Dentofacial Esthetics

From Macro to Micro

David M. Sarver

• Publisher: Quintessence Publishing Co, Inc
• Year: 2020
• ISBN:
  9781647240257
• Edition: 1
• Topic: Medicine
• Subtopic: Dentistry

Orthodontic treatment generally aims to improve the occlusion and smile esthetics of the patient. But the patient's overall facial appearance determines how they look to others, not just their smile. This book dives deep into dentofacial esthetics and teaches you how to evaluate each patient who walks through your door from the macro to the micro, focusing first on the big picture and then working your way to the minute details in order to treatment plan for the best possible outcome. The author's mantra is that "If you don't see it, you won't treat it, " so his goal is to educate dentists and orthodontists about what they should be seeing in order to yield maximally esthetic outcomes, taking into consideration concepts like esthetic balance and smile projection. This book will teach you to see the face and dentition in a different way, guiding you to understand what the problems are, how to think your way through them and put them in a perspective so that you and the patient can agree on the focus of treatment, and then how to choose the most appropriate and effective treatment methods. An invaluable resource for any orthodontist or esthetic dentist.

four

Principles of Systematic Treatment Planning

Principles of Systematic Examination: The Checklist Manifesto

The development of checklists

Checklists are now an important part of professional life, and indeed of everyday life. It’s apparent that mistakes in clinical treatment occur more often than we’d like, because it’s easy for a doctor to fail to plan properly for every eventuality, forget to ask a key question, or, in the stress and pressure of the moment, miss a step, and proper use of checklists is an important tool now in optimizing treatment outcomes. This concept can greatly benefit orthodontists in managing both routine and complex treatment.

The story of checklist development in orthodontics begins in the aviation industry in the late 1930s, prior to World War II. The US government put out bids for an airplane that could carry 10,000 pounds of bombs, foreseeing the possibility that such a plane might be needed to fly to Germany from England and to Japan from outlying islands and be able to return to its originating base. This meant we had to come up with an aircraft that traveled significantly farther, with more weight, at high altitudes, and was responsible for its own defense. The US Army Air Corps held a competition for the contract for airplane manufacturers to build the next- generation of the long-range bomber. One of the competitors was the gleaming aluminum Boeing B-17 Flying Fortress with a design that was acknowledged to be far superior to those of the competition. As Army executives watched the day of the competition, the B-17 test plane taxied onto the runway and took off beautifully. As it rose majestically and impressively, it suddenly stalled, turned, and crashed, killing two of the five crew members.

After an exhaustive postmortem of the causes of the crash, it was determined that the airplane had crashed because of “pilot error.” The investigators concluded that the new plane was substantially more complex than the previous aircraft and its competitors. Among other things, it had four engines, each with its own requirements, and aeronautics that needed constant adjustment. On takeoff, the test pilot had forgotten to release a critical switch. The conclusion? This beautiful and impressive new plane was just too complicated for even a highly experienced test pilot to fly. As a result, Boeing lost the contract, and it appeared the plane was destined to disappear into history. But the Army was still convinced of the technical superiority of the plane, ordered a few anyway, and the airplane eventually proved itself well enough to be the mainstay bomber in World War II. But once it was in production and the war was underway, the US was faced with the task of teaching thousands of civilians how to operate such a complicated machine. Not only were two pilots per airplane required, but so were eight other crew members who were responsible for the many other functions necessary for a successful mission.

In response to this need, checklists were created that were simple and short, fitting on an index card with step-by-step instructions for takeoff, flying, landing, and taxiing. (Today, pilots use digital tablets rather than index cards. This point will have significance later.) The new pilots went on to fly the B-17 so successfully that the Army ordered over 13,000 of them after the onset of World War II. That checklist system changed the course of history and quite possibly the war.

The point is simple: No matter how expert you may be, well-designed checklists can improve outcomes.The airline industry is an excellent example of the success of this methodology. Think about it—as much as we complain about the airlines, in the US you have better than a 99.9999% chance of arriving at your destination safely. This is a better safety record than many dental and medical offices can manage.

I have a friend who is a pilot who will fly me to destinations within reach in his small private plane. As a result, I have seen the checklist system at work up close. It all starts with taking time to research the weather conditions and filing a flight plan. We then go to the airplane and walk around its exterior, and check the tire pressure, make sure the flaps are moving, and check for any water in the gas tank. Once we are in the airplane, he gets out another checklist and checks all the instruments, switches, and everything in the confines of the cockpit. He then calls into the control tower, asking permission to continue out onto the tarmac, and when permission is given, we can then taxi out. When it is our turn to take off, he runs through one final checklist, and then we take off.

Let’s take going from Birmingham to Pensacola, Florida as an example of managing a trip. The flight plan is filed in Birmingham, and our “waypoints” are entered into the system so that progress is carefully mapped out, not only in terms of direction but also speed and fuel consumption and expected time of arrival. These waypoints are subsequently tracked by control towers between Birmingham and Pensacola. For example, once we are nearing the limit of the Birmingham control tower’s communication range, we are then passed off to Montgomery, Alabama, who picks up our flight plan and directs us toward Pensacola. During the flight, we are tracked by radar, but if we did not arrive at the Montgomery waypoint at the generally expected time, it would be a signal that something is not going as expected. In any event, we travel safely until we are far enough south to where Montgomery hands us off to Pensacola, which brings us in to our landing. Once we have taxied to our parking spot, one last checklist is run through for safely closing down the aircraft.

The point is simple: No matter how expert you may be, well-designed checklists can improve outcomes.

Application of checklists in treatment planning

An eloquent advocate of checklist applications to complex medical problems is Dr Atul Gawande, a thoracic surgeon in Boston, Massachusetts, who has written three books documenting his experience in controlling errors and optimizing performance in the operating room, culminating in How to Get Things Right, published in 2009. Those of you who have been in the operating room during a major procedure understand the number of people involved in the entire operation: anesthesiologists, several types of nurses, and technicians who operate special surgical systems, ...