Prof. Dr. Hesham Marei, BDS, MSc, FDS, DDS, PhD
Dean, College of Dentistry, Gulf Medical University, UAE
First of all, would like to thank Dr. Morgan and the organizing committee for your kind invitation. I’m being trained as oral and maxillofacial surgery by profession and currently serving as a dean and vice chancellor of Gulf Medical University which is one of the universities in UAE. Also I carry another hat as a educationist. I had my master and PhD in education in Netherlands. So it was a good opportunity to incorporate Bicon into the education system of Gulf Medical University. And we were able to, through a proper educational research, to prove that it is cognitively friendly. I think Dr. Morgan, for the first time, you would get this piece of information, but it’s cognitively friendly. I’m going to dive a little bit on education and some of the deep principles then will go together how we were able to prove this. So my presentation outline is about what is complex learning task and what is cognitive load theory that would enable you to understand how we were able to prove that Bicon is a cognitive friendly implant system. Then partially guided implant surgery with Bicon implants and they’ll end by limitation of computer guided implant surgery. In UAE we have 7 dental schools. We are graduating nearly 600 to 700 graduates every year. One of, this is a university where I serve as a dean, it’s Gulf Medical University and we offer dental implants training within the context of undergraduate program and master program in periodontics. And recently we are starting a residency program in implant surgery. The competencies of our graduates, regardless undergraduate or post graduates, that is the competencies of all UAE graduates revolve around professionalism, communication, health promotion, scientific knowledge and patient centered care. When we look from an educational perspective, we would define teaching and learning dental implantology to novice learner as a complex learning task. Why? Because it involves the integration of multiple competencies. The first is cognitive, the second is psychomotor, and the third is a behavioral element. And that together dictates the necessity of problem solving and taking a real decision in real times. So novice learner would have three challenges. The first one, these three domains are not integrated yet through, in a real clinical scenarios. The second one is limiting exposure makes them vulnerable to non-textbook scenarios and we are aware that it’s very difficult to have two patients that have exactly the same situation. The third is cognitive load actually increases the risk of error and decreases learning effectiveness. So in order to understand what’s meant by cognitive load, we have to understand that we have actually three types of memory. The first one we call it the sensory memory. So when you have a new information, new knowledge, that is relevant to your practice, it goes from the sensory memory, which is the first memory, to the second memory, which is the working memory. So two channels, auditory channels, and the visual channels. The working memory is of limited capacity. It’s exactly like the RAM of your computer. The random access memory of your computer. So if you have a memory of your computer, which is thirty two or sixty four or whatever sixteen, and you open four or five applications, and then you want to open application number six or number seven, you’ll find your computers not responding. Why? Because you have overloaded the working memory. That is exactly what we have in teaching and learning for a novice learner. So the working memory of a novice learner actually can withstand seven plus or minus two chunks of knowledge. If you load it more, that would lead to what we call it cognitive overload. And the working memory, it’s important because it processes the information, it processes the skills, and save it in the long term memory. The long term memory is a big hard drive. It’s a hard drive with indefinite capacity. And what differentiates a novice from an expert is the structure and organization of knowledge, and the acquired skills in the long term memory. So the long term memory, there’s two types, which are declarative for facts and knowledge, and there’s procedural for surgical techniques and motor skills. So going back to the working memory, which is important for processing information and new skills. This working memory with any task, with any learning task, it get exposed to three types of loads. The first load, we call it intrinsic load. The second load, call it extraneous load. And what is left after intrinsic and extraneous, we call it germane load. So if we want to apply this to implant learning, and that is important for teaching and learning, and important for any dentist who wants to start training on dental implantation. Actually, there is high intrinsic load for novice because it’s, as I said, complex step, involve flap design, osteotomy, adjusting the direction, protection of vital structure, implant placement and closure. And here, precision is required. And as I said, it’s not yet internalized into schema in the long term memory. So the result is that the core task itself overwhelms the working memory. So what is the second type of fluid that imposed on the working memory? We call it extraneous load. The extraneous load that happens as a result of no supervision or making independent judgment or having unfamiliar instruments, working in unfamiliar situations, in unfamiliar clinics, and lack of proper assistance. That results in that the working memory is burdened by non learning related stressors. So if we look to this graph, we’ll understand that if this is the intrinsic load and that is extraneous load, so what is left in the working memory is very minimal for skill development and professional development. So the results would be poor learning, high risk of error during the procedures and lack of professional developments. Through our educational research, we were able to measure the intrinsic load that is imposed on the working memory during placement and restoration of Bicon implants. So, the question is, how to reduce that intrinsic load, and how to reduce extraneous load in order to free the working memory for processing the skill and processing new information to the long term memory. This can be done by having, number one, partially surgical guide. Especially we are speaking about partially guided surgery with a pilot drill. That is for the start of the procedures. So by having a partially guided surgery, you are actually outsourcing the critical decisions to a third party. So when you outsource the clinical decisions to a third party, you are reducing the cognitive load on the learner. That is number one. Number two, reducing decision making at the point of care. See, making all the decisions that are needed in term of what would be the implant length, implant diameter, what would happen if I have a dehiscence defect on the buccal side, that all decisions needs to be planned before the procedures. So limiting the number of decisions that need to be taken in real time. Standardize the surgical sequence. That actually will increase and improve the confidence. So the results would be that the results would support long term development of expertise, so what we call it scaffolding experience. And here that we refers to reducing the intrinsic loads by these maneuvers in order to help the learning to be more effective and more efficient. So in benefits, cognitive benefits of partially guided surgery, improve confidence, focused attention, and better learning. So we were able to measure through a validated questionnaire, the cognitive load that fall on the working memory of the learner, of the learner during implant surgery. And we measure this with partially guided surgery, with Bicon, and also with other systems. So what we have found is that load that is placed on the working memory with Bicon implants, especially if it is partially guided, is very minimal, which free the working memory for learning and development of the skill and processing the skills to the long term memory. So the routine practice of our undergraduate and postgraduate students is if they have partially edentulous patients or completely edentulous patients, they will finish superior treatments, do CBCT, and then do their measurements. And they will go and have CBCT virtual planning. Then they will have the computers for doing registration of the STL and the CBCT. And they will have a surgical guide that is printed, ready for the surgical procedure. And as I said, it’s only for the pilot drill. So they place the surgical guide, and they do the first drill, flapless, to mark where exactly the future implant placement would be. And I believe, if we are speak about a prosthetically driven treatment plan, that is impossible without having a guide that transfer the plan from the virtual site to the oral cavity site. So they do the first pilot drill, and then the open flap, and this case is one of my students cases during their undergraduate practice. And they follow the protocol of Bicon by placing the implants two millimeter below the crest, And then they place the healing plug and they close it up. The patients would wait for two, three months before the restoration. And they usually do a sectional CBCT after the surgery in order to compare between the real implementation of the surgery and the virtual plan. And by this, they can learn how they have deviated during the freehand procedures from the virtual plan. To speak about limitation of computer guided implant surgery, and here I’m speak about the limitation when we use a fully guided flapless technique. All us are aware that we have multiple steps and there is an error in every step. Error during calibration of CBCT, during having the DICOM files, errors during the intraoral scanning and getting the STL, especially if you are scanning a fully edentulous patient. Errors during the surface registration of the STL with the CBCT. And errors that is related to the quality of the printer that you are using. And error relating to surgeon experience. And finally, the type of the guides. Is it teeth supported, bone supported, or mucosa supported. All these factors actually dictate the accuracy of your final outcome. So as a conclusion, when we have a printed surgical guide, and a partially guided implant surgery, that reduces the intrinsic load by transforming high stakes, complex 3D task into a predictable, simplified mechanical process. It acts as cognitive extension for novice dentists, allowing them to engage safely in their independent practice while still developing procedural skills and anatomical precision. By this, I would like to thank you all for your attention.