Game-based learning in orthodontic education: a systematic review

Orthodontics requires development of cognitive and psychomotor competencies (e.g., diagnosis, treatment planning, bracket placement, wire bending) to ensure safe, effective patient care. Multiple pedagogical approaches are used (lectures, seminars, clinical practice, case-based learning, technology-enhanced simulations including virtual/augmented reality). Game-based learning (GBL) has grown in dental education, offering feedback-driven, engaging, and entertaining learning that may improve knowledge and motivation, though high-quality evidence remains limited. Given increasing GBL studies in orthodontics but unclear comparative effectiveness versus traditional methods, this review evaluates the educational impact of GBL in orthodontic education.

Prior literature indicates rising use of GBL in dental and health professions education, suggesting benefits for knowledge, engagement, and motivation, but highlights a need for higher-quality studies and more rigorous designs. Technology-enhanced simulations (including VR/AR) are effective in orthodontic training for planning and safe practice. Existing integrative and rapid reviews in dentistry report potential effectiveness of serious games but emphasize the paucity of robust trials. There is also evidence that immediate feedback, competition, and immersive environments are key mechanisms for engagement and learning, yet applications targeting psychomotor skills in orthodontics remain underexplored.

Design: Systematic review following established guidelines to minimize bias. Databases: Scopus, PubMed, ProQuest Dissertations & Theses Global, and Google Scholar. Timeframe: January 2000 to December 2023; last search on 28 January 2024. Supplementary searches: Reference list screening and gray literature where feasible. Search strategy: PICO-informed terms focusing on orthodontics (population), game/gamification/edutainment/simulation/VR/AR (intervention); comparison terms were omitted to maximize sensitivity; outcomes included knowledge, skills, competence/performance, engagement, motivation, and satisfaction. Inclusion criteria: Empirical studies evaluating GBL in orthodontic education within the timeframe. Exclusion: GBL for non-orthodontic practitioners (e.g., patients, surgeons), studies lacking GBL details or educational outcomes, and non–full-text articles. Selection: Two independent reviewers screened titles/abstracts and full texts, with disagreements resolved by discussion and third-researcher consultation. Risk of bias: RCTs assessed with RoB 2 (domains: randomization, deviations, missing data, outcome measurement, selective reporting), with “some concerns” recorded as “moderate risk”; non-RCTs assessed with ROBINS-I (confounding, selection, intervention classification, deviations, missing data, outcome measurement, selective reporting). Data extraction: Details of GBL, subjects, objectives, methodology, participants, outcomes, key findings, and risk of bias. Synthesis: Narrative synthesis due to heterogeneity across interventions and outcomes.

• Included studies: 7 total (4 RCTs; 3 questionnaire surveys). Participants included predominantly dental undergraduates; 1 study involved orthodontic residents. - Risk of bias: 6 studies had moderate risk; 1 had low risk. - GBL formats: 5 digital/technology-enhanced (including VR and online games); 1 gamified traditional learning with an audience response system; 1 card game. - Topics: basic orthodontic concepts, model analysis, cephalometric tracing/analysis, orthognathic prediction, and orthodontic bracket bonding. - Performance outcomes (3 studies): Two RCTs found GBL improved knowledge retention or cephalometric tracing accuracy versus traditional methods; one RCT found no significant difference between VR and 2D tracing for orthognathic diagnosis/treatment planning. - User experience (6 studies): Consistently positive perceptions of GBL regarding enjoyment, motivation, and engagement; RCTs comparing GBL with traditional methods reported higher motivation and positive perceptions for GBL; class involvement was not consistently different. - Overall: Evidence supports potential cognitive benefits and strong learner acceptance of GBL in orthodontic education, with mixed comparative performance effects across specific tasks.

The review addresses whether GBL improves educational outcomes in orthodontic training. Findings indicate that GBL yields positive cognitive outcomes comparable to or exceeding traditional learning in certain areas (e.g., knowledge retention, cephalometric tracing accuracy), and is consistently well-received by learners for its engaging and entertaining features (immediate feedback, competition, immersive VR). These results support GBL as a valuable adjunct within orthodontic curricula, particularly for undergraduate learning. However, heterogeneity of interventions/outcomes and prevalent moderate risk of bias limit the strength of conclusions and prevent meta-analytic synthesis. Current GBL efforts predominantly target cognitive outcomes; translating GBL to psychomotor skill acquisition (e.g., wire bending, bracket placement) via haptics and advanced simulation could extend benefits to postgraduate training. Additional rigorously designed RCTs and qualitative studies are needed to clarify mechanisms, optimize design elements, and validate efficacy across learner levels and competencies.

GBL shows promise in orthodontic education for enhancing cognitive learning, engagement, and motivation, especially at the undergraduate level, when entertaining and educational elements are integrated. While some trials demonstrate superior performance versus traditional methods, evidence quality is limited and heterogeneous. Future research should include high-quality, adequately powered RCTs assessing specific outcomes, expansion to psychomotor skill training (potentially with haptics), greater inclusion of postgraduate learners, and mixed-methods approaches to understand how design features drive learning within game cycles.

• Most included studies had moderate risk of bias; only one showed low risk, limiting confidence in pooled inferences. - Heterogeneity across interventions, outcomes (knowledge retention, tracing accuracy/speed, motivation), and measures precluded meta-analysis. - Predominant focus on cognitive outcomes; lack of studies on psychomotor skills relevant to orthodontic practice. - Participant populations largely undergraduates, limiting generalizability to postgraduate training. - Variation in study designs (RCTs vs surveys) and small samples in some studies likely reduce precision and external validity.