- Objective To design and evaluate the impact of virtual reality presurgical practice on the performance of actual endodontic microsurgery, and to evaluate the effectiveness of haptic virtual reality (VR) simulator training using microcomputed tomography (micro-CT) tooth models on minimizing procedural errors in endodontic access preparation. Methodology The virtual reality system operates on a laptop with a 1.6 GHz Intel processor and 2 GB of main memory. Volumetric cone-beam computed tomography (CBCT) data was acquired from a fresh cadaveric porcine mandible prior to endodontic microsurgery. Ten inexperienced endodontic trainees were randomized as to whether they performed endodontic microsurgery with or without virtual pre-surgical practice. The virtual reality simulator has microinstruments to perform surgical procedures under magnification. After the initial endodontic microsurgery all participants served as their own controls by performing another procedure with or without virtual pre-surgical practice. All procedures were videotaped and assessed by 2 independent observers using an endodotic competency rating scale (from 6-30). Fourth year dental students underwent a pretraining assessment of access cavity preparation on an extracted maxillary molar tooth mounted on a phantom head. Students were then randomized to training on either the micro-CT tooth models with a haptic VR simulator (n = 16) or extracted teeth in a phantom head (n = 16) training environments for 3 days, after which the assessment 2 was repeated. The main outcome measure was procedural errors assessed by an expert blinded to trainee and training status. The secondary outcome measures were tooth mass loss and task completion time. Results A significant difference was observed between the scores for endodontic microsurgery on molar teeth completed with virtual pre-surgical practice and those completed without virtual presurgical practice; median 24.5 (range =17-28) versus median 18.75 (range = 14-26.5), P = 0.041. A significant difference was observed between the scores for osteotomy on a molar tooth completed with virtual pre-surgical practice and those completed without virtual pre-surgical practice; median 4.5 (range = 3.5-4.5) versus median 3 (range = 2-4), P = 0.042. Post-training performance had improved compared with pre-training performance in error scores in both groups (P < 0.05). However, error score reduction between the haptic VR simulator and the conventional training group was not significantly different (P > 0.05). The VR simulator group decreased significantly (P < 0.05) the amount of hard tissue volume lost on the post-training exercise. Task completion time was not significantly different (P > 0.05) in both groups. Conclusions Pre-surgical practice in a virtual environment using the 3D computerized model generated from the original CBCT image data improved endodontic microsurgery performance. Training on the haptic VR simulator and conventional phantom head had equivalent effects on minimizing procedural errors in endodontic access cavity preparation.