed reality are scheduled for specific points throughout the curriculum to coincide with classroom and cadaveric learning.
For instance, students took HoloAnatomy’s “Thoracic Cage & Pulmonary Cavity” module while studying the musculoskeletal system early in their second year and the “Ascending and Descending Tracts” module using the new HoloNeuro application during the same semester’s neuroanatomy course.
“It’s immersive and experiential learning that gives us another way of seeing human anatomy in a new and totally different perspective,” said David Rolf II, DMD, associate dean for academic affairs at the dental school. “With HoloAnatomy, our students can navigate into and around structures in the body in ways they’re unable to do in a cadaver.”
This emphasis on excellence in anatomical sciences education is partly a recognition that healthcare is becoming more collaborative and interdisciplinary, which students will encounter when entering the workforce, said Rolf, who collaborated on the launch of HoloAnatomy along with the dental school’s dean, Kenneth Chance, DDS (DEN ’79), and Associate Professor Michael Landers, DDS (DEN ’76).
“It’s as vital as ever that our students understand the whole health of their patients,” Rolf said, “and how dental professionals are increasingly part of holistic approaches to treatment and care.”
Learning aspects of dentistry via mixed reality would have been unimaginable for Elkowitz’s grandfather, but he would have been fascinated by its possibilities, she said. He had an enduring admiration for his alma mater, and he encouraged her to apply. Just prior to her acceptance to the dental school, he passed away.
“It makes it even more special to be here, carrying on his legacy now, in my own way,” Elkowitz said. “Having these unique educational experiences would make him proud—of me and of our school.”
Attainment and retainment
The advancement of educational technology is no surprise to Rebecca Enterline, a research associate at the School of Medicine involved in the dental school’s adoption of HoloLens.
After all, she helped design and create artwork for HoloAnatomy. Case Western Reserve became the first higher education institution to use HoloLens technology in 2014—back when it was still an unpublicized Microsoft project.
Not only has Enterline had a hand in creating the innovative new learning experience through the software students use, but she also has had a front-row seat to witness how they benefit.
Enterline and university colleagues conducted peer-reviewed studies while building, piloting and launching HoloAnatomy. The data they collected has consistently demonstrated that the mixed-reality approach is an effective and efficient educational tool for students.
Specifically, some of the published findings show that HoloAnatomy decreases the time necessary for anatomy instruction without sacrificing student understanding of
the material.
Researchers also found no significant differences in exam performance between students who learned anatomy through mixed reality and those who learned through cadaveric dissection. Another study showed that students retained knowledge from HoloAnatomy sessions held years before.
“All of our technological approaches are to make students more practice-ready, confident and precise,” said Chance. “This is not technology for technology’s sake—it’s to facilitate the most efficient and time-saving learning methods to create the best-trained individuals who will then provide optimum treatment and healing for patients.”
Even as mixed reality has proven to be a viable approach to teaching gross anatomy, university health sciences students still take part in cadaveric dissection, which has a distinct educational value all its own, said Enterline.
Medical and dental students, she said, “will be laying hands on patients as future healthcare professionals. It’s difficult for technology to mimic the tactile experience of cadaveric dissection.”
New body of knowledge
Before trying mixed reality for class, Mena Morcos, a second-year dental student, was admittedly skeptical, thinking, “it would be the same as a cadaver, just digitized.”
But Morcos was struck by the level of specificity in the software’s anatomical renderings: “It was additive and has stuck with me,” he said. “Now that we’ve experienced both virtual and traditional dissection, I feel they’re both better for existing side by side.”
Using mixed reality in the dental school is meant to augment students’ experiences in the cadaver lab, said Rolf, who oversees the dental school’s predoctoral curriculum. In between dissections—virtual or traditional—students also use a new complementary tool to enhance their learning: Complete Anatomy, 3D4Medical’s software platform of interactive 3D modules that facilitates learning at each student’s own pace on their laptop, tablet or smartphone.
Combining all of these approaches early in students’ dental education is deliberate; it prepares them to effectively integrate and apply their anatomy knowledge and skills as they start clinical work in their third year.
“I am feeling more confident looking ahead to the clinic,” said Hauptman, who is also class president. “My ultimate goal is to make my patients healthy and happy because I love making people smile.”
Meet Yomi
Yomi joined the dental school in September. But Yomi is not a faculty member or student—it’s a robot used for both students’ clinical training and the treatment of patients.
As the first and only FDA-approved dental robotic system for implant surgery, Yomi physically guides a surgeon to perform a procedure as was planned using scans and software pre-operatively. If a surgeon is moving in the wrong direction, Yomi resists, offering tactile feedback.
In general, a robot-assisted approach reduces time, errors and patient discomfort—placing implants with a high level of accuracy, said Gian Pietro Schincaglia, DMD, professor, chair and graduate program director in the Department of Periodontology.
“The potential of robotic technology in dentistry is huge,” he said. “The implications of digital fit our profession well—because what we do is precision. Robotic technology is all about precision.”
Case Western Reserve is among only four dental schools in the country with a Yomi robot, joining New York University, Boston University and West Virginia University. Fewer than 150 are in place at practices around the country, given that the technology was only recently brought to market by healthcare startup Neocis.
“Our students understand technology will never replace a competent and caring dentist,” said Chance. “We use new methods along with our ethics, our knowledge, skills, critical thinking and judgment.”
Treating and teaching
Yomi is part of the dental school’s emphasis on same-day dentistry, which calls on a range of technologies to reduce the time and number of appointments needed to treat patients.
In that spirit, Yomi offers what’s known as a “digital implant workflow,” explained Schincaglia. It first implements digital scanners that map a patient’s mouth (instead of a mold- based impression), then surgical software to simulate and plan restorations. Finally, it uses 3D printing to create devices necessary for placing implants precisely.
“Patients can be treated faster with less surgical trauma,” said Schincaglia. “There’s a clear advantage from a service perspective.”
For teaching, Yomi serves as a didactic tool, complementing traditional freehand training for placing implants. Holding a drill attached to Yomi’s three-jointed arm, residents’ movements and placements are guided throughout surgery, though they maintain control of the drill at all times. Their first few implants are performed with the robot, and students gradually move to a traditional freehand approach.
“Students automatically incorporate information that can be utilized when they perform surgeries freehand,” said Schincaglia, who joined the dental school in 2021 from West Virginia University, where he established one of the first robotic dental implant programs in the country. “They already have the feeling of drilling bone and how precise you have to be.”
Mercurious “Mark” Mina, DMD (DEN ’22), a senior resident in the periodontology residency program at the dental school, has performed implants both with and without Yomi’s guidance.
“The possibility for error is much smaller with Yomi. That makes a big difference in placing implants at exact angles and positions in a jaw’s limited space,” said Mina. “It’s ideal for the patient—whatever you planned beforehand is getting done exactly.”
Surgical robotics have transformed multiple medical disciplines and enabled early adopters to differentiate their practices and become the recognized leaders in their fields, Schincaglia said.
Current and prospective students at the dental school are fully aware of the advantages and appeal of such breakthrough devices, said Chance. They’re also drawn to innovative teaching and learning techniques, including mixed reality, that can give them an edge in preparing to enter their profession.
“This generation is very much rooted in technology,” said Chance. “Our students are playing a part in the future of dentistry, and they are already leaders in this space.”
—Daniel Robison