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Contemporary Orthodontic Workflows: A Panacea for Efficiency?

2023; Elsevier BV; Volume: 29; Issue: 1 Linguagem: Inglês

10.1053/j.sodo.2023.02.002

1558-4631

Nikhilesh R. Vaid, Samar M. Adel,

Dental Education, Practice, Research

We remember a conversation with a senior orthodontic colleague who said, “At this point as we speak, around 10,000 brackets are being bonded and the same number of airplanes are taking off or landing in the world, where do you think we experience more errors- in bracket positions or with the airplanes?” The answer is obvious to most of us! The first flight by the Wright Brothers was on December 17, 1903- approximately around the same time when the specialty of Orthodontics was finding its feet. The relatively error-free systems that aviation has adopted have contributed to the consistency with which efficacy is attained in the field. Technology enhances its application and precision manyfold when coupled with structured Workflows, Checklists and Standard Operating Procedures (SOPs). The orthodontic landscape is metamorphosizing itself and the infusion of newer biomaterials, inter-specialty techniques and appliance systems warrants a structured and organized approach to orthodontic efficacy and efficiency.1Sondhi Anoop A management manifesto: standard Operating Protocols and the application of checklists for orthodontic practices.Semin Orthod. 2016; 22 (ISSN 1073-8746): 262-269Abstract Full Text Full Text PDF Scopus (3) Google Scholar,2Vaid N.R. Sabouni W. Wilmes B. Bichu Y.M. Thakkar D.P. Adel S.M. Customized adjuncts with clear aligner therapy: “The Golden Circle Model” explained!.J World Fed Orthod. 2023; 11: 216-225Abstract Full Text Full Text PDF Scopus (7) Google Scholar This issue of Seminars in Orthodontics is dedicated to the orthodontic processes through a “workflow” lens. When digital orthodontic solutions and automated processes are the “nirvana” that our profession is aiming to attain, workflows become integral to almost every single orthodontic procedure; whether clinical, laboratory, management protocol or even publishing scholarly literature. This modality of representation of processes assumes greater significance, especially in light of artificial intelligence algorithms that require structured steps for process management.3Vaid N.R. Artificial Intelligence (AI) driven orthodontic care: a quest toward utopia?.Semin Orthod. 2021; 27: 57-61Abstract Full Text Full Text PDF Scopus (13) Google Scholar The modern history of workflows can be traced to Frederick Taylor and Henry Gantt, although the term itself was not in use during their lifetimes. One of the earliest instances of the term “workflow” was in a railway engineering journal from 1921. It is in the post-war era when the work of W. Edwards Deming and Joseph M. Juran led to a focus on quantifying metrics and systems for total quality management and introduced systems like Six Sigma.4https://en.wikipedia.org/wiki/Workflow. ascessed on 05/02/2023.Google Scholar Deming stated,“If you can't describe what you are doing as a process, you don't know what you're doing”. Profound words that should resonate with every professional. Today, there is a considerable amount of interest in the application of workflow systems for healthcare, and Orthodontics is no exception to the rule. Simply speaking, a workflow is an organized representation of activities that are necessary to complete a task. Each step in a workflow has a specific step preceding and succeeding it, with the exception of the first and last steps. These workflows can be linear, where an outside event initiates the first step; or in a loop structure where the completion of the last step usually initiates the restart of the first step. Workflow management software can generate flowcharts, process maps, geometric symbols and arrows to define relationships. Workflows can be categorized in various ways but at a basic level, they get grouped as either “Sequential” or “Parallel”. A Sequential workflow has a series of steps that happen one after another to complete the task. i.e. Metal Printing in Orthodontics. The workflow progresses along a sequential path based on which rules get triggered. In the Parallel Workflow Approach, a series of steps is tackled concurrently to move the task toward completion. Practice Management Systems and Virtual Consultations employ this approach. At this point, it is also important to understand that workflows can be referred to as process workflow, case workflow or project workflow. A process workflow is for predictable tasks that can be repeatable. i.e. laboratory steps for 3D printing. A case workflow is where you don't know the path to complete the procedure from the start, but the path reveals itself as more data is gathered. Both process and case workflows are quite similar, the key difference between the two is that a case workflow is dependent on human intervention to discern the right path when more data is available. i.e. commencing non-extraction treatment in borderline malocclusions. A project workflow has a structured path similar to process workflows but there will be more flexibility along the way. In theory, a project workflow is good for only one item and might not be reproducible at all times. i.e. orthodontic tooth movement in patients with multiple missing teeth. Though workflows, processes and checklists sound similar, there is a subtle difference between the three.5https://www.process.st/help/docs/difference-workflows-and-runs/accessed on 05/02/2023Google Scholar A workflow only describes the sequence of tasks. A process is also a broader term that encompasses data, reports, notifications and forms required to get a task from start to finish in a structured environment, for example, the workflow for preparing an indirect bonding tray might be the initiator, but the process will also involve selecting the bracket prescription, choosing the bracket manufacturer, choosing the software for print orders, selecting the 3D printing resin material, as well as the 3D printer and many other factors that would be important for the task to be completed. A checklist differs from the workflow in the manner that it is only an elementary version of a workflow. Checklists may work for individuals working on a project but have little value when it comes to efficiency for collaborative working. Also, checklists make it difficult to track items that one might need to go back to at an earlier stage in a workflow. It would be safe to assume that a workflow tool is an enhanced version of an automated checklist. The benefits of using a workflow system are manifold. Firstly, consistency is ensured, which is repeatable and can be measured i.e., indirect bonding systems. It also increases transparency and visibility of steps involved in the task. Procedures can be assigned to many people, and subdivided into smaller tasks (i.e., bonding attachments or performing IPR by auxiliary staff) improving operational resiliency. Another important feature is the ability to see bottlenecks and redundancies and identify ways to automate them. This enables optimization, better productivity and streamlining of processes, saving both time and resources. The challenges to creating and adopting efficient workflow patterns are the ability to reconcile multiple data sources, have timely external audits and create accountability for the processes. For those clinicians who intend to incorporate workflows into their protocols, it is important to understand that workflows work successfully only when adequate collaboration is accounted for. Inability to delegate and not accounting for ad-hoc (taking off attachments for an important social event and then having them put on before the next aligner) requests can cause frustrations and overshooting deadlines. The “Workflow” culture requires our mindsets to transcend the “tick-list” methodology and be more proactive and organized.6Vaid Nikhilesh Is all well with orthodontic care in the private sector?.APOS Trends Orthod. 2014; 4 (May-June): 51Crossref Scopus (2) Google Scholar Vaid did allude to understanding the logical trail and the learning corpus that leads to AI-driven algorithmic solutions in Orthodontics. For most applications, the list of influences and inputs that determine machine actions are still undisclosed.3Vaid N.R. Artificial Intelligence (AI) driven orthodontic care: a quest toward utopia?.Semin Orthod. 2021; 27: 57-61Abstract Full Text Full Text PDF Scopus (13) Google Scholar Data provenance records the history of the creation of a data object, and if this object has been created as a result of a workflow, then recording the history of that creation becomes easier. This allows an understanding of both intermediate and initial data employed to initialize the workflow. The importance of data provenance cannot be underestimated. The complete provenance records for any data facilitate reproducibility in scientific processes. In engineering sciences, provenance challenges workshops have concluded that various systems capture similar information about workflow processes and despite workflows presenting data in different ways, the input variables can be collated for a larger pool.7Bose R. Foster I. Moreau L. Report on the international provenance and annotation workshop, IPAW'06, 3 5 May 2006, Chicago.ACMSIGMOD Record. 2006; 35 (51 53)Google Scholar If all data was stored in a workflow pattern by different research groups around the world, pooling this data to create optimal systems would have become easier. Integrating workflows into educational systems with the advent of digital technology is critical to them becoming commonplace. Cattaneo and Cornelis in this issue have reported four steps to incorporate a fully digital workflow into the orthodontic postgraduate teaching environment.8Cattaneo & Cornelis. https://doi.org/10.1053/j.sodo.2022.12.005Google Scholar This paper should stimulate further thought into creating benchmarks for digital workflows in teaching. Thakkar et al., have discussed a seamless workflow for in-house aligner fabrication through a six steps process by integrating the linear flow of each individual procedure into an efficient process.9Thakkar et al. https://doi.org/10.1053/j.sodo.2023.01.004Google Scholar They emphasize the importance of every team member understanding the overall workflow and specific digital tasks assigned to them. Graf and co-workers explain biomaterials used for 3D metal printing through a workflow process that can reduce errors and improve predictability with practical tips to the reader that might allow additive printing technology to be used chairside with ease.10Graf et al. https://doi.org/10.1053/j.sodo.2023.01.001Google Scholar Wilmes discusses the workflow of TADs use in the anterior palate for expanded options in orthodontics and orthopaedics. The processes have been explained to minimize failure and improve clinical applicability.11Wilmes. https://doi.org/10.1053/j.sodo.2022.12.009Google Scholar Woo et al., have evaluated the clinical performance of automation employed by different digital set-up models. Valuable insights into the effectiveness of different automated digital set-ups, improvement in PAR indices and time efficiency have been deliberated. It is interesting to note that an increased level of automation at this stage does not really lead to time efficiency. However, automated processes are still new to orthodontics and we can expect considerable improvements in times to come.12Woo et al. https://doi.org/10.1053/j.sodo.2022.12.010Google Scholar Adel et al., have traversed through the management of different biomaterials and workflows prescribed for the prevention and treatment of White Spot Lesions (WSLs). The volume of research and newer materials that have been employed in the treatment of WSLs is substantial, however, evidence-based protocols and workflows for WSLs management were limited in scholarly literature and these guidelines will be a valuable tool for clinicians.13Adel et al. https://doi.org/10.1053/j.sodo.2023.01.002Google Scholar Peikar introduces an interesting concept of independent tooth movers on the lingual surfaces of teeth for efficient orthodontic tooth movement. This concept is in its infancy and scholarly literature awaits their data.14Paikar. https://doi.org/10.1053/j.sodo.2023.01.006Google Scholar Kandil and co-workers discuss the SARDAC technique through a biomechanical evaluation, clinical applicability and workflow processes for the same. This seems to be a promising lingual workflow that incorporates TADs placement efficaciously.15Kandil et al. https://doi.org/10.1053/j.sodo.2023.01.003Google Scholar With systematic workflows becoming the order of the day for domain aspects of orthodontic care, it is also important that the way patients perceive and interact with care providers is revisited. Katyal and Vaid introduce “Virtual First” as a new modality for orthodontic consultations. Detailed workflows for the same have been deliberated in this issue.16Katyal & Vaid. https://doi.org/10.1053/j.sodo.2023.02.001Google Scholar Newer materials and their introduction into orthodontic processes have been exponential in the last few decades. Researchers around the world do employ testing methodologies to evaluate the properties of these materials. Siriengalakshmi et al., have outlined the scope protocol and different testing apparatuses used for material testing in Orthodontics. This should be a valuable guide for young researchers wanting to embark on material science projects.17Srirenga et al. https://doi.org/10.1053/j.sodo.2022.12.011Google Scholar In the biomaterials field, there has been an increased interest in nanotechnology, Padmanabhan charts the application, current status and futuristic applications of nanotechnology in Orthodontics.18Sridevi. https://doi.org/10.1053/j.sodo.2023.01.005Google Scholar Nickel Titanium arch-wires are integral to contemporary orthodontic protocols. The Japanese ISW has numerous applications and improved deflection characteristics. Yonemitsu et al., revisit the characteristics and clinical applications of the ISW in orthodontics and its relevance today.19Yonemitsu et al. https://doi.org/10.1053/j.sodo.2022.12.008Google Scholar 3D printing has opened up possibilities like non before. Customization and personalized treatment can today be in the truest sense, employed for all products used in Orthodontics. Panayi explains the concept, design, production, and evidence of in-office 3D-printed custom brackets.20Panayi et al. https://doi.org/10.1053/j.sodo.2022.12.006Google Scholar The latest buzz in materials science is our ability to directly print aligners without having to print models, thereby, increasing efficiency. Panayi et al., discuss the workflow and processes integral to this newest edition in the orthodontists’ armamentarium.21Panayi et al. https://doi.org/10.1053/j.sodo.2022.12.007Google Scholar Ray Kurzweil, the famed American futurist has made some predictions that seemed improbable at the turn of the century. His predictions were based on the law of accelerating returns. The idea is that technology advances exponentially because every advance helps fuel the next one. Simply speaking, in the realm of computing, Moore's law has actually plotted exponential growth and nanotechnology is a reality today. Ray Kurzweil in his book “ The singularity is near”, states that computers will routinely pass the Turing test by 2029.22https://en.wikipedia.org/wiki/The_Singularity_Is_Near. accessed on 05/02/23Google Scholar In the same decade, nanobots will be able to practically cure any disease and heal any wound. Nanobots will also spontaneously create food by reorganizing existing matter. He also predicts that by the 2030s, advancing technology will enable the understanding of the human brain workflow to such a degree that it will be possible to upload someone's neural structure into a robotic body. All predictions are open to interpretation, and technology might grow exponentially to a point where cognitive sciences might not be able to keep pace. However, data processes, workflows and systematizing protocols will still be the order of the day.23Vaid N.R. Digital technologies in orthodontics-an update. Semin Orthod 24 (4), 373–375Google Scholar If we were to peruse orthodontic literature, five years from now, will the contents of this issue of Seminars in Orthodontics, still be relevant? “Que Sera Sera !” Fig 1.