Available online at www.sciencedirect.

com

Health Professions Education 2 (2016) 8098

www.elsevier.com/locate/hpe

3D Anatomy Models and Impact on Learning: A Review

of the Quality of the Literature$
Samy A. Azera,b,n, Sarah Azerc
a
King Saud University, College of Medicine, Department of Medical Education, PO Box 2925, Riyadh 11461, Saudi Arabia
b
Australian Professional Teaching, 3016 VIC, Australia
c
Box Hill Hospital, Eastern Health Melbourne, Australia
Received 22 April 2016; accepted 13 May 2016
Available online 24 May 2016

Abstract

Background: The aims of this study were to identify studies exploring three-dimensional (3D) anatomy models and their impact
on learning, and to assess the quality of research in this area.
Methods: PubMed, EMBASE, and the Web of Knowledge databases were searched using the following keywords "3D anatomy",
"three dimensional anatomy," "3D virtual reality anatomy," "3D VR anatomy," "3D anatomy model, 3D anatomy teaching", and
anatomy learning VR . Three evaluators independently assessed the quality of research using the Medical Education Research
Study Quality Instrument (MERSQI).
Results: Of the 94,616 studies identied initially, 30 studies reported data on the impact of using 3D anatomy models on learning.
The majority were of moderate quality with a mean MERSQI score 10.26 (SD 2.14, range 6.013.5). The rater intra-class
correlation coefcient was 0.79 (95% condence interval 0.750.88). Most studies were from North America (53%), and Europe
(33%) and the majority were from medical (73%) and Dental (17%) schools.
Conclusions: There was no solid evidence that the use of 3D models is superior to traditional teaching. However, the studies
varied in research quality. More studies are needed to examine the short- and long-term impacts of 3D models on learning using
valid and appropriate tools.
& 2016 King Saud bin Abdulaziz University for Health Sciences. Production and Hosting by Elsevier B.V. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Three dimensional anatomy; Anatomy teaching; 3-D models; MERSQ instrument; Research quality

1. Introduction changes have been a continuous debate and triggered

With the introduction of reformed curricula in
medical, dental and other allied health schools, most
schools have reduced the total hours allocated for
anatomy teaching and laboratory practical hours. These
the emergence of innovative teaching and learning
strategies in order to maximize students' learning of
anatomy in the new context.1
Anatomy is a discipline where spatial visualization is
of importance. Students need to learn not just

Peer review under the responsibility of King Saud bin Abdulaziz University for Health Sciences.
n
Corresponding author at: Department of Medical Education, College of Medicine, King Saud University, PO Box 2925, Riyadh 11461, Saudi
Arabia. Tel.: +96614699178.
E-mail address: azer2000@optusnet.com.au (S.A. Azer), drsarahazer@gmail.com (S. Azer).

http://dx.doi.org/10.1016/j.hpe.2016.05.002
2452-3011/& 2016 King Saud bin Abdulaziz University for Health Sciences. Production and Hosting by Elsevier B.V. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098
anatomical structures and functions but also spatial
relationships to surrounding structures.2 While anat-
omy textbooks and anatomy atlases provide two-
dimensional (2D) static anatomical illustrations, they
are of limited value in exposing three-dimensional (3D)
dynamics of anatomical structures.3 Learners may nd
it difcult to visualize 2D images as 3D and understand
certain dynamic aspects of functional anatomy. For
example, identifying the structures related to the
caudate lobe when the liver is moved to different
planes/positions.
In anatomy, students have to rotate and manipulate
structures from various views to identify anatomical
structures. Visual-spatial ability has been dened as the
ability to mentally manipulate objectives in three dimen-
sions.4 Such ability is important for medical students to
understand anatomical structures and is also important to
surgical trainees and surgeons. Therefore, the ability to
visualize and mentally manipulate 3D structures and
correctly identify them and related structures is an
important skill to medical and dental students when the
anatomy is presented in various planes and positions.5
Research in this area may not only assess visualspatial
abilities of students during learning but also assess the
development of a pedagogical technology to enhance
students learning skills and the advancement of medical
training.6
Considering the importance of 3D learning and
teaching anatomy models in medical, dental and other
allied health curricula, understanding the range of
models used and the impact of using such 3D strategies
on students' learning necessitates a revision of studies
covering 3D models. The focus is to evaluate different
factors affecting learning by using 3D anatomy models
and their impact on the learning process. This review
aimed at (1) assessing the impact of using 3D anatomy
models on students learning using a scoping review
approach,7 and (2) assessing the quality of research of
studies identied using Medical Education Research
Study Quality Instrument (MERSQI) for quantitative
studies.8,9 The MERSQI is a multifaceted instrument
for assessing the quality of medical education studies
and has been shown to have reliability and validity
evidence with high inter-rater and intra-rater reliabil-
ity810 and it has been shown that MERSQI scores
correlate with expert ratings about study quality.11 In
structuring this review, the ndings from the studies are
integrated using critical analysis and thematic synth-
esis.12 Gaps in this area and future directions of
research have been identied and discussed.
81
2. Methodology
2.1. Study design
This review is based on a scoping review approach, a
method commonly used to explore questions when
little knowledge has been identied. Therefore, the ve
stages summarized by Arksey and OMalley were
followed. Stage 1: identifying the research question,
stage 2: identifying relevant studies, stage 3: study
selection, stage 4: charting the data, and stage 5:
collating, summarizing and reporting the results.7
2.2. Study stages
The ve stages used in the study can be summarized
as follows.
2.2.1. Stage 1: identifying the research question
The research questions of this review are:
 What 3D methods used in teaching and learning
anatomy?
 What is the impact of using 3D anatomy models on
students learning?
 What is the quality of published research?
2.2.2. Stage 2: identifying relevant studies in the
literature
The following electronic databases: PubMed,
EMBASE, and the Web of Knowledge were searched.
The keywords used in the search were: "3D anatomy",
"three dimensional anatomy," "3D virtual reality anat-
omy," "3D VR anatomy," "3D anatomy model, 3D
anatomy teaching" and anatomy learning VR . The
search was conducted by the author (who is trained as a
doctor and is a professor of medical education) and two
research assistants (both have medical background) from
01 to 15 January 2015. Papers available online ahead of
the print version were included.
Three-dimensional (3D) anatomy models comprise
digital, and non-digital (physical) models that can be
moved into different positions/planes to enable learner
to learn the relationship between different anatomical
structures in space and mentally manipulate objectives
in three dimensions. Visual-spatial ability also known
as spatial visualisation ability is dened as the ability to
mentally manipulate objectives in two- and three-
dimensional gures,4 while virtual reality (VR) is a
computer-simulated environment that can simulate real
82 S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098
world or imaged worlds. Most current virtual reality
environments are displayed either as a computer screen
or with special stereoscopic displays.4
Second, using the same search words, the webpages of
the following medical education journals were searched
Academic Medicine, Medical Education, Medical
Teacher, BMC Medical Education, Advances in
Health Sciences Education, Teaching and Learning in
Medicine, European Journal of Dental Education, and
Journal of Dental Education.
Third, the webpages of the following journals on
anatomy and anatomy education were searched: Anato-
mical Science International, Journal of anatomy,
Surgical and Radiologic Anatomy, The Anatomical
Record, Anatomical Science Education, Clinical
Anatomy and Annals of Anatomy. The same search
words were used in searching the journals websites. Other
sources for eligible studies were the list of references of
related systematic reviews and research papers identied
in this search. Because there were a few papers published
on the research topic during the years 20002004, it was
decided to focus the search for papers from 01 January
2000 up to the end of December 2014.
2.2.3. Stage 3: inclusion and exclusion criteria and
study selection
Studies were included if they were assessing the impact
of using 3D anatomy models on students learning. Only
studies in the English language that addressed 3D
anatomy in undergraduate medical, dental and allied
health courses were included.
The exclusion criteria were as follows: (1) descriptive
studies on the use of 3D models in teaching without
assessing the impact on learning, (2) studies descripting the
development of 3D models, (3) studies on the use of 3D in
veterinary medicine, (4) the use of 3D in planning surgical,
orthopedic or anesthetic procedures, (5) advanced 3D
models used in enhancing surgical skills, and advanced
training, (6) use of 3D in understanding malformation, rare
conditions or design of surgical technique, (7) history of
3D development, (8) use of 3D models in studying
comparative anatomy, (9) abstracts, conference proceed-
ings, discussion papers on 3 technologies and gross
anatomy, (10) reviews, commentaries, debates, letters to
the Editors, editorials on using 3D models in anatomy,
(11) papers in languages other than English, and (12)
duplicate papers.
The assessors independently reviewed all databases
using the above stated criteria. Papers identied were
placed on an Excel sheet (Microsoft Corporation, Red-
mond, WA, USA). Each evaluator applied the exclusion
criteria independently. Disagreements were discussed in a
meeting until a nal consensus was reached. Copies of
the full articles were obtained for the studies that appeared
to represent the best t with the research questions.
2.2.4. Stage 4: charting the data
The data were charted on spread sheets to record the
title of the papers, authors, country of the rst author/
university where work was done, year of publication,
journal/source, type of study, aims/objectives, what was
carried out, and other key information about results/
conclusions. Data were summarized using numerical
summary. The numerical summary included number of
participants, and key information found.12
2.2.5. Stage 5: collating, summarizing and reporting
the results
Systematic examination of the methodological rigor of
the studies enabled the grouping of the studies. Extracted
data were synthesised descriptively to map different
aspects of the literature as outlined in the study key
questions. Studies were grouped according to country of
origin of the rst author, settings and study participants,
study design and research methodology used, outcomes
measured, and the year of publication.
2.3. MERSQI scoring of studies
The MERSQI has been used in assessing the quality of
published medical education research.8 The instrument
comprises 10 items in six domains: study design, sampling
method (number of institutes and response rate), type of
data, validity of the evaluation instrument, data analysis,
and outcomes. For each domain the maximum score is
3 and the total possible MERSQI score is 18 with a range
of 518.9 Higher scores indicate that the study is well
designed, has valid instruments and provided measurable
outcomes beyond gain of knowledge and skills. The use of
the MERSQI in this study follows the study by Reed et
al.8 and was carried out at the following stages: First, three
evaluators (the author and two research assistants)
reviewed the use of the instrument and practiced its use
independently to assess seven studies other than those
included in the study. Second, the scores obtained were
reviewed in a meeting with the aim to clarify the meaning
of each item in the scoring scheme, orient the researchers
to the use of the instrument and improve consistency
among all raters. The raters also documented their
decisions about applying MERSQI coding in a written
manual for future references. Third, the 30 studies were
rated independently by the three evaluators using the
MERSQI scoring manual. The scores obtained from the
three evaluators were used to calculate The rater intra-class
 S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098 83

correlation coefcient (IIC) to determine inter-rater relia-
bility.811
3. Results
3.1. Studies included in this review
The search results of PubMed, EMBASE and the
Web of Knowledge databases yielded 90,393 articles
and 4223 articles were identied from searching eight
journals on medical and dental education and seven
anatomy journals (Fig. 1). The results were as follows:
Academic Medicine 21, Medical Education 27, Med-
ical Teacher 40, BMC Medical Education 10,
Advances in Health Education 19, Teaching and
Learning in Medicine 6, European Journal of Dental
Education 22, and Journal of Dental Education 461,
Anatomical Science International 266, Journal of
Anatomy 698, Surgical and Radiologic Anatomy 501,
The Anatomical Record 914, Anatomical Science
Education 249, Clinical Anatomy 651, Annals of
Anatomy 306. Other searches from the list of refer-
ences yielded 32 articlesmaking a total of 4223.
After excluding duplicates, a total of 4807 articles were
identied. On applying the exclusion and inclusion
criteria by two evaluators independently, a total of 83
papers were assessed for eligibility. Finally after read-
ing the full text of articles, 53 articles were excluded
making a total of 30 articles meeting the criteria for
synthesis in this review.1342
Most studies were conducted in North America (16/
30; 53%), and Europe (10/30; 33%). The remaining
were from Asia (3/30; 10%), and Australia (1/30; 3%).
No studies from Africa or South America were found

Fig. 1. Results of search strategies and selection procedure for a systematic review for studies on 3D anatomy models and impact on learning.
84 S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

(Table 1). The majorities of the studies (15/30, 50%)
were published in 20092014 and (9/30; 30%) were
published in 20092011. Only (5/30,17%) were pub-
lished in 20062008 and (1/30, 3%) were published in
20002005 (Table 1).
models,21,28 laparoscopic dissection,42 arthroscopic
examination,29 anatomy glove learning system,39 and
colour coded models.23 Interestingly some of the 3D
digital anatomy models were integrated tools covering
gross anatomy and related radiological knowledge.27,40

3.3. Participants schools

3.2. The 3D anatomy models
The 3D digital models in the studies included in this
review can be classied into: (i) 3D web-based models
(3/30; 10%),14,18,30 (ii) 3D computer- and mobile-based
models (21/30; 70%),13,1517,19,20,22,2427,3138,40,41 and
(iii) non-digital (physical) 3D anatomy models (6/30;
20%). These physical models comprised: clay
Table 1
Summary of characteristics of the 30 papers included in the
systematic review on 3D anatomy models.
Studies Number (%) References
The participants were from Medicine (22/30,73%)13
16,18,19,2126,29,3137,40,42
and Dentistry (5/
30,17%).20,27,30,33,35 The remaining studies were from
Kinesiology.28,33 Only one study was from each of the
following allied health schools: Health Sciences,33
Massage therapy,39 Occupational therapy,33 Phy-
siotherapy,33 Psychology,17 and Social science.41 Some
studies had participants from 2 or more institutes,34 or
from several schools33,35 (Table 2).
3.4. Impact of using 3D anatomy models on learning

Place of the To carefully evaluate the impact of using 3D models

study on learning, critical evaluation of the studies is
Africa 0 (0) 0 addressed under the following points:
Asia 3 (10) 20,21,40
Australia 1 (3) 27 (1) Factors affecting learning by using 3D anatomy
Europe 10 (33) 15,19,22,25,29,31,34,37,38,42
models: A number of factors have been shown to
North 16 (53) 13,14,16
America 18,23,24,26,28,30,32,33,35,36,39,41 affect learning by using 3D models. These factors
South 0 (0) 0 are:
America Factors related to the 3D model such as the design
of the 3D software, availability of visual and
3D models
auditory information simultaneously, cognitive
3D Web-based 3 (10) 14,18,30
models load and complexity of the tasks included in the
3D computer- 21 (70) 13,1517,19,20,22,2427,31 program, and innate difference from traditional
and mobile- 38,40,41 teaching methods,33,39 multiple orientations pro-
based models duced by the software.13
3D non-digital 6 (20) 21,23,28,29,39,42
Factors related to learner characteristics such as
(physical)
models innate visual spatial ability,13,17,32 learners trans-
formation and search skills,41 prior orientation to
Study type the 3D technology,36 students personal home-
Controlled 7 (23) 20,25,28,32,34,39,41 work,38 cognitive load on the learner,35 gender of
Crossover 3 (10) 19,29,33
Quasi 5 (17) 21,27,36,38,40
the student,15,16 and degree of learner control.17
experimental Although not all these characteristics can be
Prospective 1 (3) 30 modied, identication of learners aptitudes
study and trends may better facilitate teaching and
Randomized 14 (47) 1318,2224,26,31,35,37,42 learning approaches.
controlled
Factors related to the curriculum and the learning
Publication year environment such as integration of the 3D tool
20122014 15 (50) 2842 with other components in the curriculum, time
20092011 9 (9) 1927 allocated to the use of the 3D tool, availability of
20062008 5 (17) 1418 faculty to provide feedback to students when
20032005 0 (0) 0
needed, anatomical region studied,16 stage of
20002002 1 (3) 13
learning in the curriculum,18 and the use of 3D
Table 2
Impact of using anatomy three-dimensional educational tools on students learning.

Author, year 3D teaching tool University/ Type of Research question/aim Participants (number) What was carried out/measured Results/limitations
[Reference] used Hospital, study
country

Garg et al., 3D computer McMaster Randomised Examining the role of multiple Undergraduate medical Students were allocated to Certain key or canonical
200213 anatomy model University, controlled orientations in learning students (n87) either multiple-view (MV) viewpoints of an object are
Canada. study anatomy from 3D computer group (any of 36 possible critically important for spatial
models. angles) of rotation or a key- learning. Multiple orientations
view and wiggle group provided by the computer-
(KVW where students can based anatomy software may

S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

control six views near 0 and offer minimal advantage to
180 degree on computer some learners.
workstation.
Nicholson 3-D anatomical ear McGill Randomised Test the educational First-year medical students The intervention group The intervention groups mean
et al., model University, controlled effectiveness of a computer (n 60) completed a Web-based tutorial on the quiz was higher than the
200614 Montral, study generated 3-D model on the on ear anatomy that included mean score for the control
Canada. ear and inner ear. the interactive model, while a group. The difference was
control group took the tutorial signicant.
without exposure to the model.
At the end, both groups
answered15 quiz questions to
evaluate their knowledge of
3-D relationships within the
ear.
Guillot Visuo-spatial Universit Randomized Investigated the relationship Undergraduate medical Students completed the Group Men scored better than women
et al., representation Claude Bernard controlled between visuo-spatial students (n184) Embedded Figures Test on both GEFT and MRT, but
200715 model. Lyon, France. study representation, mental rotation (GEFT), Mental Rotation Test the gender effect was limited to
(MR) and functional anatomy (MRT) and Gordon Test of the interaction with MRT
examination results. Visual Imagery Control. The ability in the anatomy learning
time spent on personal process. Signicant
assignment was also correlations were found
considered. between visuo-spatial, MR
abilities, and anatomy
examination results.
Hisley et al., Direct and indirect Des Moines Randomized Compare physical dissection Undergraduate top rst-year The physical dissectors All students, regardless of
200816 3D digital models. University, controlled using an embalmed cadaver medical students (n 16) proceeded with their direct gender, dissection method, and
Iowa, USA. study and digital dissection using 3D methods, whereas the digital anatomical region dissected
volume modelling of whole dissectors generated and performed signicantly better
body. manipulated indirect 3D digital on questions presented as
models. After 6 weeks, rotating models requiring
corresponding student spatial ordering or viewpoint
anatomical assignment teams determination responses in
compared their results using

85
 86
Table 2 (continued )

Author, year 3D teaching tool University/ Type of Research question/aim Participants (number) What was carried out/measured Results/limitations
[Reference] used Hospital, study
country

photography and animated contrast to requests for specic

digital visualizations. lexical feature identications
Levinson VR brain anatomy McMaster Randomised Determine the effects of First-year psychology students Two phases for intervention High degree of learner control
et al., University, controlled learner control over the (n 120) were described. Main outcome may reduce effectiveness of
200717 Ontario, study e-learning environment and measure was 30-item post-test learning. Multiple views may
Canada. key views of the brain versus of brain surface anatomy impede learning particularly for
multiple views in the learning structure identication. those with relatively poor

S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

of brain surface anatomy. spatial ability.
Marsh et al., 3D models of University of Randomized To assess the effectiveness of Undergraduate medical Both groups attended lecture Students who used the module
200818 embryonic Cincinnati controlled using web-based learning students (n76) (s) on embryonic folding performed better than those
development. College of study module that combines 3D whereas only students in the given only traditional
Medicine, Ohio, graphics and 3D models of study group were allowed resources. The ndings suggest
USA. embryonic development on access to the 3D module via that the 3D computer-assisted-
students learning. Blackboard. Both groups instruction modules in general
completed the same 14- are more useful if used toward
question quiz. Results from the later stages of learning,
both groups were analysed. rather than as an initial
resource.
Donnelly Virtual Human University of Cross-over Investigate the use of VHD in First-year medical students Using a crossover design, the There were no signicant
et al., Dissector (VHD) Durham, UK. study facilitating students ability to (n 89). investigation was undertaken differences between the two
200919 software interpret cross-sectional as two 20-minute self-directed groups at any tested stage.
images and understand the learning activities using VHD
relationships between in a computer suite and
anatomical structures. prosections and models in the
dissecting room, interspersed
between 3 tests identifying
anatomical structures (pre-,
mid- and post-session).
Hu et al., Dental 3D Wuhan Controlled Investigate the effects of Undergraduate dental students One group received their The D3DM-assisted group
200920 Multimedia University, study. introducing a software (n 53) training program in the worked faster, and no worse
System (D3DM) Hubei, China. program, named the Dental 3D traditional way, unassisted by than the traditional group
Multimedia System (D3DM), 3D technology. The second during the training in labs.
into the education of a group group received their training
of junior dental students in program in the traditional
their preclinical practice. manner, but also used the
D3DM to supplement their
education.
Oh et al., Clay models in Sungkyunkwan Quasi- Ask students for their views Undergraduate medical Two feedback surveys were Clay modelling appears to be a
200921 learning anatomy University experimental about the use of clay models in students (n70). completed by students. To useful supplement to
School of study. learning anatomy and assess assess the impact on learning, conventional anatomy and
 Medicine, the effectiveness of this students who used the clay radiologic anatomy education.
Suwon, Korea. method. models and students from Students average scores on CT
another school that did not use examinations were higher than
clay models were examined that of a group that did not use
twice by each school; once clay models.
after nishing the gross
anatomy course and six months
later.
Abid et al., 3D model of Universiti Randomized Compare 3D and traditional Medical students from two Students from two universities The 3D technique is
201022 teaching peritoneal Paris v, Paris, controlled chalk teaching efciency in universities (n 165). were taught peritoneal signicantly more efcient than
embryogenesis. France. study terms of student memorization embryogenesis either via a 3D the traditional chalk technique
concerning peritoneal technique (interactive DVD for the teaching of peritoneal
embryogenesis. ROM) or via the traditional embryogenesis. However, more

S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

chalk technique. Both groups assessment is needed
were subjected to an evaluation particularly on long-term basis.
test including 34 questions
Estevez 3D neuroanatomy Boston Randomised Implement and evaluate a new First year Undergraduate Students were taught 3D physical modelling is an
et al., tool University controlled tool for teaching 3D medical students (n 101). neuroanatomy according to effective method for teaching
201023 USA. study neuroanatomy. traditional 2D methods. Then, spatial relationships of brain
during laboratory review, the anatomy and will better prepare
experimental group constructed students for visualization of 3D
3D color-coded physical neuroanatomy. Limitations:
models of the periventricular Limited to a small area in
structures, while the control neuroanatomy. Based on one
group re-examined 2D brain school.
cross-sections.
Hu et al., A three- University of Randomised Evaluate a 3-d method of Undergraduate medical The primary outcome measure The 3D educational computer
201024 dimensional (3D) Western controlled teaching laryngeal anatomy. students (n100) was the score on a 20-question model of the larynx was not
educational Ontario, Canada trial. laryngeal anatomy test; the shown to be superior to written
computer model of secondary outcome measure lecture notes in its efcacy in
the anatomy of the was a student opinion teaching anatomy. Limitations:
larynx questionnaire. The study is based on the
larynx only and conducted in
one school.
Codd and Three-dimensional University of Controlled Evaluate the use of 3D virtual Second year Undergraduate Three groups were identied: Virtual reality anatomy
Choudhury, virtual reality Manchester, study reality when compared with medical students (n 39). (i) a control group (no prior learning can be used to
201125 computer models. United traditional anatomy teaching knowledge of forearm compliment traditional
Kingdom methods. anatomy), (ii) a traditional teaching methods effectively
methods group (taught using Limitations: the groups were
dissection and textbooks), and assessed on anatomy of the
(iii) a model group (taught forearm only by using ten
solely using e-resource). questions.
Keedy et al., Interactive 3D University of Randomised Determine whether an Undergraduate medical Participants were randomized While the interactive 3D
201126 presentation of CaliforniaSan controlled interactive 3D presentation students (n46). into two groups: 3D group: multimedia module received
liver and biliary Francisco, study depicting liver and biliary presented with a computer- higher satisfaction ratings from
anatomy USA. anatomy is more effective for based interactive learning students, it neither enhanced
module comprised of nor inhibited learning of

87
 88
Table 2 (continued )

Author, year 3D teaching tool University/ Type of Research question/aim Participants (number) What was carried out/measured Results/limitations
[Reference] used Hospital, study
country

teaching than a traditional animations and still images to complex hepatobiliary

textbook highlight various anatomical anatomy. Limitations: Based
structures, or 2D group: on one school.
presented with a computer-
based text containing the same
images and text without
interactive features

S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

Vuchkova 3D visualisation University of Quasi- Investigate the effect of 3D Fourth-year dental students Students were trained in oral Quantitative assessment of
et al., software in oral Queensland, experimental visualisation software on (n 59). radiographic interpretation by students did not show
201127 radiography Australia study. students learning of oral using the software. The improvement in their
radiographic interpretation assessment of the intervention radiographic interpretation test
from 2D radiographic images. included a radiologic after training using the 3D
interpretation test and a visualisation software.
structured Likert-scale survey. However, students were
positive about the 3D program
as per the survey.
Bareither Clay modeling University of Controlled Comparing clay modeling to Undergraduate Kinesiology Clay and module groups No signicant differences were
et al., Illinois at study written modules to determine students (n39). participated in weekly one- seen between interventions or
201328 Chicago, USA. the degree of improvement in hour classes using either clay learning preferences in any
learning and retention of modules or answering written group
anatomical relationships. questions, respectively. Control
group received no intervention.
Assessment included: pre- and
post-assessment and between
post-assessment and retention
examinations.
Knobe et al., Arthroscopy RWTH Aachen Cross-over Whether musculoskeletal Second year, undergraduate, Comparing musculoskeletal Arthroscopy may be attractive
201229 versus ultrasound. University, study. ultrasound or arthroscopic medical students (n 242) ultrasound vs arthroscopic to students. Ultrasound seems
Germany methods can increase the methods. Both groups also to be inferior to the
anatomical knowledge uptake. learnt anatomy via dissection. arthroscopic, and is regarded
The control group only had by students as more difcult to
dissection. learn. Limitation: Limited to
one school, small number of
students, did not measure long
term impact.
Maggio Interactive media University of Prospective Analyze the introduction of First-year dental students One-third of students were The interactive module was
et al., in dental Pennsylvania, study online independent learning (n 118). given an interactive media just as effective as the
201230 morphology USA. module for dental morphology module for dental anatomy traditional classroom method.
instruction. instruction. The remaining However, the online module
students experienced the
 traditional course mainly positively engaged the
lectures. At the end of the students.
module, a written examination
and survey were given to both
groups.
Metzler 3D presentation University of Randomized Evaluates whether training on Undergraduate medical A teaching module was used The correct interpretation of
et al., Heidelberg, controlled 3D presentation enhances the students (n73). consisting of one learning part 2D imaging does not differ in
201231 Heidelberg, study. understanding of 2D images. and two examination parts students trained in either 3D or
Germany. (EP). Students were 2D.
randomized to training with
either 2D or 3D.
Nguyen A 3D computer University of Controlled Assess factors that inuence Medical students, staff and Participants studied a group of Visual ability (VA) had a
et al., generated visual Western study spatial anatomy faculty members (n60). anatomical structures in one of positive inuence on SAT
201232

S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

representation of a Ontario, comprehension. three visual conditions (control, performance but instruction
group of Ontario, static, dynamic) and one of two with different computer
anatomical Canada. interactive conditions visualization could modulate
structures (the (interactive, non-interactive). the effect of VZ on task
aorta, trachea, and Before and after the study performance.
esophagus). phase, participants
comprehension of spatial
anatomical information was
assessed using a multiple-
choice spatial anatomy task
(SAT) involving the mental
rotation of anatomical
structures.
Roach et al., 3-D videography University of Cross-over Assess the efcacy of 3D Undergraduate students from Students were assigned a The study did not nd
201233 Western study video as a medium to support allied health sciences including random numeric label for the signicant differences or
Ontario, Canada the acquisition of complex medicine, dentistry, duration of the study. enhanced surgical skills.
surgical skills. The evaluation kinesiology, occupational Following the completion of Limitations: More sensitive
was carried out using a global therapy, and physiotherapy the Mental Rotation Test scales of measurements may
rating scale. (n 43). (MRT), participants were need to be used in future
randomly assorted to one of studies.
four groups and given 15
minutes to view an 8 min long
video (2D). Following viewing
of the video participants were
asked to perform the surgical
skill they had just viewed. The
same process was repeated
using another randomised
surgical video (3D).
Ruisoto 3-Dimensional University of Controlled Whether 3D volumetric Participants were volunteers Eighty participants were 3D volumetric visualization
et al., neuroimaging Salamanca, study visualization helps learners to recruited from different assigned to each experimental helps to identify brain
201234 model. Salamanca, identify and locate subcortical universities and medical condition: 2D cross-sectional structures such as the
Spain. structures more precisely than centers located in Central visualisation vs 3D volumetric hippocampus and amygdala,
Spain, Northwestern Spain, visualization. Accuracy in more accurately and rapidly

89
 90
Table 2 (continued )

Author, year 3D teaching tool University/ Type of Research question/aim Participants (number) What was carried out/measured Results/limitations
[Reference] used Hospital, study
country

classical cross-sectional and Northeastern Spain. The identifying brain structures, than conventional 2D
images (2D). participants level of education execution time, and level of visualization
was classied under two condence in the response
categories: novices and experts were measured.
(n 80).
Khot et al., Virtual reality University of Randomized Examine the effectiveness of Undergraduate medical and Students had ten minutes to Computer-based learning
201335 (VR) computer- Western controlled the three formats of anatomy dental students (n60). study the names of 20 different resources appear to have

S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

based model Ontario, study learning. pelvic structures. The outcome signicant disadvantages
versus static Ontario, measure was a 25 item short compared to traditional
computerised Canada. answer test consisting of 15 specimens in learning nominal
models (KV) nominal and 10 functional anatomy.
versus plastic questions, based on a cadaveric
models. pelvis. All subjects also took a
brief mental rotations test
(MRT) as a measure of spatial
ability, used as a covariate in
the analysis.
Tworek LINDSAY Virtual University of Quasi- Identify possible factors that Faculty and second year A validated tool measuring External, personal media
et al., Human Project Calgary, experimental can affect expectations and medical students (n 180). impact across pedagogy, usage, along with students'
201336 Calgary, study. successful implementation of a resources, interactivity, and awareness of the need to apply
Canada. 3D computer-assisted learning factors outside the immediate anatomy to clinical
software (LINDSAY). learning event was used in professional situations drove
conjunction with observation, expectations of LINDSAY
and focus groups to critically (3D) Presenter.
examine the impact of attitudes
and perceptions of all
stakeholders in the early
implementation of LINDSAY.
Mller-Stich 3D presentation of University of Randomized Dene the impact of the Undergraduate medical Medical students were Students exposed to 3Dr and
et al., liver anatomy Heidelberg, controlled addition of key views to CT students (n156). randomized to three groups 3D performed signicantly
201337 Heidelberg, study images (2D) and the use of (2D or 3Dr or 3D) and asked better than those exposed to
Germany real 3D (3Dr) on the to answer 11 anatomical 2D. There were no signicant
identication of liver anatomy questions and 4 evaluative differences between 3D and
questions.
 when compared with regular 3Dr and no signicant gender
3D images (3D). differences.
Hoyek et al., 3-D digital Universit A quasi- Assess the effectiveness ofFirst year kinesiology students The teacher used two- The ndings supported that 3D
201438 anatomy animation Claude Bernard experimental 3-D animation method. (n 391). dimensional (2D) drawings digital animations were
Lyon, study design embedded into PowerPoint effective instructional
Villeurbanne, by comparing slides and 3D digital multimedia material tools in
France two groups animations for the rst group teaching human anatomy
from (2D group) and the second (3D especially in recalling
different group), respectively. knowledge requiring spatial
classes. ability.
Lisk et al., Anatomy Glove University of Controlled Evaluate the effectiveness of Massage therapy students Students were allocated into AGLS and the traditional 2D
201439 Learning System Toronto, study Anatomy Glove Learning (n 73). two groups and drew muscles learning approach are equally
(AGLS) Ontario, Canada System (AGLS). onto either: (1) the glove using effective in promoting

S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

AGLS instructional videos (3D students self-condence and
group); or (2) paper with knowledge of hand anatomy.
palmar/dorsal views of hand
bones during an instructor-
guided activity (2D group). A
self-condence measure and
knowledge test were completed
before, immediately after, and
one-week following the
learning conditions.
Murakami Anatomy-CT, a Gunma Quasi- Assess the impact of using Medical students and academic Students perspectives about The method yielded positive
et al., 3D model University experimental Anatomy-CT model on staff (n 126). the project were evaluated by student perspectives and
201440 integrating human Graduate study. students learning. using surveys. Academic signicant improvements in
anatomical School of performance was evaluated radiology skills in later clinical
dissection with Medicine, from the yearly trends of scores course.
computed Maebashi, for anatomy and individual
tomography (CT) Japan. types of problems used in
radiology. classes. Correlations between
different types of examinations
were calculated.
Nguyen Spatial Western Controlled Test whether there are multiple Undergraduate science and Forty-two students completed a Understanding spatial
et al., visualization University, study strategies used to solve the social science students (n 42). standardised measure of spatial visualization ability is the main
201441 models Ontario, spatial task (SAT) and whether visualization ability, a novel source of variation in spatial
Canada. the strategy choice of high- spatial anatomy task, and a anatomy task performance,
versus low-visualization of questionnaire involving irrespective of strategy.

91
92 S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

accurate when solving the task

visualization ability were more
models as part of self-directed learning activ-

learning by medical students,

Participants with high spatial

scores in the short and long-

as evidenced from their test
ities.19 Interestingly, different types of computer

Three-dimensional anatomy

models enhances anatomy

education with dissection
visualization might be effective for different
learners,32 and therefore, could affect the learning
What was carried out/measured Results/limitations

process and the construction of knowledge.39

problem. While one or two of these factors were examined
in some studies, there is a need for careful

terms.
assessment of each of these factors and under-
standing strategies that can maximize learning by

laparoscopic dissection models,

and group III attended lectures

were examined immediately at

laparoscopic training. Students
using 3D tools.
processes and strategies used

group II attended dissection-

while performing the spatial
personal self-analysis of the

as well as dissection-based

2 weeks after intervention.

A number of studies showed that volumetric
Group I attended lectures,
assigned to three groups.
Students were randomly

the end of teaching and

visualization improves the identication and loca-
based training using

lization of anatomical structures by learners in

both morphological and functional images and
anatomy task.

improved students performance in anatomical

tasks on short-term basis.14,18,21,22,34,37,38,42 The
study by Ruisoto et al.34 not only showed
increased accuracy in students performance but
also less response time to complete a task. Other
studies found that 3D multimedia learning models
Undergraduate medical

enhance students' learning compared to traditional

Participants (number)

teaching methods,26 and showed a relationship

students (n46).

between the use of 3D computer models and

spatial abilities.13,17,32 Three studies showed
enhancement of students performance on long-
term basis.16,21,42
However, not all studies showed that 3D
models are better than 2D images or traditional
using models of the inguinal
Examine the added value of
individuals inuences task

dissection-based teaching,

teaching. Khot et al.35 even showed that

Research question/aim

computer-based modalities are not as effective

region in embalmed

as physical models of pelvic anatomy. The

authors found that 2D pictures are as effective
performance.

specimens.

as virtual reality (VR) models. They concluded

that computer based learning 3D resources appear
to have signicant disadvantages compared to
traditional specimens in learning normal anatomy.
Randomised

Similar ndings were reported.13,17 Also the

Medical Center, controlled
Type of

study by Lisk et al.39 showed that Anatomy

study

Rotterdam, the study

Glove Learning System (AGLS) and the tradi-

tional 2D learning approaches had the same effect
on students self-perceived condence and knowl-
Netherlands
University/

edge of hand anatomy. A number of studies also

Hospital,

Erasmus
country

showed that there was no differences when 3D

outcomes where compared to 2D or traditional
teaching.19,21,24,2628,30,32,33 However, students in
3D-Laparoscopic
Author, year 3D teaching tool

these studies reported that learning by using 3D

models was more satisfactory when compared to
dissection

textbooks images and traditional teaching mod-

Table 2 (continued )

alities.20,25,26,29,34,3638,40
[Reference] used

(2) In two studies the participants were from more

ten Brinke

than one school.33,35 Although 11 studies had 100

201442
et al.,
Table 3
Summary of Medical Education Research Study Quality Instrument (MERSQI) domain and item scoresa for 30 studies on 3d anatomy models and their impact on learning.

Domain MERSQI item Studies no. Item possible Maximum Item mean Domain mean
(%) score domain (SD) (SD)

Study design 1. Study design 3 2.40 (0.67) 2.40 (0.67)

Single group cross-sectional or single group posttest only 3 (10) 1
Single group pretest and posttest 0 (0) 1.5
Nonrandomized, 2 (or more) groups 12 (40) 2
Randomized controlled trial 15 (50) 3
2. No. of institutions studied 3 0.56 (0.21) 0.85 (0.44)
1 27 (90) 0.5

S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

2 2 (6.6) 1
42 1 (3.3) 1.5
Sampling 3. Response rate,% (highest reported) 1.15 (0.41)
Not applicable 0
o 50 or not reported 7 (23.3) 0.5
5074 7 (23.3) 1
Z 75 16 (53.3) 1.5
Type of data 4. Type of data 3 2.20 (0.99) 2.20 (0.99)
Assessment by study participant (e.g., self-reported data) 12(40) 1
Objective measurement (e.g., OSCE, written exam) 18 (60) 3
Validity of evaluation 5. Internal structure 3 0.00 (00) 0.06 (0.25)
instrumentb
Not applicable 0
Not reported 30 (100) 0
Reported 0 (0) 1
6. Content (purposeful process to instrument development) 0.13 (0.34)
Not applicable 0
Not reported 26 (86.6) 0
Reported 4 (13.3) 1
7. Relationships to other variable (criterion, predictive or discriminate 0.50 (0.51)
validity)
Not applicable 0
Not reported 15 (50) 0
Reported 15 (50) 1
Data analysis 8. Appropriateness of analysis 3 0.66 (0.47) 0.96 (0.55)
Data analysis inappropriate for study design or type of data 10 (33.3) 0

93
94 S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098

Domain mean or more participants,15,17,2224,29,30,3638,40 the

1.40 (0.24)

10.26 (2.14)
remaining had the number of participants less than
100. One study had the number of participants as
low as 16 students.16
(SD)

(3) Theoretical basis of the studies: Most studies did

not explore the theoretical basis for their ndings or
1.26 (0.44)

1.40 (0.24)
Item mean

came with logical explanation to justify their

ndings.
(SD)

(4) Validity of methods used and results: Most

studies did not provide evidence for the validity of

All comments in parentheses are meant for clarication. OSCEobjective structured clinical examination, SPstandardized patient, SD standard deviation.
methods used. The authors tried a number of
Maximum

strategies to support their research design. For

domain

example, the use of randomized controlled stu-

dies,1318,2224,26,31,35,37,42
18
3

controlled stu-
dies,20,25,28,32,34,39,41 and crossover studies.19,29,33
However, the assessment of impact was based on
Item possible

testing knowledge learnt by answering quiz ques-

tions,14,16,26 theoretical examinations,20,24,26 and
score

practical examinations.25
1.5
1

1
2

2
3
Studies no.

A few studies did not justify their results or provided

20 (66.6)

22 (73.3)
22(73.3)
8 (26.6)

7 (23.3)

1 (3.33)

weak justication. For example, the study by Mura-

0 (0)

kami et al.40 reported that the 3D model yielded

(%)

strongly positive students' perspectives and signi-

cantly improved students skills in radiology in later
clinical years. However, this improvement in radiology
skills could be an associated change rather than a
cause-effect outcome.
Data analysis appropriate for study design and type of data

Knowledge, skills (e.g., OSCEs, SPs as outcome measure)

Satisfaction, attitude, perceptions, opinion, general facts.

3.5. Assessing study qualitiesMERSQI scores

Descriptive analysis only (means and variances)

Table 3 summarizes the MERSQI scores for the 30

Each items 5, 6, and 7 can apply to different instruments used in the study.
Beyond descriptive analysis (any comparisons)

studies by item and domain. The total mean of

Behaviours (e.g., physician actual practice)

MERSQI score was 10.26 (SD 2.14, range 6.0

13.5). The study with the highest MERSQI score was
a randomized controlled study showing that three-
dimensional presentations improve in the identication
Patient/health care outcomes
9. Complexity of analysis

of surgical liver anatomy. This study earned the highest

score because it was a randomized controlled study,
had a higher number of participants ( 4 75), used
objective measures, that were appropriate for study
MERSQI item

10. Outcomes

design and the type of data and the data analysis was
beyond descriptive analysis. However, the outcomes of
the study were at the level of knowledge and skills
obtained and did not explore higher levels of outcomes
outlined by MERSQ instrument.
The study with the lowest MERSQI score reported the
use of LINDSAY Virtual Human Project. The study did
Table 3 (continued )

not compare work done to a control group, was based on

one school, and was not a randomized study. The
Total score

assessment did not use objective measures and was not

Domain

validated. The data analysis was inappropriate for study

b
a
 S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098
design and the outcomes were about satisfaction of the
students that participated in the study.
4. Discussion
4.1. General discussion
A total of 30 studies were identied from searching
PubMed, EMBASE, the Web of Knowledge databases,
eight journals on medical and dental education and seven
anatomy journals. These models were 3D web-based
models, 3D computer- and mobile-based models and 3D
non-digital (physical) models. Interestingly these physical
models comprised a range of innovative ideas and were
from different countries including USA,23,28 Canada,39 the
Netherlands,42 Germany,29 and Korea.21 The use of
physical model indicates that schools are not only moving
into 3D digital models but also there is a place for physical
model in teaching anatomy; although the major trend is
directed to digital models.
It is obvious from these studies that students favoured
the use of 3D anatomy models and found these models
more satisfactory when compared to traditional teaching,
textbooks and lectures.19,20,24,26,28,30,31,33,39 However, not
all studies demonstrated that 3D anatomy models are
superior to 2D images or enhanced students' performance
in anatomy. One study showed that 3D anatomy models
has several disadvantages compared to traditional teach-
ing,35 and a number of studies showed that there was no
differences between 3D anatomy models and traditional
teaching or 2D images.19,20,24,2628,30,33,39 The studies that
showed an impact on learning, mainly demonstrated
an improvement in performance on short-term
basis.14,18,21,22,34,37,38,42
Of these 30 studies, the rst study that was indexed in
PubMed was published in (year 2002).13 However, nearly
80% of the studies found were published in the last 6 years
indicating progressive interest in 3D anatomy models.
Most studies were from North America and Europe. Only
one study was from Australia and no studies were from
Africa or South America. The majority of the studies were
from Medicine and Dentistry. Very few studies were from
other allied health schools.
Because of the variability in the outcomes from these
studies, it was decided to assess the quality of the studies
using a standardized measure such as MERSQ instrument.
MERSQ instrument has been widely used in the literature
to examine studies on training health care professionals
across the education continuum on chronic disease care,43
coaching to enhance surgeons' operative performance,9 the
impact of physicians' occupational well-being on the
quality of patient care,44 and learning outcomes of
95
participation in student-run clinics.45 The aims of such
assessment were (1) to assess the quality of the literature
on 3D anatomy models and the impact of using such
approaches on learning, (2) to explore whether the
available literature on this area has provided quality studies
that can answer our questions in regard to the place of 3D
models in the teaching and learning, and (3) to enable the
research community to clearly see the overall pictures and
the gaps in the literature that needs further studies and
assessment.
The MERSQI scores obtained from this study are
comparable with the mean scores obtained from the
systematic reviews of simulated-based training for laparo-
scopic surgery (mean 11.9),46 undergraduate medical
education in substance abuse (mean 10.42),47 and use
of simulation in neurosurgical education (mean 9.21).48
In the presence of several variables among these systematic
reviews such as the topic researched, the nature of the
research conducted, the journals in which these studies
were published and others, such comparisons on the
quality of educational studies may reect a common
deciency in the literature particularly in regard to the
assessment of validity to support the tools being used in
educational studies; a common deciency also observed in
the studies included in this systematic review.
4.2. Implications for anatomy teaching
Although a number of factors affecting learning by
using 3D models have been identied from these studies,
we are still in need of research that carefully assesses the
impact of these factors while using 3D anatomy models.
These factors can be grouped into three categories:
(i) factors related to the 3D model such as the design of
the model, availability of visual and auditory information
simultaneously, and orientations produced by the soft-
ware,13,33,39 (ii) factors related to the learner characteris-
tics,13,1517,32,35,36,38,41 and (iii) factors related to the
curriculum and the learning environment,16,18,19,32,39 These
factors should be considered by designers of new 3D
models and course designers, as well as teaching staff.
Given the increasing interest in 3D anatomy models
as evidenced from the increasing number of published
research in this area, there is a need for multi-
institutional studies that examine theories behind learn-
ing by using 3D tools and impact of learning by 3D
models on the enhancement of knowledge, comprehen-
sion, clinical skills, integration, and application. Cur-
rently most studies focused on testing knowledge learnt
by answering quiz questions to evaluate their knowl-
edge of 3D relationships,14,16,26 theoretical post-test
examinations,20,24,26 and practical examinations.25
96 S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098
While these methods may provide limited information
about the usefulness of 3D anatomy models, there is a
need for in-depth research in this new area that can
provide answers to questions about the purpose of
using 3D anatomy models in the curriculum, and the
place of 3D anatomy teaching in the undergraduate
curriculum and how we can assess the impact of using
3D models on students learning. Other questions that
need answers, will 3D anatomy models prepare stu-
dents in a better way to clinical examination and
understanding of clinical subjects such as surgery and
medicine? What are the long-term impacts of learning
by using 3D anatomy model? Can 3D models help in
learning surface anatomy not just gross anatomy and
related subjects?49
This systematic review is not without limitations. In
order to ensure that most papers on the topic have been
considered, it was decided to design a search strategy
covering three major databases: PubMed, EMBASE,
and the Web of Knowledge. Seven keywords were
used in searching these databases, as well as the
websites of eight medical and dental education journals
as well as seven anatomy journals. Also, the lists of
references in related research papers identied were
searched for any paper related to this review. This
rigorous approach of study selection and explicit
assessment of relevance of papers as per the inclusion
and exclusion criteria resulted in the inclusion of 30
studies in this systematic review. However, despite
these precautions, the restriction of study retrieval from
medical, and dental education and anatomy journals
may not be optimal as no search of other allied health
care journals was conducted. Because journals from
allied health disciplines such as nursing, physiotherapy,
and occupational therapy were not searched, there may
be studies from these disciplines that were not
included. However, a few papers from these disciplines
were found from searching the three databases and it is
unlikely that any more data will make signicant
changes to the outcomes of this review.
This review focused only on papers in the English
language. It is possible that there are papers in the
literature addressing the inclusion criteria and the aims
of the study and were not included because they were
in languages other than English.
Finally, extraction and coding of data, as it is the
case with other reviews, can be subject to opinion of
the observers. To minimize this possible confounding
factor, it was decided to pilot the study and to use a
systematic approach, secure consensus between the
evaluators at different stages of data charting, collec-
tion and critical evaluation.46
5. Conclusions and future research directions
There is evidence of progressive interest in the use of
3D anatomy models over the last 6 years as evidenced
from the number of publications. These studies showed
that 3D anatomy models in digital and non-digital
(physical) format are favored by students in medical,
dental and other allied health schools and can be used
to support the curriculum and enhance students skills
in spatial visualization of anatomical relationships.
First, factors affecting learning by using 3D models:
although a few factors have been identied from these
studies, there are a number of factors that need to be
studied. For example, students learning needs, stu-
dents learning style, educational design of 3D model,
digital versus physical models, and effect of training
prior to using 3D models. More important, is to
understand the interactions between learners and 3D
technologies in order to identify potential advantages
and limitations and ideal methods to be used in
assessing the impact of 3D models on learning.
Second, exploring the medium-term and long-term
impacts of learning by using 3D anatomy models. For
example, is learning by using 3D models prepare
students and trainees to surgical procedures. Apart
from the enhancement of students skills in anatomy
performance, what are other skills developed by
learners when they use 3D anatomy models in their
learning?
Third, There is a need for new studies of high
research quality by considering the limitations identi-
ed in this review in their design.
With these recommendations for research in mind,
this review presents a framework with which research-
ers interested in 3D anatomy models will be able to
develop a pedagogical technology to enhance students
learning skills and undertake comparative studies of
research relating to 3D anatomy models and their
impact in undergraduate medical, dental and allied
healthcare curricula.
Conict of interest
The author declare that they have no competing
interest.
Authors contribution
SAA, started the design of the study and its
methodology, SAA and SA searched the databases,
collected the data, analysed the ndings, and created
the two lists, SAA and SA interpreted the ndings,
 S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098
ranked the articles, creation of tables, created the
gures and drafted the manuscript. SAA and SA
contributed to the revision of the manuscript and
approved the nal manuscript for submission.
Funding/support
This work was funded by the College of Medicine
Research Center, Deanship of Scientic Research,
King Saud University, Riyadh, Saudi Arabia.
Acknowledgements
The authors would like to thank Diana Azer for her
assistance and reviewing the manuscript. Also thanks
Dr. Lily Scott for her assistance in this work and Ms.
Mae Eustaquio for her secretarial help.
References
1. Azer SA, Eizenberg N. Do we need dissection in an integrated
problem-based learning medical course? Perceptions of rst- and
second-year students. Surg Radiol Anat 2007;29(2):173180.
2. Berney S, Btrancourt M, Molinari G, Hoyek N. How spatial
abilities and dynamic visualizations interplay when learning
functional anatomy with 3D anatomical models. Anat Sci Educ
2015;8(5):452462.
3. Langlois J, Wells GA, Lecourtois M, Bergeron G, Yetisir E,
Martin M. Spatial abilities of medical graduates and choice of
residency programs. Anat Sci Educ 2015;8(2):111119.
4. Vandenberg SG, Kuse AR. Mental rotations, a group test of
three-dimensional spatial visualization. Percept Mot Skills
1978;47(2):599604.
5. Ullman S. Three-dimensional object recognition based on the
combination of views. Cognition 1998;67(12):2144.
6. Yiannakopoulou E, Nikiteas N, Perrea D, Tsigris C. Virtual
reality simulators and training in laparoscopic surgery. Int J Surg
2015;13:6064.
7. Arksey H, OMalley L. Scoping studies: towards a methodolo-
gical framework. Int J Soc Res Methodol Theory Pract 2005;8:
1932.
8. Reed DA, Cook DA, Beckman TJ, Levine RB, Kern DE, Wright
SM. Association between funding and quality of published
medical education research. J Am Med Assoc 2007;298(9):
10021009.
9. Min H, Morales DR, Orgill D, Smink DS, Yule S. Systematic
review of coaching to enhance surgeons' operative performance.
Surgery 2015;158(5):11681191.
10. Reed DA, Beckman TJ, Wright SM, Levine RB, Kern DE, Cook
DA. Predictive validity evidence for medical education research
study quality instrument scores: quality of submissions to JGIM's
Medical Education Special Issue. J Gen Intern Med 2008;23(7):
903907.
11. Cook DA, Reed DA. Appraising the quality of medical education
research methods: the medical education research study quality
instrument and the NewcastleOttawa scale-education. Acad Med
2015;90(8):10671076.
97
12. McCrae N, Purssell E. Eligibility criteria in systematic reviews
published in prominent medical journals: a methodological
review. J Eval Clin Pract 2015;21(6):10521058.
13. Garg AX, Norman GR, Eva KW, Spero L, Sharan S. Is there any
real virtue of virtual reality?: the minor role of multiple
orientations in learning anatomy from computers. Acad Med
2002;77(10 Suppl):S97S99.
14. Nicholson DT, Chalk C, Funnell WR, Daniel SJ. Can virtual
reality improve anatomy education? A randomised controlled
study of a computer-generated three-dimensional anatomical ear
model. Med Educ 2006;40:10811087.
15. Guillot A, Champely S, Batier C, Thiriet P, Collet C. Relation-
ship between spatial abilities, mental rotation and functional
anatomy learning. Adv Health Sci Educ Theory Pract 2007;12
(4):491507.
16. Hisley KC, Anderson LD, Smith SE, Kavic SM, Tracy JK.
Coupled physical and digital cadaver dissection followed by a
visual test protocol provides insights into the nature of anatomi-
cal knowledge and its evaluation. Anat Sci Educ 2008;1(1):
2740.
17. Levinson AJ, Weaver B, Garside S, McGinn H, Norman GR.
Virtual reality and brain anatomy: a randomised trial of e-
learning instructional designs. Med Educ 2007;41:495501.
18. Marsh KR, Gifn BF, Lowrie Jr. DJ. Medical student retention
of embryonic development: impact of the dimensions added by
multimedia tutorials. Anat Sci Educ 2008;1(6):252257.
19. Donnelly L, Patten D, White P, Finn G. Virtual human dissector
as a learning tool for studying cross-sectional anatomy. Med
Teach 2009;31(6):553555.
20. Hu J, Yu H, Shao J, Li Z, Wang J, Wang Y. Effects of dental 3D
multimedia system on the performance of junior dental students
in preclinical practice: a report from China. Adv Health Sci Educ
Theory Pract 2009;14(1):123133.
21. Oh CS, Kim JY, Choe YH. Learning of cross-sectional anatomy
using clay models. Anat Sci Educ 2009;2(4):156159.
22. Abid B, Hentati N, Chevallier JM, Ghorbel A, Delmas V,
Douard R. Traditional versus three-dimensional teaching of
peritoneal embryogenesis: a comparative prospective study. Surg
Radiol Anat 2010;32(7):647652.
23. Estevez ME, Lindgren KA, Bergethon PR. A novel three-
dimensional tool for teaching human neuroanatomy. Anat Sci
Educ 2010;3(6):309317.
24. Hu A, Wilson T, Ladak H, Haase P, Doyle P, Fung K.
Evaluation of a three-dimensional educational computer model
of the larynx: voicing a new direction. J Otolaryngol Head Neck
Surg 2010;39(3):315322.
25. Codd AM, Choudhury B. Virtual reality anatomy: is it compar-
able with traditional methods in the teaching of human forearm
musculoskeletal anatomy?. Anat Sci Educ 2011;4(3):119125.
26. Keedy AW, Durack JC, Sandhu P, Chen EM, O'Sullivan PS,
Breiman RS. Comparison of traditional methods with 3D
computer models in the instruction of hepatobiliary anatomy.
Anat Sci Educ 2011;4(2):8491.
27. Vuchkova J, Maybury TS, Farah CS. Testing the educational
potential of 3D visualization software in oral radiographic
interpretation. J Dent Educ 2011;75(11):14171425.
28. Bareither ML, Arbel V, Growe M, Muszczynski E, Rudd A,
Marone JR. Clay modeling versus written modules as effective
interventions in understanding human anatomy. Anat Sci Educ
2013;6(3):170176.
98 S.A. Azer, S. Azer / Health Professions Education 2 (2016) 8098
29. Knobe M, Carow JB, Ruesseler, M, et al. Arthroscopy or
ultrasound in undergraduate anatomy education: a randomized
cross-over controlled trial. BMC Med Educ 2012;12:85.
30. Maggio MP, Hariton-Gross K, Gluch J. The use of independent,
interactive media for education in dental morphology. J Dent
Educ 2012;76(11):14971511.
31. Metzler R, Stein D, Tetzlaff, R, et al. Teaching on three-
dimensional presentation does not improve the understanding of
according CT images: a randomized controlled study. Teach
Learn Med 2012;24(2):140148.
32. Nguyen N, Nelson AJ, Wilson TD. Computer visualizations:
factors that inuence spatial anatomy comprehension. Anat Sci
Educ. 2012;5(2):98108.
33. Roach VA, Brandt MG, Moore CC, Wilson TD. Is three-
dimensional videography the cutting edge of surgical skill
acquisition?. Anat Sci Educ 2012;5(3):138145.
34. Ruisoto P, Juanes JA, Contador I, Mayoral P, Prats-Galino A.
Experimental evidence for improved neuroimaging interpretation
using three-dimensional graphic models. Anat Sci Educ 2012;5
(3):132137.
35. Khot Z, Quinlan K, Norman GR, Wainman B. The relative
effectiveness of computer-based and traditional resources for
education in anatomy. Anat Sci Educ 2013;6(4):211215.
36. Tworek JK, Jamniczky HA, Jacob C, Hallgrmsson B, Wright B.
The LINDSAY Virtual Human Project: an immersive approach
to anatomy and physiology. Anat Sci Educ 2013;6(1):1928.
37. Mller-Stich BP, Lb N, Wald, D, et al. Regular three-
dimensional presentations improve in the identication of
surgical liver anatomy a randomized study. BMC Med Educ
2013;13:131.
38. Hoyek N, Collet C, Di Rienzo F, De Almeida M, Guillot A.
Effectiveness of three-dimensional digital animation in teaching
human anatomy in an authentic classroom context. Anat Sci Educ
2014;7(6):430437.
39. Lisk K, McKee P, Baskwill A, Agur AM. Student perceptions
and effectiveness of an innovative learning tool: anatomy glove
learning system. Anat Sci Educ 2015;8(2):140148.
40. Murakami T, Tajika Y, Ueno, H, et al. An integrated teaching
method of gross anatomy and computed tomography radiology.
Anat Sci Educ 2014;7(6):438449.
41. Nguyen N, Mulla A, Nelson AJ, Wilson TD. Visuospatial
anatomy comprehension: the role of spatial visualization ability
and problem-solving strategies. Anat Sci Educ 2014;7(4):
280288.
42. ten Brinke B, Klitsie PJ, Timman R, Busschbach JJ, Lange JF,
Kleinrensink GJ. Anatomy education and classroom versus
laparoscopic dissection-based training: a randomized study at
one medical school. Acad Med 2014;89(5):806810.
43. Bogetz JF, Rassbach CE, Bereknyei S, Mendoza FS, Sanders
LM, Braddock 3rd CH. Training health care professionals for
21st-century practice: a systematic review of educational inter-
ventions on chronic care. Acad Med 2015;90(11):15611572.
44. Scheepers RA, Boerebach BC, Arah OA, Heineman MJ,
Lombarts KM. A systematic review of the impact of physicians'
occupational well-being on the quality of patient care. Int J
Behav Med 2015;22(6):683698.
45. Schutte T, Tichelaar J, Dekker RS, van Agtmael MA, de Vries
TP, Richir MC. Learning in student-run clinics: a systematic
review. Med Educ 2015;49(3):249263.
46. Zendejas B, Brydges R, Hamstra SJ, Cook DA. State of the
evidence on simulation-based training for laparoscopic surgery: a
systematic review. Ann Surg 2013;257(4):586593.
47. Kothari D, Gourevitch MN, Lee, JD, et al. Undergraduate
medical education in substance abuse: a review of the quality of
the literature. Acad Med 2011;86(1):98112.
48. Kirkman MA, Ahmed M, Albert AF, Wilson MH, Nandi D,
Sevdalis N. The use of simulation in neurosurgical education and
training. A systematic review. J Neurosurg 2014;121(2):
228246.
49. Azer SA. The place of surface anatomy in the medical literature
and undergraduate anatomy textbooks. Anat Sci Educ 2013;6(6):
415432.