CLICKING INTO PLACE
An interactive patient resource for Temporomandibular Disorder (TMD)
MIRIAM WAITE
DECLARATION
No portion of the work referred to in this thesis has been
submitted in support of an application for another degree or qualification of this or any other university, or institute of learning. The research presented in this thesis is my own, including any mistakes, unless otherwise stated.
COPYRIGHT
Copyright in text of this thesis rests with the author. Copyright
on illustrations, of any form, in this thesis rests with the author. Copies, by any process, either full or of extracts, may be made only in agreement with instructions given by the author and lodged in the University of Dundee Library. Details may be obtained from the librarian. This page must form part of any such copies. Further copies, by any process, of copies made in accordance with such instructions may not be made without explicit permission of the author.
The ownership of intellectual property described herein is
vested with the University of Dundee, subject to prior agreement to the contrary, and may not be made available for use by third parties without the written permission of the University, which will prescribe the terms and conditions of any such agreement. Further information on the conditions under which enclosure or exploitation may take place is available from the Head of the Centre of Anatomy and Human Identification.
CONTENTS Abstract ......................................................................................................................... p1 1. Introduction ............................................................................................................ p2 2. Research context ............................................................................................... p4
2.1 TMJ anatomy and normal function ......................................... p4
2.2 General TMD background ........................................................... p6
2.3 Literature review .............................................................................. p8
3. Methodology ........................................................................................................ p14
3.1 Animations ........................................................................................... p14
3.1.1 3D computer model sculpting ................................ p14
3.1.2 3D animation ..................................................................... p17
3.1.3 3D rotating images ...................................................... p20
3.2 2D anatomy illustrations ............................................................. p21
3.3 iBook ........................................................................................................ p22
4. Results .................................................................................................................... p25
4.1 Patient questionnaire .................................................................. p25
4.2 Specialists’ questionnaire ........................................................ p28
5. Discussion ............................................................................................................. p31
5.1 Data analysis ....................................................................................... p31
5.2 iBooks as an improvement on leaflets ............................. p33
5.3 Future considerations ................................................................. p34
6. Conclusion ............................................................................................................ p36 7. References ........................................................................................................... p38
FIgure 0 - A page from the iBook
ABSTRACT Addressing a perceived comprehension-deficit in patients surrounding their temporomandibular disorder (TMD), an interactive book (iBook) was created for the iPad. This iBook used 2D anatomical illustrations, ‘3D’ explanatory videos and ‘3D’ rotatable images to accompany textual advice, focussing on anterior disc displacement with reduction. Overwhelmingly positive reviews collected from TMD patients following their dental consultation gave strong support for the conclusion that this resource aids understanding of the most common temporomandibular disorder. 1
1 . INT ROD U C T ION
The temporomandibular joints (TMJs) are the points at
which the lower jaw, the mandible, is attached to the temporal bones of the cranium. Being a ginglymoarthrodial joint, the TMJ allows for rotary motion, while also permitting a gliding motion between the articular surfaces. This hinging and sliding action, crucial to the TMJ’s role in mastication, gives the mandible a wide range of movement. Facilitating this movement, by separating the surfaces and reducing friction, is the articular disc. This disc is a biconcave fibrocartilaginous structure situated between the condyloid process of the mandible and the mandibular fossa of the temporal bone. A few muscles and ligaments attach to the disc in order to stabilise it, but in some instances (perhaps due to trauma or hyperextension) this is not wholly sufficient and the disc can deviate from its normal position. This movement of the disc can create discomfort in the jaw and a disconcerting popping, or clicking, sound. Occurring in around 57% of Temporomandibular Disorder (TMD) cases (Manfredini et al. 2010), this anterior disc displacement with reduction is most often benign and resolves itself, but communicating to a patient about what exactly is happening, what should be happening, and how best to look after it can be difficult with just words and twodimensional pictures. Because of this, this project aims to use 3D computer software to create more accessible imagery and incorporate it into an iPad-based patient information resource 2
that should help reassure those afflicted.
IS AN I BOOK
an
effective medium FOR
COMMUNICATIng TMD PATIENT
INFORMATION
? 3
2. RESEARCH CONTEXT 2.1 TMJ ANATOMY AND NORMAL FUNCTION (A CONCISE OVERVIEW; REFERENCING OKESON, 2012, THROUGHOUT)
The joint is located just in front of the ear, where the
condyle of the mandible meets the glenoid fossa of the temporal bone (Fig. 1). Surrounding it are several muscles (Figs. 2 & 3) that open and close the jaw. Only the superior head of the lateral pterygoid muscle has fibres that attach to the disc.
Restricting the joint’s movement are several ligaments,
most notably the capsule and lateral ligaments. The capsule also serves as a container for the fluid in the joint. This fluid is formed within cavities above and below the articular disc, and reduces friction between this disc and the cartilaginous bone coverings. The disc is the most important part of the joint. It is a biconcave fibro-cartilaginous structure that is attached to the surrounding bones via small ligaments to the sides (Fig. 4) and ligament-like strips of collagen (posteriorly) and elastin (anteriorly). Posteriorly the disc is at its fattest, the middle portion is where the pressure is loaded in the disc, anteriorly it is fatter and squashier again. There is no nerve supply directly into the disc, the sensory area is within the retrodiscal tissue, between the posterior disc attachments.
The jaw-opening has two distinct motions: hinging and
sliding (Fig. 5). The hinging motion occurs between the mandible and the disc, the sliding between the disc and the temporal 4
Temporal bone External acoustic meatus
Condyle
Glenoid fossa
Mandible
Figure 1 - Skeletal anatomy of the TMJ
Temporalis
Capsule Lateral ligament
Masseter
Figure 2 - Superficial soft tissues surrounding the TMJ
Articular disc
Synovial fluid
Lateral pterygoid (Superior head) (Inferior head)
Posterior discal extensions Retrodiscal tissue
Anterior discal extensions
Posterior auricular nerve
Figure 3 - Cross section of the joint
5
bone. It is the intra-articular pressure that keeps the disc in its place and not the superior lateral pterygoid or ligament-like extensions, the features that attach to the disc. Figure 4 (left) - TMJ (anterior view). AD, articular disc; CL, capsular ligament; LDL, lateral discal ligament; MDL, medial discal ligament; SC, superior joint cavity; IC, inferior joint cavity (Okeson, 2012)
Figure 5 (above) - Normal TMJ function (Okeson, 2012)
2.2 GENERAL TMD BACKGROUND (REFERENCING OKESON, 2012, THROUGHOUT)
TMDs are very common, with studies finding, on average
40-60% of the population has at least one detectable sign associated with the disorder. Up to 80% of these are women.
With the TMJ being such a complicated joint, there
are several different pathologies that can arise from it, all falling under the diagnostic umbrella of TMD. Sometimes the muscles are affected (myofascial pain), and this pain can seem to come from within the joint; at other times it is the disc or the ligaments which are at fault. Often there are a number of factors involved, complicating the diagnosis.
The most common TMD sees the articular disc slipped
forwards, in the jaws’ resting phase, and making a clicking noise 6
Figure 6 - Anterior disc displacement with reduction (Okeson, 2012)
or feeling as it moves back to the normal position during jaw opening: this is called anterior disc displacement with reduction (Fig. 6). Sometimes another click is heard as the disc slips back to the abnormal position at the end of the jaw-opening cycle.
Due to its multifactorial aetiology, a lot of which is
unknown, TMD is difficult to treat with any universal plan. Most of the time it clears up on its own, but sometimes an anterior repositioning splint can help by bringing the mandible (and by extension the condyle) forward, onto the disc, eliminating the need for reduction. 7
2.3 LITERATURE REVIEW
The current literature available for the explanation of
TMDs, produced by different NHS trusts, essentially follow the same format: firstly, the general anatomy of the joint (showing the disc between the mandibular condyle and the glenoid fossa) is presented using a single black-and-white cross-sectional image (Fig. 7, King’s), although the example from the Cosham hospital is completely image-free; next the symptoms are listed, with emphasis placed on pain, clicking and limited mouth opening; finally there are instructions that the patient can follow to ease the recovery of the joint. Some of the information given is not consistent between the leaflets, one explicitly states that TMDs are “totally benign” (King’s) while another puts it more conservatively, claiming “TMD is rarely a sign of serious disease” [my emphasis] (Oxford). Similarly the pictorial explanations vary in complexity, but none go into any detail as to how the joint works, or include a demonstration of any pathological aetiology. Overall the leaflets seem unconcerned with explaining why and focus on what. Indeed, perhaps indicative of the unconcern for true patient education, the image included in the Oxford Radcliffe Hospitals’ leaflet even mislabels the temporal bone.
Is it worthwhile to provide more detailed information
to patients? Evidence suggests that patients given greater amounts of information about their condition and choices exhibit greater satisfaction with their treatment and adherence to that treatment (Naik, 2012). When it comes to establishing 8
a level of detail, the degree of understanding in the general
population must be thoroughly considered. The subject of ‘health literacy’ has been the subject of many articles, with the strict definition supposedly being hard to establish (Berkman, 2010) and the importance of doing so claimed by more than one author (Berkman, 2010; Nutbeam, 2000; Zarcadoolas, 2005). One possible definition suggested is that health literacy is the “degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions”. It could be argued that the ‘health’ part of ‘health literacy’ is irrelevant and that ensuring clarity of language is universally important in all public communication. What are the temporomandibular joints "VV>Ã > Þ]Ê Ì iÀÊÌÞ«iÃÊ vÊ (TMJs)
treatment can help, such as adjusting the biting surfaces of your teeth, medication or gentle jaw exercises. It is very rare to need specialist dental care (orthodontics) or jaw joint surgery to correct TMJPDS.
• The TMJs are the most complex joints in the body.
! ! ! ! !
work or neighbours are frequent causes, but it could be anything. Anxiety, fear, depression, agitation and tension affect production of chemical messengers in the bloodstream called hormones. These have a number of effects on the body but these include making joints more difficult to move because the joint fluid becomes thicker. For some reason the jaw joint is particularly sensitive. The muscles have to work harder, so they ache. The cartilage inside the joint may even get pulled out of place.
Stress is probably the most important factor, but the others may contribute. How is it treated? Treatments can be divided into general and specific:General Things that can help include heat and massage to the joint and muscles. Simple painkillers, such as Paracetamol are helpful, especially if the condition is mild. Every effort should be made to make your jaw open and close straight up and down without protruding it as it opens.
!
Avoid opening the jaw too widely, especially yawning. Avoid chewing excessively and cut tough food into small pieces. Avoid pushing the jaw into strained positions for any length of time.
!! !! !! ! ! !
Specific
!
Page 2
Splints These may be made from soft or hard plastic. Soft splints are used to try to prevent a teeth clenching or grinding habit or to
• They are located either of thin control muscle spasm. Soft splints on are made from side clear, soft, plastic and are rather like gum shields that sports persons wear. the are head between lower Hard splints similar to braces tothe straighten the jaw teeth, but withoutand wires, skull. except on the back teeth to keep the splint in. They are often effective when the bite is out of balance or if there is a prominent click in the joint, as it helps to reposition the • These are theIfjoints open and then cartilage inside the joint. the bitethat is really unbalanced teeth may occasionally need to be ground down to correct this. If close the jaw. it is severe, the teeth may need to be moved or surgery may be needed, particularly in the younger patient. If you have dentures They for sochewing these• may need are to be essential adjusted or replaced they fit or bite together better.
! !
What can I do? Treatment is based around self care – the more you help yourself, the more effective your treatment.
and are the most frequently used Physiotherapy joints in the body.
UÊ ii«ÊÞ ÕÀÊÌiiÌ Ê>«>ÀÌ°Ê/ iÊV ÀÀiVÌÊÀiÃÌ }Ê« Ã Ì Êv ÀÊÞ ÕÀÊ >ÜÊ ÃÊÌ Ê have your teeth slightly apart and your tongue resting on the floor of your mouth. This allows your jaw and muscles to rest and relax. frequently 9 ÕÀÊÌiiÌ ÊÃ Õ `Ê ÞÊÌ ÕV ÊÜ i ÊÞ ÕÊ>ÀiÊV iÜ }]ÊÃÜ> Ü }Ê> `Ê gets better of its own accord. sometimes speaking. Medication UÊ Û `Ê «i }ÊÞ ÕÀÊ ÕÌ ÊÀi> ÞÊÜ `i° ThisItcan divided into pain relievers and muscle relaxants. called facial arthromyalgia (FAM) or temporomandibular is be sometimes Pain relievers (other than simple medications such as UÊ Û `Ê >L ÌÃÊÃÕV Ê>ÃÊV iÜ }ÊÞ ÕÀÊv }iÀ > ÃÊ> `Ê}Õ ° andjoints causes pain affecting the temporomandibular joint dysfunction Paracetamol) are used to treat (TMJD) acutely painful and patients UÊ Û `ÊÃÌÀ> }ÊÞ ÕÀÊ iV Ê> `ÊL>V ÊÜ Ì Ê«À }i`Ê« ÀÊ« ÃÌÕÀi]Êv ÀÊ with signs of inflammation. Muscle relaxants are used to treat and/or the muscles. (TMJ) stiffjoint and painful muscles. Most of surrounding them also tend to relax example, when you are working at a computer or a desk. patients generally and some cause drowsiness. However, because many patients are under stress of some kind, they can benefit UÊ >ÌÊv `ÃÊÌ >ÌÊÞ ÕÊ` Ê ÌÊ ii`ÊÌ ÊV iÜÊ >À`Ê ÀÊv ÀÊ>Ê }ÊÌ i° TMD? from Who this kind gets of medication. Medication would not be used UÊ ÊÜi>ÀÊÌ iÊ >À`ÊL Ìi}Õ>À`Ê vÊÞ ÕÀÊ`i Ì ÃÌÊ} ÛiÃÊÞ ÕÊ i° without a discussion of the benefits and side effects. • It most commonly affects young adults, but can occur in children and UÊ /ÀÞÊÌ ÊÀi`ÕViÊÌ iÊà ÕÀViÃÊ vÊÃÌÀiÃÃÊ ÊÞ ÕÀÊ viÊ vÊ« Ãà L iÊ> `Ê` Ê ÀiÊ Page 3 older people. general physical exercise if you can. This can take the form of exercises, manipulation, ultrasound or heat treatment to the joint and/or muscles. It is often effective when the jaw opening pattern needs correcting or if there is painful muscle spasm. It is also very effective if the cause of the problem Thiswasisanainjury. common, painful condition which
What is TMD?
! ! !
! ! • Women may be slightly more likely to suffer from it than men. Please be patient – 9 out of 10 patients with TMJPDS get Counselling
As stated before, stress is a very important component in many patients. One of the most effective means of help is to • It may people have a understand that youoccur may be in under stress andwho to try to come to terms with it. Many patients feel better as a result of knowing habit. this. It is not always this easy, so skilled counsellors can be employed to help. A few patients even benefit psychotherapy.
better following these simple suggestions. tooth grinding or jaw by clenching
• It may occur when people are stressed or anxious – for example when studying for exams, moving house, or starting a new job.
• It may also affect those in certain occupations, where it is necessary to talk frequently or hold the jaw in an awkward position – for example musicians.
Figure 7 - NHS TMD leaflets (left to right): Queen Alexandria Hospital, Cosham; King’s College Hospital, London; John Radcliffe Hospital, Oxford
4 9
Guidelines for optimising the understandability of leaflets
have been created by the NHS and are available online (NHS, 2010). They include such suggestions as using the active, rather than passive, voice; and using a question and answer format to break up the text. The article ‘Patient information leaflets - the state of the art’ (Kitching, 1990) lists more recommendations for improving the intelligibility of text, agreeing with the NHS on most points. The same article goes on to list guidelines in the correct usage of typographical features, bringing together results from various studies. Contrasting with the NHS’s requirement to use a sans serif font (ideally Frutiger), Kitching claims that such a font actually reduces the rate of comprehension. The references the author cites were taken
Figure 8 - Screenshot of the www.nhs.uk entry on TMD
10
from the 1970s, and so are not very current, whereas there are more recent studies that conclude there is no difference in ease of comprehension between serif and sans serif fonts (Arditi et al 2005); it is font size that matters more, 12pt being better than 10pt. Remarks on the usefulness of illustrations were also presented by this article: the author cites several studies which argue against the use of colour illustrations over simple labelled black and white images. Similarly the use of images in place of text, symbols, are easily misunderstood by their intended, semi-literate, audience. Since this article was published in 1990, it is probably too dated to have explored the benefits of 3D resources that can be produced today.
Often the first port of call for medical information is
the internet (Rasberry, 2014), for laypersons and doctors alike. Increasingly, NHS patient information is delivered electronically, from televised health advice in GPs’ surgeries, to internetbased guidance on www.nhs.uk (Fig. 8). Comparing the patient satisfaction from the use of traditional paper information leaflets with that from computerised animated information, Bader and Strickman-Stein (2003) concluded that the patients ‘overwhelmingly’ preferred the latter. Reinforcing this conclusion that innovative information resources are beneficial to patients’ understanding of their conditions are the findings of Eggers et al (2007) from a similar experiment. Without presenting a convincing counter-argument, Wiljer and Catton question whether patient preference regarding how information is presented should be the deciding factor in leaflet content. 11
They do suggest that multimedia options should be carefully considered for their relative benefits and that gimmicks ought to be avoided, since it is possible that ‘flashier’ is assumed to be ‘better’ without unbiased evidence. It is this author’s opinion that it is important to choose the right ‘gimmick’ for the occasion: for example using 3D images to understand a complex 3 dimensional structure like the TMJ, or developing a computerised patient resource for use on a portable machine like an iPad that can be used like an electronic leaflet.
With 20 million tablet computers being used in the UK
(in 2013 - Dredge 2013), and 59% of them being Apple iPads, it appears that an iPad-based resource would be available to a large proportion of patients. For the remainder of patients it must be considered whether they might be alienated by the technology. In a study from the Journal of Health Communication, 610 patients were posed a series of questions aimed at determining their health literacy level (e.g., “In general, would you say your health is...”) using a touchscreen application which ‘speaks’ the text. Some (14%) patients had never used a computer before, yet 72% of the overall test group rated the application positively.
In addition to this evidence in favour of replacing paper
leaflets with multimedia versions is the financial argument. With cuts in the NHS affecting patient information resources (Campbell et al 2011) it seems pertinent to explore cost-effective solutions. According to Graham et al (2010), that solution is iPad-based: taking figures from Aberdeen Maternity Hospital, 12
the authors determined that in a 4-year cycle, allowing for technological renewal, the cost per person was 26 pence, comparing favourably to paper leaflets.
There is extensive literature available exploring the
benefits of 3D versus 2D for medical education, with most extolling the rewards of the 3D versions. Unfortunately it is harder to find any studies that focus on the education of patients. With digital animations being accepted as being a more engaging educational tool than their textbook counterparts (Tait 2009; Vernon, 2002; Flores 2013), it could be assumed that 3D would be more beneficial to patients. Hermann (2002) assessed patients’ acceptance of 3D computer imaging over textual education and found that they were not averse to having their information delivered this way. Whether that translates to effective learning is unclear.
Also largely unavailable are accurate 3D representations
of the TMJ itself. The vast majority of imagery obtainable comprises 2-dimensional cross-sections of the joint, even supposed ‘3D animations’ only present the information in an unrealistic cross-sectional fashion (see: https://www.youtube. com/watch?v=X5YXuhgiI74). What is available, (del Palomar, 2006; Okeson, 2012) is not available to patients.
13
3 . ME THODOLOGY 3.1 ANIMATIONS 3.1.1 3D Computer model sculpting
Figure 9 - Screenshot of initial skull laser scan taken within ZBrush
A laser scan of a skull (donated by Dundee Dental
School) was imported in .obj format into the 3D modelling software, ZBrush (version 4r6)(Fig. 9). Using the smooth brush, imperfections in the scan were removed. Areas in the model that the laser scan was unable to reach (i.e. in the orbits and nasal cavities) had to be remodelled in ZBrush using the ‘build clay’ brush and the ‘ZAdd’ and ‘ZSub’ functions. In order to create muscle and other soft tissues for later animation, new sphere3D SubTools were appended in the SubTool menu and modelled using the Move brush. 14
Following caucasian tissue depth guidelines (using
knowledge gained from this course’s facial reconstruction series of workshops), the skull was given a face, using the same sculpting methods described above. Eyeballs were created separately and modelled according to an online video tutorial http://vimeo.com/28501320. Being separate from the rest of the model allowed the eyeballs to be assigned a different material to that of the skin.
The models were painted in ZBrush using the polypaint
and Spotlight functions. Texture was added by importing an image of orange peel into Spotlight (as outlined in this online tutorial https://www.youtube.com/watch?v=3Wibt9qhwB8), which projected the hills and troughs of the peel.
As the face model initially had too high a polygon count
(meaning that it would cause a significant delay in rendering the final animation), and the mesh was too disorganised (also increasing render time), the model was taken through a process called ‘ZRemesher’ to reduce the polygon count to about 10% of its original detail (after first leaving a duplicate SubTool with all the messy detail intact). This low-poly mesh was subdivided until the polygon count was back to just over the original; so that when the ‘Project All’ button was pressed, with only the original and new SubTools visible, the new mesh took on all the detail from the original, disordered, mesh.
On a clone of the new, organised, mesh the UV map was
made (using the UV Master plugin). This UV map creates a 2D image representation of the 3D surface so that the computer 15
can understand how to orientate the textures and the user can more easily edit those textures. Once the UV map is in existence, the other maps can be exported using the ‘Multi Map Exporter’ plugin. These other maps being the texture map (the painted detail) and the displacement map (the bumpy detail from the high-poly version of the model for projection onto the low-poly version). The optimum settings can be found Fig. 10.
The beginnings of the animations were also completed
in ZBrush, using its ‘3D layers’ to create ‘Blend Shapes’ for exporting into Maya. When a 3D layer is created for a SubTool (in the ‘Layers’ palette), that SubTool can be resculpted and ZBrush will provide all the intermediary forms between the original SubTool and its resculpted 3D Layer version, so that the morph acts as an animation. An online tutorial (https://www. youtube.com/watch?v=24wiiBVfw7k) explains this technique, and also details how to use the GoZ function within ZBrush to export these Blend Shapes to Maya for further animation. The UV maps and texture maps had to be made for the rest of the SubTools before exporting.
16
Figure 10 Optimum map export settings in ZBrush 4R6. Left to right: general options; displacement map options; mesh export options
3.1.2 3D Animation
With the blend shapes having been imported into Maya
(version 2015), the next stage was to compile them into the three animations. The first step was to create and position the camera from which the animation would be viewed. Next the skin model was superimposed onto the skull. Most textures were imported along with the blend shapes, but for the skin model this had to be done separately by selecting ‘colour attribute’ on the blinn (default material) in the attribute editor and choosing the appropriate file. Also within the attribute editor, the displacement map was assigned to the shader group. In order for the displacement map to display correctly, it was necessary to change the render engine in the render settings
17
Figure 11 - Screenshot of After Effects showing keyframing transitions
window (Window> Rendering Editors> Render Settings) from Maya Software to mental ray.
The first animation begins with the whole model rotating
and the skin (with eyes) disappearing. The disappearances were achieved by keyframing the transparency, specular roll off, eccentricity and reflectivity of the blinn materials at their default values, then keyframing them all at zero after the rotation had finished. If only the transparency is reduced, artefacts from the shininess of the blinn remain in the final render. The eyeballs only differed from the other objects by the initial specular roll off value being set at 1. 18
After keyframing the blend shapes, from within the
blend shape window (Window> Animation Editors> Blend Shape), the animating part of the process was finished. Next the lighting had to be introduced to the scenes. The ambient lighting was created by downloading an HDR image from the internet (http://zbyg.deviantart.com/art/Free-HDR-For-StudioRender-157557355), taking it into Photoshop to reduce the size to 30% and add a 100 pixel gaussian blur to it, and assigning it to the image based lighting node under the indirect lighting tab in the render settings. Three additional directional lights, one blue, one orange, one white, set at 50%, gave the scene a more dramatic appearance.
The animations were rendered out at 1080p with the
alpha channel and imported into Adobe After Effects CC (version 12.2.1.5). The presence of an alpha channel allowed for the background colour to be changed. Labels and title pages (using the Helvetica Neue font in UltraLight) made as .png images with transparent backgrounds in Photoshop and exported across. Most of the labels were transitioned in and out by keyframing the opacity, but the directional arrows for the hinging and sliding of the condyle within the first animation were given radial and linear wipes respectively (fig. 11).
In some places it was necessary to slow down the
action. After Effects has a feature, used extensively in all three animations, called pixel motion blend framing which reduces the judder that results from stretching out the frames longer than 24fps. 19
3.1.3 3D Rotating images
The selected area of the skull model chosen for use as
a moveable 3D image was masked in ZBrush and the rest of the model deleted by first clicking the ‘HidePt’ button under the Visibility menu, then clicking ‘Del Hidden’ from the ‘Modify Topology’ subsection within the Geometry menu. This in turn was UV unwrapped, texture mapped and exported to Maya (fig. 12). Once in Maya, the model was moved to the centre of the grid and everything exported as a .dae (the file format that iBooks Author accepts in its 3D widget). The same was done with the anterior repositioning splint model.
Figure 12 - Creating the .dae file in Maya
20
3.2 2D ANATOMY ILLUSTRATIONS
A screenshot was taken of the skull and skin models from
Maya and imported into Adobe Illustrator CS6 where each of the separate components were outlined using the Pencil, Smooth and Pen tools. For the gradient colouring, the paths were duplicated and the duplicates filled with a flat colour before meshes were applied. Meshes are grids of anchor points which can have colours assigned to them, thereby blending colours between the anchor points. Because the meshes were proving to be difficult to customise precisely, a plugin was downloaded called ‘Mesh Tormentor’ (http://www.meshtormentor.com/) which makes it easier to move the inside anchor points in a complicated mesh. Even with this enabled, the mesh that Illustrator initially lays down within a shape can be difficult to organise. Particularly with the temporalis muscle, the initial anchor points did not follow the desired fan shape. Temporalis’s mesh began as a rectangle and was modified from there (fig. 13), the anchor points being splayed out accordingly.
The inside line work for the muscle fibres was made
with the pencil tool with the stroke profile changed to one with tapered ends. In order to make the fibres blend better with the base mesh’s colour scheme, the stroke’s opacity was reduced to 50% and the colour was darkened and lightened in parts. Because the default for Illustrator is to make each stroke revert back to 1pt stroke weight, uniform width profile and 100% opacity, it was important to deselect the ‘New Art Has Basic Appearance’ option in the Appearance window’s menu. 21
The bone cross-section texture (fig. 14) was made with a
pattern of randomly-sized round paths where the stroke has a linear gradient on it to give the appearance of depth and the fill is a block dark colour. So that the tiles tessellated more convincingly, it was necessary to drag some of the paths a little way out of the master-pattern box and to offset the ‘bricks’ by 1/2.
The disc was given a semi-translucent appearance by
applying an ‘inner glow’ from the ‘Stylize’ section of the ‘Effect’ menu. This looks pixelated unless the size of the image is high enough. The nerve was created by outlining the stroke from the ‘Path’ section of the ‘Object’ menu and uniting the paths from the ‘Pathfinder’ window.
3.3 iBOOK
The opening page of the iBook was created in Photoshop
using a still from one of the animations. First a cooling filter 82 (Image> Adjustments> Photo Filter…) was applied, then a gaussian blur (Filter> Blur> Gausian Blur…) and an iris blur (Filter> Blur> Iris Blur…). In iBooks Author a dark grey, 40% opaque rectangle was placed over the top to highlight the white Helvetica Neue UltraLight text. For the following pages the same image was used, but without the iris blur and with a much stronger gaussian blur. The dark patch from the muscle was lightened with a soft dodge tool because it had too little contrast with the black text (Helvetica Neue Regular). 22
To make the iBook interactive, Three of iBooks Author’s
Figure 13 (left) Mesh creation for the temporalis within Adobe Illustrator
Figure 14 (right) The pattern tiles were staggered to obscure the repetition
widgets were used: Media (for the videos), Interactive Image, and 3D (for the .dae files). The relevant files were just dragand-dropped into the widgets. Finally the whole project was exported to a .ibook format.
23
Figure 15 - The questionnaire given to the patients, with the patients’ responses drawn on. Each patient has been assigned a colour. For legibility reasons, the comments box has remained black.
24
4 . R E S U LT S
Nine TMD patients, having already been seen by a dentist,
were given the iBook in a waiting room of the Dundee Dental Hospital. They were given as much uninterrupted time as they wanted to finish the book but were not left alone with the iPad. In order to get a better idea of the usability of the resource, the patients were not helped if they struggled. One patient in particular was seen to have skipped a whole video accidentally. After the patients had finished with the iBook they were asked to fill in a questionnaire (Fig. 15).
Five specialists were also given the resource to peruse
and a different questionnaire to fill out (Fig. 17). These questions aimed at finding out how to improve the accuracy and efficiency of the resource for a future application, and, since the patients’ opinion on the matter was more relevant, not its usability or understandability.
Generally the responses from both groups were very
positive. The following paragraphs will focus on highlighting noteworthy features within the data.
4.1 PATIENT QUESTIONNAIRE (Fig. 15)
For the patient questionnaire, it is only when the bottom
of the list is reached that the participants start to disagree, and the most common response stops being ‘strongly’ agreeing with the study. One person, although ticking that ‘strongly agree’ box 25
for the ‘overall it was a useful tool’ statement, diverged from the rest of the group at the ‘I would prefer this to a paper resource’, voting firmly in favour of a paper equivalent. Only one other patient did not strongly agree with the statement, although this other patient preferred neither medium.
Importantly, the two statements which received the best
reviews (8 ‘strongly agree’s and 1 ‘agree’ for each of them) were ‘the 3D animations helped my understanding’ and ‘overall it was a useful tool’.
While four patients thought that it would be useful to see
the iBook before seeing the dentist, this item is notable in being the one in which more patients gave a neutral (neither agree nor disagree) than a positive response.
As every participant was female, there can be no
comparisons made on the relationship between gender and reaction to the resource. There was a surprising age bias as well, with the majority of patients (5/9) falling into the 21-30 bracket, and only 1 person each in 4 other categories making it impossible to say anything about the tendencies of the different age ranges.
Not apparent in the questionnaire results are the verbal
observations made to the author regarding the resource. Not everyone wrote down these extra comments, most preferring to express their (positive) opinions in casual conversation after handing back the questionnaire. One patient did admit to having struggled with the iPad’s gesture-based interface but still ticked the ‘strongly agree’ box to register her preference for this 26
medium over a paper leaflet.
There was originally meant to be a series of video
interviews with afflicted patients giving tales of their experiences to reassure new patients. However, due to a reluctance to complicate the resource unnecessarily, these patient experience videos were abandoned; although the related topic remained on the questionnaires. Nevertheless, only 3/9 either did not comment or responded with ‘neither agree nor disagree’.
Figure 16. The waiting room
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4.2 SPECIALISTS’ QUESTIONNAIRE (Fig. 17)
While most of the responses from the specialists were
unanimously positive, there were three main contentious issues: first, whether the resource was ‘too complicated’, with opinions almost equally divided; secondly whether it ought to have a narration or not, a feature which most specialists agreed would be beneficial; and latterly where the resource would be most useful. Interestingly, this final one, an open question (not requiring a yes/no answer) elicited two similar responses: three specialists thought that the iBook should be shown in the surgery, and two after diagnosis. Although only one person suggested in the further comments box that the resource should be made available to patients at home, they were not the only one to verbally communicate this concept.
It was the ‘further comments’ box which was expected
to bring forth the constructive criticism necessary for future development. The suggestion that the resource could be used to teach students was given twice in the feedback and again in verbal communication.
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Figure 17 - The questionnaire for specialists with the responses compiled together. They each were assigned a different colour.
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5 . DI S C U S S I ON
Overall the results from the patients and the specialists
appear to agree that the iBook produced was beneficial to patients, but that there is definite room for improvement.
5.1 DATA ANALYSIS
In total, 20 hours were spent by the author in the waiting
room, waiting to see patients from the TMD clinic; yet only nine patients were available to test the iBook. There was one day where 4 hours went by with no patient-testing. Reasons given were: the clinic was too busy for the dentists to be able to introduce the iBook to the patients; the patients were unwilling; or the dentists deemed the patients unsuitable to comment on or use the resource. This final reason for patient nonparticipation may have skewed the results somewhat because ‘unsuitable’ might have meant that they would have struggled with the concepts or language. In order to properly assess the iBook’s universal applicability, these people’s opinions would be as necessary as the more literates’.
In addition to possible patient-screening, another factor
limiting the evaluation of the resource’s significance is the complete absence of male participants. Although TMDs are more prevalent in the female population (some studies citing a 4:1 ratio - Warren et al 2001, Okeson 2012), having no male patients in the study is a notable drawback. Overall, with the data set being so restricted, no statistical analysis can be 31
conducted.
As the questionnaire had to have been written prior
to the resource being created - in order to ensure it met with ethical approval - the questions were later found to be imperfect to get the feedback desired. For example, it would have been useful to have known what type of TMD the patients had been diagnosed with and whether the patients had used an iBook before. With a further survey of a greater number of patients, these would be useful to aid comparison within the current data set.
Another possible bias stems from the fact that the
patients were browsing through the iBook whilst sat directly next to the author. Although anonymous on the questionnaire, the subjects knew that they could have been being watched, meaning that their answers could have been positively embellished so as not to offend the author. Although this should be taken into consideration, on balance it seems unlikely that out of all 13 people surveyed (patients and specialists together) there would be no apparent negative reactions.
The 3D rotatable images were liked by the patients but
particularly well-received by the specialists. One comment from a patient identified the difficulty in understanding the model’s orientation once it had been moved out of its starting position; whereas a TMD specialist distinguished the ‘The 3D rotatable images were useful’ statement by annotating it with ‘these were excellent’. The disparity is likely to be due to the difference in familiarity with the anatomy between the two 32
groups. The dentists already had a lot of experience with the 2D representations of the joint and were possibly reacting to its novelty and envisaging further applications for the images.
In the results it was commented that 6 out of the 9
patients responded with either ‘strongly agree’ or ‘agree’ to the statement regarding the usefulness of the patient experience videos that were never included in the iBook. There are a few things that this information could mean: perhaps no one read the questions thoroughly, which would impact negatively on the usefulness of the study; it is also possible that the meaning of the statement was misunderstood, which raises the questions whether the other statements were too ambiguous and whether the responses can be trusted or not. Nevertheless, as there was little divergence in the answers, the data are unremarkable.
5.2 iBOOKS AS AN IMPROVEMENT ON LEAFLETS
The obvious advantage of leaflets, currently the most
common method employed by dentists for communication of TMD patient information, over iBooks is their cheap disposability. Although iPads could never be handed out to patients to take home, they are believed to be surprisingly cost-effective for in-clinic communication (discussed in section 2.3). Three of the specialists who were consulted believed that the iBook should be used as a prop for the dentist in the surgery and all agreed that it was an improvement on current TMD literature.
The iBook format allowed for videos and interactive
images to be placed alongside text. The potential gimmicky 33
nature of these features was a concern before the iBook was trialled on patients. However, upon receiving the very positive responses from both groups regarding the usefulness of the 3D aspect of the resource, the ‘gimmicks’ proved the worth of using the electronic, interactive medium of the iBook. The patients commented that the 3D animations were especially helpful in improving their understanding of their condition, justifying the original basis for the project. 2D descriptions of the joint on paper leaflets did not satisfy the patients. As a particular compliment to the concept, the author was told by one of the participants that ‘this is the first time [she had] been able to understand what’s going on’.
5.3 FUTURE CONSIDERATIONS
Three out of five specialists thought that the resource
would benefit from having a narration. The argument for this is that patients with a low literacy level (around 16% of adults in the UK are defined as being ‘functionally illiterate’, i.e. have a reading age below 11 - National Literacy Trust, 2014) would find it easier to follow a spoken rather than a written book. While this may be the case, it could be difficult to implement a narration into the clinical setting. Headphones would need to be provided if the patient were in the waiting room and ambient noises could be overpowering. If the iBook were to remain as an in-clinic resource, the first improvement to its communicative effectiveness could not be the addition of a voiceover. 34
There was some discussion over whether the written
content might be overly detailed and unnecessarily complicated. Although there were no complaints from the patients of it being the case, it has already been discussed (section 5.1) that the less-competent patients may have been screened out of the process, skewing the results. On balance it would be a good idea to simplify the language, to eliminate the need for voiceovers that could accomplish the same goal of increasing understandability.
In response to the patient who commented on the
difficulty in understanding the 3D rotatable images without context, anatomical diagrams should accompany the 3D model (sketched example shown in fig. 18).
Furthermore, as the TMJ was highlighted in an ongoing
PhD project at Dundee Dental School as an area which dental students struggle to understand spatially, it would be a good idea to adapt the resource for student teaching.
Figure 18 - In situ example of a way to contextualise the rotatable image.
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6. CONCLUSION
Overall, the TMD iBook was very well-received by patients
and specialists alike. No firm assertions can be made regarding the resource’s usefulness, due to a small sample size, but feedback suggests that it succeeded in being more a more engaging user experience that standard paper leaflets and improved patients’ understanding of their condition.
It would be interesting, in future research, to see if this
increased TMD comprehension could be tracked to a better clinical outcome, or whether the much-maligned black-andwhite leaflet is sufficient after all.
ACKNOWLEDGEMENTS
Firstly, I’d like to thank the kind patients and dentists
that generously gave their time to this project; Sean the Maya guru for staying past 6 on a Friday to make sure my animation rendered in time; my lovely coursemates for all their words of advice and encouragement; also Andrew, Liz and Clare at the dental school for all their help; finally my excellent supervisors Caroline and Mark. It’s been fab. 36
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Miriam Waite, Medical Art MSc Research Project. 2014
miriamwaite.co.uk