Received: 15 October 2023 Revised: 21 December 2023 Accepted: 3 March 2024

DOI: 10.1002/jdd.13517

ORIGINAL ARTICLE

Kern’s six-step approach allows for meaningful

implementation of an orthognathic surgery training course

Kian How Tan BDS, MDS1,2 Chee Weng Yong BDS, MDS1
Raymond Chung Wen Wong BDS, MD, PhD1

1 Facultyof Dentistry, National University

of Singapore, Singapore, Singapore Abstract
2 Dental
Branch, Singapore Armed Forces Objectives: This study investigated the effectiveness of simulation training in
Medical Corps, Singapore, Singapore improving the confidence and competency of oral and maxillofacial surgery
Correspondence (OMS) residents in performing orthognathic surgery (OGS).
Raymond Chung Wen Wong, Faculty of Methods: Kern’s six-step approach was applied when designing the simulation
Dentistry, National University of
training for OMS residents. The difficulties encountered by the residents when
Singapore, 9 Lower Kent Ridge Road,
Singapore 119085, Singapore. learning OGS were considered when designing the training program. A training
Email: [email protected] course consisting of didactic sessions, hands-on training on three-dimensional
training models, and an assessment tool was implemented for OMS residents.
Kian How Tan is prior postgraduate
student. Improvement in the confidence and competence of OMS residents in performing
OGS, fidelity of the three-dimensional models, and satisfaction with the course
was evaluated.
Results: All OMS residents (10/10) completed the course. The perceived diffi-
culty in learning OGS was mainly related to the manipulation of the jawbones.
While there were improvements in the median confidence and competence
scores (3/5 to 4/5), only the differences in competence were found to be sta-
tistically significant (p < 0.01, Wilcoxon signed-rank test). Improvements in
confidence and competence did not correlate. The mean fidelity scores of both
the maxillary and mandibular models were adequate at 3.2 out of 5. Overall,
satisfaction with the course was high (5/5).
Conclusions: The six-step approach provides a guided process for educators
to formulate a training course directed toward the perceived needs of students.
Targeted training can significantly enhance the students’ competence. Greater
efforts should also be put in place to allow simultaneous developments in the
students’ confidence along with their competence.

KEYWORDS
dental education, dental model, maxillofacial surgery, orthognathic surgery, simulation
training

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the
original work is properly cited.
© 2024 The Authors. Journal of Dental Education published by Wiley Periodicals LLC on behalf of American Dental Education Association.

974 wileyonlinelibrary.com/journal/jdd J Dent Educ. 2024;88:974–982.

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TAN et al. 975

1 INTRODUCTION gram were invited to participate in this study. This study

was implemented using Kern’s six steps, as shown in
Orthognathic surgery (OGS) is one of the most com- Figure 1.
mon types of surgery in oral and maxillofacial surgery
(OMS). Common surgical procedures for OGS include Le
Fort I maxillary osteotomy (LF1), bilateral sagittal split 2.1 Kern’s steps 1 and 2: problem
osteotomy (BSSO) of the mandible, and genioplasty. These identification, general needs assessment,
procedures require surgeons to perform precise osteotomy and targeted needs assessment
cuts in a confined space with limited visualization. Surgi-
cal errors may lead to severe complications, such as profuse The scope of practice for OMS residents upon graduation
bleeding and paresthesia. As the surgeries are performed includes OGS. As discussed previously, achieving mastery
via a transoral approach, observers or residents can only of the procedure during the residency program was identi-
have limited visualization of the surgical field. On the same fied as a problem. This was related to the complexity of the
note, supervision by senior surgeons is often difficult and procedure and the potential risks to patients. Subsequently,
stressful because they may not always have a full view of a targeted needs assessment was performed.
the surgery. The combination of junior surgeons’ inexpe- All residents pursuing an OMS Master of Dental Surgery
rience and inadequate supervision has also been shown to in Singapore were invited to complete a preliminary sur-
increase the risk of complications.1,2 vey to share their difficulties in learning OGS. This survey
Kern’s six-step approach to curriculum development listed the steps of the surgery, and the residents were asked
is a systematic method for designing training courses in to indicate if they experienced difficulties with the steps.
healthcare programs.3,4 The six steps include (1) prob- Non-surgical factors, such as time, lack of opportunity, and
lem identification and general needs assessment, (2) needs limited visualization, were also included in the survey. Res-
assessment of targeted learners, (3) goals and objectives, idents were also allowed the opportunity to express any
(4) educational strategies, (5) implementation, and (6) other difficulties faced in the free-text portion.
evaluation and feedback. This approach allows the course For LF1, the surgical steps in which at least half of
to be designed based on the training needs perceived the residents experienced difficulties included designing
by both the educators and students. Specific methods the ostectomy (50%), osteotomy using a handpiece/saw
were also planned to evaluate the effectiveness of the (50%), repositioning of the bone (90%), and fixation of
implemented course. the bones (70%). For BSSO (Figure 2), 50% of the resi-
This approach has been widely adopted in medical dents experienced problems in designing the osteotomy
training, encompassing radiology,5 surgery,6–8 obstetrics and repositioning of the bone. Eighty percent and 90% of
and gynecology,9 and emergency medicine.10,11 One of the the residents found osteotomy using the handpiece/saw
key features described was the evaluation of the issues and osteotomes difficult, respectively. When considering
and problems faced by students. Education programs or nonsurgical factors (Figure 3), the fear of causing injury
curricula developed using this approach generally report to patients was the most common challenge reported by
favorable results and significant improvement in con- 70% of the residents. Limited visualization, time factor,
fidence and competence.6,12,13 The approach was also and lack of opportunity to operate were also reported
reported to allow a more efficient and structured training in 50% of the responses. The details are illustrated in
curriculum to produce competent physicians.11 Currently, Figures 2–4.
there are few studies describing Kern’s six-step approach
in dental education,14,15 and no studies have described
this approach in OGS. The objective of this study was to 2.2 Kern’s step 3: goals and objectives
evaluate the effectiveness of Kern’s six-step approach in
improving OMS residents’ confidence and competence in The goal of the course will be to provide a sustainable train-
OGS. ing course that can help OMS residents gain mastery in
OGS. A subjective measure of self-perceived confidence in
the procedure was evaluated. This reflects how the resi-
2 METHODS dent views his or her capability or readiness to perform
the procedure. An objective measure of competency is
This study was reviewed by the Institutional Review Board also evaluated. This reflects how an educator or instruc-
of National University of Singapore (NUS-IRB-2021-312). tor views a student’s capability or readiness to perform the
All OMS residents in the Singapore OMS training pro- procedure.
 19307837, 2024, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.13517 by INASP/HINARI - PAKISTAN, Wiley Online Library on [16/02/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
976 TAN et al.

FIGURE 1 Current study’s curriculum planning as related to Kern’s framework. OGS, orthognathic surgery.

FIGURE 2 Difficulties experienced in learning Le Fort I.

2.3 Kern’s step 4: educational strategies for the participants. These lessons focused on the indi-
cations and surgical steps of LF1 and BSSO. The details
Education strategies were planned to have a two-prong are summarized in Table 1. This was followed by case-
approach. The first approach would be to ensure that all based discussions whereby the residents are required to
OMS residents have the theoretical foundation to perform verbalize and explain the indications, treatment plan, and
OGS. Therefore, a series of didactic lessons were conducted the steps of the surgery. However, hands-on simulation
 19307837, 2024, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.13517 by INASP/HINARI - PAKISTAN, Wiley Online Library on [16/02/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TAN et al. 977

FIGURE 3 Difficulties experienced in learning bilateral sagittal split osteotomy.

FIGURE 4 Other difficulties experienced when learning orthognathic surgery.

training was the focus of the course, as the problems mities were obtained and converted into digital imaging
surfaced were mostly related to the surgical steps. and communications in medicine (DICOM) files. The
The preliminary survey reflects that most OMS resi- DICOM files were used to three-dimensional (3D) print
dents are concerned with osteotomies and fixation plating models for the simulation training session (Figure 2). The
of OGS. Furthermore, there are stress factors related to maxillofacial skull complexes were then mounted on a
the operation of an actual patient. Therefore, a simulation bench top. The armamentarium required for the surgery
workshop that allow hands-on training outside of an clin- was also provided to the residents. The oral and maxillo-
ical environment was devised to target these highlighted facial objective structured assessment of technical skills
issues. The cone beam computed tomography images of (OMOSATS) framework was used as an assessment tool for
the two patients with different types of dentofacial defor- simulation training.16
 19307837, 2024, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.13517 by INASP/HINARI - PAKISTAN, Wiley Online Library on [16/02/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
978 TAN et al.

TA B L E 1 Didactic training for oral and maxillofacial surgery residents.

No. Title Objectives
1 Patient assessment and evaluation Residents to be able to:
∙ Understand and conduct a comprehensive history taking for an
orthognathic surgery candidate. This includes motivations for treatment,
medical history, dental history and social history
∙ Indicate and interpret relevant investigations for a patient. This includes
both plain films and computed tomography
∙ Understand the rationale of a systematic facial analysis and using it to
formulate a treatment plan
2 Indications, surgical steps and Residents to be able to:
complications of Le Fort I osteotomy of ∙ Understand the indications of the surgical procedure
the maxilla ∙ Understand the anatomical basis of the surgery
∙ Appreciate the vital structures which may be encountered during the
surgery
∙ Understand the steps of the surgery and the potential pitfalls for each steps
3 Indications, surgical steps, and
complications of bilateral sagittal split
osteotomy of the mandible
4 Complications of orthognathic surgery Residents to be able to:
∙ Understands the etiology, prevention, and management of the potential
complications

2.4 Kern’s step 5: implementation rienced by residents in the surgical steps of OGS (questions
listed in Table 2).
During the simulation session, each resident was assigned Competence was evaluated using an assessment tool
to two surgeons: one acting as the main instructor and derived from OMOSATS. A global rating scale of 1–5 was
assessor, and the other acting as a secondary assessor. The used to score residents on specific parameters, as indicated
residents were first required to perform the LF1 and BSSO by the OMOSATS (questions listed in Table 3). Compe-
procedures on a 3D printed model without instruction tence assessment was performed immediately after the
or guidance from the instructors/assessors. The residents residents’ first and second attempts at simulation surgery.
were also required to verbalize their actions and rationales The assessments were independently performed by two
in each surgical step. Using the OMOSATS framework as assessors for each resident.
an aid, the instructors provided feedback based on what Feedback of the course was collected to evaluate the
they observed from the resident’s initial performance. The fidelity of the simulation models and the conduct of
residents were also allowed to discuss any issues and the course. Unlike the outcome measures, feedback was
difficulties experienced when performing the simulated obtained from both OMS residents and instructors. A five-
surgeries. Subsequently, the main instructor demonstrated point Likert scale (1 = does not resemble live patients,
the surgical steps to the resident. Similarly, they also 5 = very closely resembles live patients) was used to
explained their actions and rationale to the residents. The assess four parameters: (1) anatomy and morphology of
residents were then allowed to repeat and perform another the models, (2) bone resistance and tactile handling dur-
set of simulated surgeries on another 3D model. ing osteotomy, (3) mobilization and repositioning of the
bone segments, and (4) plate bending and fixation with
screws. The four parameters were also targeted toward the
2.5 Kern’s step 6: evaluation and common difficulties reported by the residents. Conduct of
feedback the course was assessed based on general satisfaction and
whether the course met their expectations.
The two main outcome measures were improvement in
the confidence and competence of OMS residents in per-
forming OGS. Confidence was assessed using a five-point 2.6 Statistical analysis
Likert scale (1 = not confident at all, 5 = completely con-
fident). An electronic survey consisting of six questions Statistical analyses were conducted using IBM SPSS (ver-
was completed before and after simulation training. The sion 26.0, IBM Corp.). The Shapiro–Wilk normality test
six questions targeted the most common difficulties expe- was conducted for all sets of data. Shapiro–Wilk tests
 19307837, 2024, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.13517 by INASP/HINARI - PAKISTAN, Wiley Online Library on [16/02/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TAN et al. 979

TA B L E 2 Residents’ confidence level (mean) before and after simulation training.

LF1 BSSO
Question Before After p-Value Before After p-Value
Identifying hard-tissue anatomical structures 3.2 ± 0.632 4 ± 0.471 0.023 3.5 ± 0.850 3.6 ± 0.843 0.888
Osteotomy design 3.1 ± 0.738 4 ± 0.471 0.014 2.7 ± 0.483 3.6 ± 0.699 0.014
Osteotomy 3.2 ± 0.789 3.6 ± 0.699 0.234 1.9 ± 0.876 2.8 ± 0.422 0.014
Mobilization of bone segments 2.8 ± 0.789 3.4 ± 0.843 0.096 2.0 ± 0.667 2.6 ± 0.699 0.034
Repositioning of bone segments 2.4 ± 0.516 3 ± 0.667 0.034 2.1 ± 0.876 2.6 ± 0.699 0.096
Plate bending and fixation with miniplates 2.9 ± 0.994 3.9 ± 0.738 0.033 3 ± 1.054 4 ± 0.471 0.040
Abbreviations: BSSO, bilateral sagittal split osteotomy of the mandible; LF1, Le Fort I maxillary osteotomy.
*p-Value < 0.01.

TA B L E 3 Pre- and post-demonstration competence mean score for residents.

LF1 BSSO
Outcome Before After p-Value Before After p-Value
Respect for tissue 3.30 ± 0.801 4.05 ± 0.826 <0.001* 2.90 ± 0.553 3.90 ± 0.718 <0.001*
Time and motion 3.05 ± 0.686 4.05 ± 0.26 <0.001* 2.85 ± 0.489 3.90 ± 0.718 <0.001*
Instrument handling 2.80 ± 0.696 4.15 ± 0.813 <0.001* 2.70 ± 0.657 4.00 ± 0.795 <0.001*
Knowledge of instruments 3.40 ± 0.883 4.25 ± 0.786 <0.001* 3.05 ± 1.050 4.30 ± 0.801 <0.001*
Use of assistants 2.80 ± 0.616 4.15 ± 0.813 <0.001* 2.85 ± 0.813 4.00 ± 0.858 <0.001*
Knowledge of LF1 osteotomy procedure 2.90 ± 0.788 4.25 ± 0.716 <0.001* 2.95 ± 0.887 4.25 ± 0.639 <0.001*
Knowledge of LF1 plating procedure 3.10 ± 0.852 4.10 ± 0.716 <0.001* 3.15 ± 0.875 4.20 ± 0.894 <0.001*
Abbreviations: BSSO, bilateral sagittal split osteotomy of the mandible; LF1, Le Fort I maxillary osteotomy.
*p-Value < 0.01.

revealed that all data did not follow a normal distribu- 3.1 Confidence and competence level
tion. A Wilcoxon signed-rank test was conducted to check
for significant changes in the confidence and competence The median pre- and post-training confidence scores for
scores. The mean and median scores were tabulated sepa- the residents were 3 and 4, respectively. For LF1, improve-
rately for the maxilla and mandible. Finally, the inter-rater ments in confidence were observed in all six surgical steps
reliability of the two assessors was tabulated. Based on that were assessed. This is especially for the identification
Bonferroni adjustment, statistical significance was set at of hard-tissue anatomy, osteotomy design, repositioning
p < 0.01 for all tests. of bone segments, and fixation, where there were greater
numerical differences. However, none of the parameters
was improved were statistically significant (p not < 0.01).
3 RESULTS This is similar for BSSO, where larger numerical dif-
ferences (improvements) were observed for osteotomy
All invited residents (n = 10/10) participated in the work- design, osteotomy, mobilization of bone segments, and
shop and completed the pre- and post-workshop surveys. fixation; none of which achieved significant statistical dif-
Three of the residents were at the start of their third and ference (p not < 0.01). The details are summarized in
final year of the OMS training program, whereas four and Table 2.
three residents were at the start of their second and first Prior to the demonstration by the surgeons/instructors
year of training, respectively. The number of OMS resi- (first attempt), the median competence score was 3,
dents training in Singapore at the time of the study was 10 and the mean was 2.98 ± 0.675. A statistically sig-
in total (100%). nificant improvement in the mean competency scores
Seven surgeons participated as instructors and asses- was found across all individual parameters (p < 0.01,
sors during the course. All seven surgeons were active in Wilcoxon signed-rank test). The median and mean
teaching OGS to OMS residents prior to the course. A pre- competence scores were 4 and 4.11 ± 0.730, respec-
workshop briefing and demonstration were also conducted tively (second attempt). The details are summarized in
to calibrate the surgeons. Table 3.
 19307837, 2024, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.13517 by INASP/HINARI - PAKISTAN, Wiley Online Library on [16/02/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
980 TAN et al.

The inter-rater reliability between the two surgeons most residents found performing actual osteotomies chal-
assessing each resident was calculated using the intra- lenging in both LF1 and BSSO procedures. Qualitatively,
class correlation coefficient. An intra-class correlation residents also reported that fear of patient safety, limited
coefficient of 0.971 suggests a high degree of inter-rater visualization, and lack of time and opportunities were con-
reliability. There was no significant correlation between cerns when learning OGS. Based on this needs assessment,
the change in confidence and the change in competence it was decided that residents should focus on practic-
level (rest = 0.155, p = 0.668; Spearman’s rank-order corre- ing osteotomies and bone repositioning using a simulator
lation). There was also no significant correlation between model that resembles real bone.
residents’ experiences and change in competence level (rds The above-mentioned findings are not surprising, as
= ‒0.135, p = 0.709; Spearman’s rank-order correlation). OGS requires surgeons to operate in a confined space with
limited visualization for other assistants and bystanders.
Similarly, instructors and supervisors may limit the visual-
3.2 Fidelity of 3D printed models and ization of residents performing OGS. Although the inten-
course feedback tion of the surgery is to separate only a part of the maxilla
or mandible, multiple steps are required to reach the end-
All 10 residents and seven surgeons responded to the sur- point. In addition, many of these steps require the surgeon
vey grading the fidelity of the 3D printed maxillofacial to rely on tactile sensation to operate safely. These steps
models compared to real bone. Overall, the mean score often involve using osteotomes precisely in areas involv-
of both the maxilla and mandible models was 3.2 out of ing important blood vessels or nerves (lateral nasal wall
5 (standard deviation [SD] 0.909). Participants felt that the osteotomy in LF1 and the inferior dental nerve in BSSO
maxilla (mean 3.5; SD 0.680) more closely resembled real split). It is difficult to learn the tactile sensation required
bone than the mandible (mean 2.9; SD 1.018). The highest for precise bone osteotomies through observation alone.
fidelity scores for an individual component were awarded Together with the stress of operating on a patient, residents
to the plate bending and fixation with screw steps in LF1 without prior hands-on experience may be more prone to
osteotomy (40/50). On the other hand, the mobilization mistakes.
and repositioning step in BSSO were rated as the least real- Currently, the gold standard is cadaveric simulation
istic compared to real bone (23/50). General satisfaction training. However, cadavers have a limited supply and
with the course was very high, with a median score of 5. All require special facilities for both storage and training,
except one resident and two surgeons felt that the course which are often expensive.17,18 As such, many institutions
met their expectations (a score of 5/5). The remaining three seek less expensive alternatives that allow adequate train-
gave a score of 4 out of 5. All three gave feedback related to ing. This is commonly achieved via the use of 3D printed
incorporating soft tissue, that is, gingiva, in future courses. models.19 These models allow residents to practice their
surgical skills in a safe environment. Owing to its lower
cost, more repetitions are often allowed. Furthermore,
4 DISCUSSION because these models do not require special facilities, there
is greater flexibility in allowing residents to practice as and
This study sought to evaluate whether a training pro- when required.
gram based on Kern’s six steps is effective in improving Subjective surveys on change in confidence correspond
the confidence and competence of OMS residents in OGS to level 1 in the Kirkpatrick hierarchy of assessing the
procedures. The results of this study demonstrated the impact of education (valuating change in reaction or opin-
effectiveness of this educational approach in improving the ion). This is the lowest level of assessment of the impact
training outcomes of OMS residents. Although there are of education and may not relate to actual improvements
many available simulation training models, training may in surgical competence or patient outcomes. Thus, this
not be as fruitful if the models are not designed accord- study also aimed to measure the improvements in objec-
ing to the needs or difficulties experienced by the intended tively assessed competence. This corresponds to level 3 of
user. the Kirkpatrick hierarchy: a change in skill level. Using an
This study was modeled after Kern’s six-step approach objective assessment scale modeled after the OMOSATS
to surgical curriculum planning. The first component of examination, this study found a significant improvement
the study was intended to match the first two segments in residents’ competence after the simulation training. The
of the framework: problem identification, general needs two factors that contributed to this were initial famil-
assessment, and targeted needs assessment. First, OMS iarization surgery in the first model and the subsequent
residents were asked to report their perceived difficul- guidance provided by the surgeons. The lack of a cor-
ties in performing OGS. The survey results showed that relation between residents’ confidence and competency
 19307837, 2024, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.13517 by INASP/HINARI - PAKISTAN, Wiley Online Library on [16/02/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TAN et al. 981

further highlights the importance of evaluating both com- dents can then practice and familiarize themselves with
ponents. The results can be used to evaluate residents’ the procedure before operating on the patient. By doing
readiness to perform live surgery from both the resi- so, residents may have the chance to address any con-
dent’s and instructor/supervisors’ perspectives. Although cerns regarding the technical steps or patient anatomy
the surgeons did not participate directly in the study, there beforehand.
were still several benefits of performing a mentorship This study has some limitations. First, the same instruc-
role: knowledge consolidation, sense of satisfaction, stress tor was used to grade residents before and after the
reduction, and relationship building.20,21 demonstration. Despite being blinded to the study objec-
To date, the OMOSATS is the only objective structured tives, this created a potential bias in assessing before–after
assessment in the field of OMS. The OMOSATS takes ref- competency scores. Second, while the inter-rater reliabil-
erence from general surgery where objective structured ity was high, the objective assessment tool used was a
assessment of technical skills has been used for many modified version of the OMOSATS and has not yet been
years.22 Such forms of technical skill assessment have sufficiently validated. Third, the simulation models only
been shown to be effective in assessing technical compe- replicate the maxillofacial bones, but not the soft tissue
tence. The present study adapted the format of the original components such as the facial tissues, nerves, gingiva,
OMOSATS to fit an OGS station while maintaining the and mucosa. A high-fidelity model should be as realistic
five-point objective assessment scale. The components of as possible, both anatomically and physiologically. How-
the global rating scale relate well to OGS and the five-point ever, we believe that producing such an ideal model would
scale is clearly stratified to match residents’ level of per- incur significantly more resources. Finally, a focused group
formance. In addition, the high inter-rater reliability noted discussion may be able to elicit more needs and difficul-
in this study suggests that discrepancies between assessors ties compared to a survey. Future investigations should
are unlikely. An assessment tool also serves as a checklist consider correlating the effects of needs-directed simu-
or learning goal for residents, as the marking scheme can lation training on residents’ performance or confidence
also be used for self-evaluation. when performing surgery. The validation of the assess-
Despite the statistically significant improvements in ment tool can also be performed using a larger sample
competency, it was not accompanied by a similar growth size.
in the confidence level of the residents. This was also
supported by the lack of statistical correlation between
the two parameters. This highlights the importance of 5 CONCLUSION
a multi-dimensional assessment of students as a single
parameter, that is, exam or practical hands-on score may Kern’s six-step approach is a useful reference for plan-
not be a sufficient indicator of their readiness to practice on ning a training course for students. This allows training
actual patients. It also suggests that while simulation can to be based on the needs and difficulties perceived by
enhance or support training programs, it cannot replace students. Using this approach, the confidence and com-
clinical mentorship entirely. petence of OMS residents regarding OGS procedures
In the last step of Kern’s approach, evaluation and feed- improved significantly. Confidence alone is not sufficient
back data on the training design and fidelity of the printed to determine a resident’s readiness for surgery, as it is
model were obtained from the participants. The current not correlated with competence. Although the current
3D printed model was improved in a previous iteration printed bench top model has limitations, it exposes res-
by Bertin et al.19 This was achieved by including both the idents to a few key steps in OGS: osteotomy planning,
maxilla and mandible in the occlusion and mounting it osteotomy cuts with saw, removal of bony interferences,
on a benchtop. This more closely simulates the hard-tissue bone positioning, and fixation. This aligns with the partic-
component of dual-jaw OGS. The mean score of 3.2 out of ipants’ needs and perceived difficulties in learning about
5 suggests that there is room for improvement to achieve OGS.
a highly realistic maxillofacial model. Fidelity scores for
the mandible were particularly low when assessing bone AC K N OW L E D G M E N T S
feel (2.7/5) and the nature of split (2.2/5). Qualitative feed- The authors wish to thank Mr. Roland Lim, Digital Den-
back also showed that the mandible tended to fracture tistry Unit, for his support in the preparation of simulation
unfavorably during the BSSO split. The authors acknowl- models and Ms Sim Yu Fan for her guidance in the
edged that the printed models could be further improved, statistical analysis of this study.
particularly for the mandible. There are also opportuni-
ties for patient-specific customized training, whereby 3D C O N F L I C T O F I N T E R E S T S TAT E M E N T
models can be printed prior to future surgeries. Resi- The authors declare they have no conflicts of interest.
 19307837, 2024, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jdd.13517 by INASP/HINARI - PAKISTAN, Wiley Online Library on [16/02/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
982 TAN et al.

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