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I’m attending the 2023 British Orthodontic Conference in London and it has been such a fantastic meeting. After dozens of pages of notes, I’ve been copying down questions and topics to review with the orthodontic and pediatric dental residents I teach. I’ve also made a list of areas where I need to rethink my approach, including some really thoughtful questions on third molars and anterior open bite treatment proposed by Dr. Flavia Artese. My excitement continued to increase for direct printing of orthodontic aligners and 3d metal printing after listening to Dr. Simon Graf. The relationship between orthodontic treatment and gingival recession was thoroughly reviewed by Dr. James Andrews and I’ve been blown away by all the speakers, including Drs. Jennifer Galloway, Caroline Mills, Ama Johal, Linda Greenwald and Jason Smithson, who is a true artist when it comes to composite restorations of the peg laterals. Of course, the hands-on TAD placement opportunity with the featured speaker, Dr. Sebastian Baumgaertel, was one of the main draws for the meeting. 

As I sat in awe of these speakers and the BOS with their ability to host a truly remarkable event, I couldn’t help but try and think back and zoom out to the principles and strategies that have served me and our members at Burleson Seminars really well.

One big concept and theme is to step back and ask if we’re being precise or accurate, so I thought I’d include a classic article (and one of our most-requested posts) from the Burleson Seminars archive here and my thoughts below as they pertain to progress in dentistry and orthodontics. And what could be a more appropriate example, while I’m visiting the UK, to use an example from outside our industry than the famous car company, Rolls Royce? Without further ado, here is the original article and then my thoughts below:

Many of you know I’m a big fan of cars, planes, boats, basically anything with an engine. My friend and one of the smartest marketers on the planet, Dan Kennedy, shares my love for classic cars. One of Dan’s classic cars, Dean Martin’s Rolls Royce, made it into our video collection for Excellence in Orthodontics, demonstrating a valuable point of differentiation between the Rolls Royce standard and everything else. If you’ve ever driven or been driven in a Rolls, you understand there simply is no comparison.

Yet, even one of the best automobile manufacturers on the planet occasionally misfires. In 1984, Rolls Royce made the Camargue model. It was an ugly beast of a car. 

True to Rolls Royce engineering, the car was highly precise in every aspect of its manufacture, yet, according to Simon Winchester, author of a brilliant book that examines the difference between precision and accuracy, “those who had commissioned, designed, marketed and sold the car had no feel for the accuracy of their decisions.”

This story, in conjunction with several others I read in Winchester’s book, The Perfectionists: How Precision Engineering Created the Modern World, made me think long and hard about the difference between precision and accuracy, specifically as it relates to orthodontics, my practices, what I teach our members at Burleson Seminars and the future of dentistry and orthodontics.

Precision involves an ideal of meticulousness and consistency. 

Sound familiar? It’s probably what you’ve been chasing your entire career. If you walk around any orthodontic meeting and evaluate the products being sold, topics being discussed, and questions being asked, everything seems to center around precision. How can we treat cases better, faster, with less discomfort, etc. We love to split hairs and measure  fractions of millimeters. It’s what we do. As orthodontists, we are perfectionists. Everything we do centers around being meticulous and consistent. But, are we accurate?

Accuracy implies real-world truth. Sharp shooters can drive bullets or arrows in a close cluster, but if the shots don’t hit the bull’s eye, they are inaccurate. Fine watchmakers can create clocks with second hands that are exact and unvarying, but if the watch isn’t set to the correct time, it’s inaccurate.

Humans (and particularly orthodontists) have a perverse tendency to value precision at the expense of accuracy.

I’ll never forget, many years ago, a mother and her 18 year-old daughter presented in my consultation room with a problem. The girl had been in braces for over five years and the orthodontist, a man I know and respect, had explained to them both that he would not take the braces off because the upper right second molar had not yet erupted. I called him and let him know about the situation. I reviewed the case with a fine-toothed comb. The occlusion was perfect. The marginal ridges were perfect. The esthetics were perfect. The patient was happy. Mom was happy. The bill was even paid in full (not something that impacts my decision to take braces off, but something that does cause some orthodontists to hold patients hostage in “collections purgatory,” something I think is unethical and should never be done). The orthodontist admitted the patient owed nothing but that he felt strongly the case should be finished to perfection. So, away he went, for five years, shooting arrows in a close cluster, in an attempt to be highly precise, and yet missing the target entirely. He valued precision over accuracy. The accurate thing to do (the real-world truth) was to remove the patient’s braces.

I hung up the phone with the orthodontist and went back into the consultation room. I asked mom to sign a records release, which she had already done before arriving in my office. We transferred her care that day and took the braces off immediately. The patient and parent were in tears, but admitted to me that they had tried to tell the previous orthodontist (and three other doctors that wouldn’t listen) what brought them to tears in my office that day:

The following week was the patient’s senior prom and she was horrified at the thought of wearing metal braces to her last big school dance. This patient and her parent were trying to tell the previous perfectionist some real-world truth; that they wanted the braces off; that they would come back later for segmental mechanics in my office and we could erupt the second molar or extract it if we needed to at a later date. I was the first doctor willing to put my perfectionism and precision on the shelf and be accurate with this patient and her mother about what they really wanted.

The Latin root for the word precision means “to cut off” or “trim.” The sense of exactitude only came in the mass production of goods for consumers through machine tools that allowed repeatability. Fine artisans are capable of making exquisitely precise shoes, watches and furniture. Yet, their precision was for the few. Precision only started to profoundly impact society when it was created for the many. This reminds me of orthodontics. We are fine artisans, capable of making exquisitely precise results, but only for the few. The wide majority of the population on this planet has never thought about visiting one of our offices because we’ve been incredibly inaccurate in our approach to solving their problems.

In the age of digital disruption and mass production, orthodontists perpetuate self-hysteria, largely as a function of pathologic perfectionism. Has our hunger for ever-increasing precision become a cult? Have orthodontists sacrificed what patients want for their own self-indulgent perfectionism? What are the virtues of imprecision? 

In Japan, they have a term, “wabi-sabi,” which is the acceptance of imperfection, asymmetry and incompleteness. We’re obsessed today with the perceived worth of precision but at the expense of what?

I know one young lady who is now in medical school. She still has an impacted upper right second molar that hasn’t moved in six years and has no signs of pathology. She promises one day on winter break, she’ll let my friend, the oral surgeon, remove it so she can stop thinking about it. But mostly, she doesn’t think about it. She only remembers the one imperfect orthodontist who finally said “Yes!” and removed her braces before senior prom. She keeps a photo of her gorgeous smile on the dresser and sent my office a Christmas card each year, reminding us how grateful she was that she finally found someone who listened.

At the end of your life, will you look back and smile at hundreds of stories like the one I shared or will you go to your grave, hell-bent on the precision of your efforts while having missed the bull’s eye entirely?

At the 2023 BOS Meeting, I’ve experienced a real sense of trying to hit the bull’s eye for our patients. Maybe the pandemic has forced us all to re-evaluate what is important in our lives and because we survived something horrible together, we’re a little more sympathetic and compassionate towards one another, including our patients and the critically-important role we play in helping them choose what is best for them; serving as their advocate and giving them more autonomy and choice in the appliances we design, outcomes we achieve and treatment timeline. Maybe the real threat of A.I. in orthodontic treatment has forced us to consider a not-too-distant future where patients might not need us as much in the mouth or in the differential diagnosis of their condition and we’re slowly accepting the accurate approach to help more people even if that means at a lower cost per patient. 

Whatever the impetus, it’s inspiring to watch such brilliant colleagues put on a wonderful show, highlighting the best our profession has to offer and do it in a way that seeks accurate truths, not just precision for precision’s sake.

— Dustin S. Burleson, DDS, MBA

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