ISSN: 2320-5407 Int. J. Adv. Res.

11(05), 882-890

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/16941
DOI URL: http://dx.doi.org/10.21474/IJAR01/16941

RESEARCH ARTICLE
EFFECTIVENESS OF BLENDED TEACHING METHOD IN TOOTH CARVING APPLIED IN
PRECLINICAL COURSE OF DENTAL EDUCATION DURING THE COVID-19 PANDEMIC

Zhanina Pavlova
Associate Professor, Department of Prosthetic Dental Medicine, Faculty of Dental Medicine, Medical University,
Sofia, Bulgaria.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Background: The knowledge of dental morphology is essential in
Received: 20 March 2023 every aspects of dental medicine. Tooth carving is useful for
Final Accepted: 22 April 2023 development of the manual skills and has positive influence on
Published: May 2023 students’ performance in clinical practice. In the extraordinary situation
caused by the COVID-19 pandemic we needed to use innovative
Key words:-
Dental Education, Tooth Carving, blended models in teaching of dental morphology.
Teaching Methods Te Aim of the research was to perform comparative analysis of the
teeth carved by students in preclinical courses in prosthetic dental
medicine, tutored in two methods – conventional and blended, applied
in the circumstances of the COVID-19 pandemic.
Methodology: Detailed evaluation of 381 carved teeth was done
according to strictly defined criteria.
Results: The analysis of work of students tutored through blended
method demonstrates good level of the skills for reproduction of dental
morphology. The approximal and masticatory surfaces of the tooth
crown and the teeth roots of premolars and molars were reproduced in
better quality by the students in the course with blended tuition. The
differences in realization of the criteria are in range of 5%. Statistical
significance was established only in re-creation of the masticatory
surfaces of molars (p< 0.05).
Conclusion:The blended model of tuition can be considered as
effective educational model for tooth carving in courses of pre-clinics
of prosthetic dental medicine. It would be purposeful for this practice to
be combined with traditional educational methods in order to improve
the tuition quality.
Copy Right, IJAR, 2023. All rights reserved.
……………………………………………………………………………………………………....
Introduction:-
The COVID-19 pandemic brought about great challenges for the dental medicine tuition. The development of
students’ manual skills via practical tasks that they regularly perform is essential to the achievement of the necessary
competences in each and every of the studied dental subjects (Machado et al., 2020).

Corresponding Author:- Zhanina Pavlova

Address:- Associate Professor,Department of Prosthetic Dental Medicine, Faculty of Dental
Medicine, Medical University of Sofia, Bulgaria.
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Even though the direct contact between lecturers and students is irreplaceable when assimilating the practical skills,
we needed to formulate new rules and programs in this new extraordinary reality.Dental anatomy is main subject of
the dental education, being one of the fundamental courses of the preclinical course curriculum (Kellesarian, 2018;
Patil et al., 2015). The dental medicine students should have in-depth theoretic knowledge and skills in order to
analyze and reproduce the shape, function and aesthetics of each and every tooth of human dentition (Siéssere et al.,
2004). In their daily activity, the doctors of dental medicine perform recovery of the injured or lost dental tissues and
the foundation for acquiring the necessary knowledge and psychomotor skills is created namely during the initial
courses (Siéssere et al., 2004). During the tuition in Pre-clinics of prosthetic dental medicine, the practical exercises
are essential part of the educational process, aimed at supporting the knowledge of dental anatomy in detail and
developing students’ manual skills (Chutinan et al., 2018). In order to achieve this objective, the students have
practical classes in teeth carving at first course in order to acquire the necessary skills, as early as possible (Patel et
al., 2018; Field et al., 2018). Theoretical lectures, two-dimensional teeth drawing, demonstrations by the lecturers of
carving techniques, carving teeth out of soap or wax blocks are the conventional course components applied in
numerous universities (Abu Eid et al., 2013; Anwar et al., 2020).

According to some opinions, the exercises for carving teeth are more suitable for the tuition of dental technicians
(Ponniah, 2010). Nevertheless, the prevailing opinion is about the usefulness of these exercises and their positive
influence on students’ performance in clinical practice (Obrez et al., 2011; Nayak et al., 2014; Rishikesan et al.,
2021; Pandarathodiyil et al., 2021).

The opportunity of computer-assisted tuition to supplement the educational process, especially in the case of
insufficient curriculum hours is confirmed in the researches many years before the current situation caused by the
COVID-19 pandemic (McCann et al., 2010; Kirkup et al., 2019; Lone et al., 2018). The main advantage of digital
resources is the continuous access to information, no matter the time and place that allows flexible academic hours
(De Azevedo et al., 2018; Nance et al., 2009; Al-Thobity et al., 2017).

In the blended educational models, we use a mixture of various educational resources such as atlases, manual
demonstrations, video-lectures and educational videos, which produces significant improvement of students’ skills
in carving teeth (Obrez et al., 2011). Comparative studies show that the evaluations of teeth elaborated by students
who studied in the blended models are higher than the ones of students tutored in the traditional manners (Al-
Thobity et al., 2017; Chutinan et al., 2018; Alzahrani et al., 2019).

Despite the effective application of e-resources, the students prefer using them only as supplementation, not as full
replacement of the traditional lectures (Rosenberg et al., 2003; McCann et al., 2010). As most preferred method they
define the one where teeth are carving out step by step together with demonstration of the individual steps by a
lecturer (Nikzad et al., 2012; Fayaz et al., 2015; Jeyapalan et al., 2016). It is reported that this approach yields the
best results (Kilistoff et al., 2013; Anwar et al., 2020).

When carving teeth out of soap, the knowledge about dental morphology directly impact re-creation of the details,
hence the analysis of practical work is a relevant method for evaluation of the tuition quality. The data accumulation
from this kind of researches is useful for defining of the effectiveness of blended educational models in field of
prosthetic dental medicine.

Material and Methods:-

We evaluated a total of 381 teeth, carved out of soap, among three functional groups – upper left central incisor,
lower left first premolar, upper left first molar. Teeth are part of the required practical work of students in the first
course, studying Pre-clinics of prosthetic dental medicine in Faculty of Dental Medicine, Medical University of
Sofia, Bulgaria.

195 teeth were made by 65 students (40 women and 25 men) tutored in the 1 st course, winter semester of the
academic 2019/2020 year via conventional methods of full attendance lecturing and laboratory practice. 186 teeth
were made by 62 students (37 women and 25 men) tutored in the 1st course of the academic 2021/2022 year via
blended methods of tutoring in the circumstances of COVID-19 pandemic.

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Inclusion criteria:
Based on the available archive of the practical work, we selected teeth for evaluation that were made by students
whose courses were tutored by one and the same lecturers; we selected one and the same teeth of a particular
functional group (left teeth), in order to ensure comparison of results.

Exclusion criteria:
Teeth that doesn’t meet the inclusion criteria.

The full attendance model includes lectures; demonstrations of carving each and every tooth in conformity with
curriculum, presented live in the end of each lecture; demonstrations by the teachers during the laboratory exercises;
opportunity to consult teacher during the exercises.

The blended tuition, applied recently in circumstances of the COVID-19 pandemics, includes presentation of
lectures in virtual classroom; video demonstrations and hours of laboratory training reduced into half. The
demonstrations were presented as video movies whereas carving the particular tooth is performed step by step by the
teachers. It is accompanied by explanations on the applied technique and particularities in reproducing the specific
morphological details. The videos remained with continuous online access so that the students could use them at any
time and place unlimitedly.

In the present research, we evaluated retrospectively the carved teeth according to strictly defined criteria presented
in table 1.

Table 1:- System and criteria for evaluation of the carved teeth.
№ Criterion Evaluated indicators Points
1 Size of tooth If the size of tooth is in conformity with the required size (ratio 1:3 10
compared to the natural teeth)
2 Vestibular surfaces of Form of vestibular surface and expression of medial and distal edges 10
the tooth crown
3 Lingual surfaces of the Form of lingual surface and expression of medial and distal edges 10
tooth crown
4 Medial aprocsimal Form of medial aprocsimal surface and expression of vestibular and 10
surfaces of the tooth lingual edge
crown
5 Distal aprocsimal Form of distal aprocsimal surface and expression of vestibular and 10
surface of the tooth lingual edge
crown
6 Cervical line curvatures Position of cervical line curvature on vestibular and lingual surfaces of 10
the tooth
Position of cervical line curvature on aproximal surfaces of the tooth
7 Height of contour Location of the vestibular height of contour 10
Location of the lingual height of contour
8 Form of tooth roots Shape of the roots 10
9 Position of tooth roots Position of the roots toward tooth crown and tooth axis 10
10 Masticatory surfaces Evaluation of elements depending on the functional group of the tooth 10
Total points of evaluation 100
Correspondence between per cent satisfaction of the criterion and evaluation grades
<60%= 2 = “Unsatisfactory”; 60-69% = 3= “Satisfactory”; 70-79% = 4 = “Good”; 80-89% = 5= “Very good”;
90-100%= 6 = “Excellent” *
*In the Bulgarian educational system, evaluation is according to the six-point system.

Every criterion makes up 10% of the final tooth evaluation, whereas the maximum aggregate is 100 points. Every
evaluation corresponds to particular per cent satisfaction of criteria defined in the table 1.

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The incisal edge/masticatory surfaces were evaluated in detailed manner depending on the functional group of the
tooth. The 10 points for criterion №10 was formed as sum of the points during evaluation of different components as
they are presented inthe table 2.
In view of reducing the subjective mistake, the evaluation of teeth was performed by one and the same person –
lecturer with more than 20 years of experience in teaching of dental medicine.

Table 2:- Evaluated elements of incisal edge/masticatory surfaces depending on the functional group of the tooth.
Evaluation of incisal edge/masticatory surfaces
Incisor Poi Premolar Poi Molar Poi
nts nts nts
Labio-lingual location of 4 Location of the buccal 2 Location of the buccal 2
the incisal edge cusp tip cusp tips
Location of the lingual 2 Location of the lingual 2
cusp tip cusp tips; Cusp of
Carabelli
Thickness of the incisal 3 Contour and location of 4 Contour and location of 4
edge medial and distal marginal medial and distal
ridges, and the triangular marginal ridges, and the
ridges triangular ridges; oblique
ridge; transverse ridge
Form of incisal edge 3 Contour and location of 2 Contour and location of 2
medial and distal medial and distal
triangular fossae, the triangular fossae, the
central developmental central developmental
groove groove and medial
marginal developmental
groove
Total points for 10 10 10
criterion №10

Statistical Methods:
The data were statistically processed using Microsoft Excel – 2016. It was performed: descriptive analysis - mean
and standard deviation were calculated for the scores; t-test and paired t-test for the evaluation of differences with
selected significance level α = 0.05 (p<0.05).

Results:-
In this research were compared the per cent satisfaction of each and every criterion for the evaluated teeth, the most
common mistakes made by students, average grades for the courses and their share distribution.
In order to evaluate the degree of mastering the morphological features of carved teeth, was analyzed the per cent
realization of each and every criterion for the evaluated teeth. The differences in the performance of various criteria
vary from 0.5 to 8.26%, yet not in all cases these are in the interest of the course with traditional tuition(Fig. 1).

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Fig.1. Per cent realization of every criterion for the

evaluated incisors

100

80

60

40

20

0
№ of criterion 1 2 3 4 5 6 7 8 9 10
traditional tuition 81.5 86.2 81.5 81.5 76.9 83.8 81.5 73.9 75.4 81.2
hybrid tuition 87.1 82.3 79 80.6 75.8 79.8 78.2 71 77.4 84.2

When analyzing the data about the sculptured incisors, at seven of the researched criteria (№№ 2,3,4,5,6,7 and 8) we
observe differences between 0.9% and 4%, whereas the higher per cent realization is found in the course with full
attendance tuition.
Nevertheless, under three of the criteria concerning the dental dimensions, the position of root and the shape of
incisal edge we find better performance in the course with blended tuition, with 5.55%, 2.04 and 2.96%
correspondingly.
In the sculptured premolars, about five of the researched criteria (№№ 1, 2, 6, 7 and 8) we also observe higher per
cent satisfaction in the course with full attendance tuition, whereas the differences are between2.14% and 3.67%
(Fig. 2).

Fig. 2. Per cent realization of every criterion for the

evaluated premolars

100

80

60

40

20

0
№ of criterion 1 2 3 4 5 6 7 8 9 10
traditional tuition 89.2 90.8 78.5 76.9 73.9 83.1 83.1 76.9 72.3 81.2
hybrid tuition 87.1 87.1 80.6 77.4 79 80.6 79.8 74.2 75.8 82.3

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We found the re-creation of lingual, approximal surfaces, root position and the elements of the masticatory surface
of the premolars, being better in the course with blended tuition, even though with small differences between 1%
and 5%.

In the elaborated molars at five of the researched criteria (№№ 1, 2, 4, 6 and 7) we observe differences
between1.84% and 4.01%, whereas better performance is observed in the course with traditional tuition (Fig. 3).

Fig. 3. Per cent realization of every criterion for the

evaluated molars

100

80

60

40

20

0
№ of criterion 1 2 3 4 5 6 7 8 9 10
traditional tuition 95.4 87.7 81.5 80 78.5 83.1 83.9 70.8 69.2 77.4
hybrid tuition 93.5 83.9 85.5 77.4 79 79.8 79.8 75.8 74.2 85.6

The other five elements – shaping up the lingual and approximal surfaces of the tooth crown, form and position of
teeth roots and the masticatory surfaces are reproduced in better quality by the students in the course with blended
tuition.

The average grades for both courses are within the interval of 79-82 points that corresponds to grade “Very good-5”.
There is no significant difference between grades of teeth made by men and women – p>0.05 for teeth of all the
researched functional groups.The share distribution of the grades of evaluated teeth in two courses shows that the
share of“Unsatisfactory” grades is below 2% in both courses – 1.59% for the course with traditional tuition and
1.94% for the course with blended tuition correspondingly. The share of “Satisfactory” grades is 11.28% for the
course with attendance tuition and 9.68% – for the one with blended. The share of grades “Good” is 35.48% for the
course with attendance tuition and 28.20% – for the one with blended. The grades “Very good” have a share of
37.43% for the course with attendance tuition and 34.946% – for the one with blended. The share of “Excellent”
grades is 23.07% for the course with attendance tuition and 19.89% – for the one with blended.

Discussion:-
The specificity of prosthetic dental medicine requires continuous demonstration of various techniques and direct
observation of students’ work by the lecturer. In this process, the direct communication between students and
teachers, whereas the students are provided with the opportunity to ask questions and get feedback in timely manner
about their knowledge and practical work is essential. The achievement of optimal results could hardly be realized in
the circumstances of entirely distance teaching. Hence when adapting the teaching methods in the pandemic
circumstances we looked for hybrid models that are capable to provide the right balance between the distance and
attendance tuition. The analysis of students’ practical work whereas these students are being tutored in these
circumstances would allow us to evaluate and strong and weak points of the blended tuition system. This kind of
analysis helps us to establish the effectiveness of blended method regarding the practical skills acquired during the
course of pre-clinic of prosthetic dental medicine.

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The analysis results show that both approaches of teaching provide almost equivalent tuition level concerning the
practical work in this preclinical semester. The differences found in the per cent satisfaction of criteria by both
courses are without statistical significance – p>0.5 for each and every of them, with single exception – the
preparation of the masticatory surfaces of molars.

Another researched issue was whether there is difference in assimilating and reproducing of the morphological
dental features. The analysis of students’ practical work shows the following: Most often errors are made in shaping
up the roots, irrespective of the tuition method. In the course with attended tuition, the inaccurate root shaping is
found in 26% of incisors, in 23% of premolars and in 29% of molars. In the course with blended tuition, errors when
shaping up the roots were made in 29 % of incisors, in 25% of premolars and in 24% of molars. What impresses us
is that in the course of blended tuition fewer errors (in about 5% of the molars) were made when shaping up the
molar roots, compared to the ones in the full attendance course, despite the greater complexity of the morphology of
three-root teeth, like the first upper molar. These results confirm the data found in literature that the students face the
greatest difficulties when reproducing roots of teeth with numerous roots (Nance et al., 2009). The data of the
present research show that the reason is most likely related to the specific nature of the morphological features than
to the teaching methods. The interactive elements of blended tuition, in the pattern of video-demonstrations are
actually useful when overcoming the difficulties related to carving the dental roots.

In the case of premolars one more element is outstanding where errors were made and this is the accurate
reproduction of aproximal walls. In around 1/5 of the sculptured premolars we observe imprecision in shaping up
and expression of the vestibular and lingual contour and edges. This type of error was made in 24% of premolars,
carved by the students in course of attended tuition and in 21% of the ones carved in course of blended tuition.

In the course with traditional tuition, most frequently errors were established in re-creation of various details of the
masticatory surface of molars – most often when reproducing the oblique ridge, transverse ridge and the Cusp of
Carabelli. This kind of errors were observed in around 1/5 (22%) of carved molars. In the course with blended
tuition, the errors made when reproducing the masticatory surface of molars are with 8.29% lower. It is interesting to
mention that namely the masticatory surface of the first upper molar, component that includes numerous details and
has greater complexity of elaboration, is prepared in better precision by the students in blended tuition. The probable
reason behind this is the unlimited access to video films with the demonstrations prepared by the teachers. Whereas
in the traditional tuition students see this demonstration once while attending the lecture, in the hybrid system they
could play repeatedly the videos with demonstrations of carving the particular tooth, stop or replay the recording of
various stages and compare the quality of the teeth made by them with the ones on screen. The included in videos
explanations help not only for better understanding of carving methods but also for reinforcement of the theoretical
knowledge about teeth morphology. The results obtained in present research confirms the opinion shared by Nance
et al. (2009) that via hybrid teaching methods including digital technologies as assisted help, we could achieve good
results in the practical work, despite the morphological complexity of the tooth being carve out.

Despite the reduced academic hours for attended laboratory practice, in the course with blended tuition we didn’t
find significant omissions in reflecting the main characteristics and details when carving teeth. The analysis
demonstrates sufficiently good level of utilizing the knowledge about the dental morphology and the practical skills
for its reproduction, which is comparable to providing the students of the course with traditional tuition before the
pandemics. The results of the present research confirm the opinion of numerous authors on the purposefulness of
implementing innovative methods for teaching dental morphology(Lone et al., 2018; Risnes et al., 2019). The share
distribution of grades also confirms this opinion. It shows that the share of “Satisfactory” grades in blended tuition is
1.6% lower compared to the traditional tuition. More significant difference is observed in the shares of grades
“Good” – in the course with blended tuition, their share is 7.28% higher, and the share of grades “Very good” is
2.49% lower compared to the course with traditional tuition. Based on the data we could see that in the course with
blended tuition the highest numbers of teeth were graded as “Good”. Nevertheless, the share of grades “Very good”
and “Excellent” also remains high and we observe comparable proportion of grade distribution in both courses. The
differences in share distribution of grades didn’t show statistical significance – p > 0.05.

The applied system for evaluation has been tried in practice many times and has proven its effectiveness for
evaluation of the carved teeth in detail. This manner of evaluation makes it possible to differentiate the most
common mistakes made by students and undertake actions for their reduction. Information about the aspects of tooth
morphology that hinder the students during tooth carving helps the lecturers in directing their efforts so that a

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possible deficit of students’ knowledge could be easily overcome. The accumulation of knowledge about the
qualities of students’ work, in different tutoring circumstances, is a foundation for the development of innovative
teaching methods and the improvement of curricula.

The successful completion of the practical work in the established terms confirms the opinion that the continuous
access to information provided by the digital resources allows flexible academic hours and making up for the
insufficient hours for attended tuition(Nance et al., 2009; Juneja et al., 2016). We sustain the opinion shared by other
authors that despite the effective application of digital resources, these should be used only as a supplement, not as
comprehensive replacement of traditional lecturing (McCann et al., 2010).

Conclusion:-
The blended pattern of tuition, applied during the COVID-19 pandemic can be considered as effective educational
model for tooth carving in courses of pre-clinics of prosthetic dental medicine. By this method was achieved
sufficiently good level of utilizing the knowledge about the dental morphology and the practical skills for its
reproduction, which is comparable to these of the students tutored in the course with traditional methods before the
pandemic. Provided students with continuous online access to the digital lectures and demonstrations, prepared by
teachers, facilitate the educational process. The integration of digital resources used during the blended tuition in the
traditional methodologies would bring about optimization of the academic curricula and improvement of the tuition
quality.

Conflicts of Interest:
The author declares no potential conflicts of interest with respect to the research, authorship and publication of this
article.

Sources of funding:
The study did not receive any funding.

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