Reframing orthodontics: Designing accelerated orthodontics by managing error — the BioDigital way: part 3

Dr. Rohit C.L. Sachdeva discusses the journey of error management in clinical practice

The road to wisdom?

Well, It’s plain and simple to express:



And err again

but less

and less

and less”

— Piet Hein from Grooks “The Road to Wisdom”



The key dimensions of quality care that drive the philosophy and practice of Bio-Digital Orthodontics are patient centeredness, patient safety, and clinical effectiveness.1-2 Errors committed during the delivery of care have the highest potential of negatively impacting these quality measures and, as a result, treatment time. Strategic approaches to error management in clinical practice have been substantially neglected by the orthodontic professionals in their pursuit of the holy grail of accelerated orthodontic care.

Figure 1: Various types of images used for care design and planning. Note the CBCT provides information regarding bone, crown, and roots. The OraScan is limited to the crowns and gingival tissue. suresmile® offers the service of merging the CBCT image with the OraScan and 2D extraoral frontal images

A culture of patient safety cannot be practiced without confronting the causes of orthodontic errors and their appropriate management.

This journey of error management in clinical practice can only begin by recognizing the various types and sources of errors and then finding ways to prevent them or, at a minimum, to develop appropriate barriers to arrest their propagation. I have found that errors in clinical practice commonly manifest around what I term the 7 M’s:

  1. Miscommunication
  2. Misdiagnosis
  3. Misplanning
  4. Misprescription
  5. Mismanagement
  6. Misadministration
  7. Misaction

The root cause of these is grounded in deficits of knowledge, inadequate skills, and the violation of rules.

The objective of this paper is to familiarize the reader with the principles, the tools, and the clinical practices that I use and have developed in the service of error-proofing the care of my patients with a focus on managing the 7 M’s. These practices have resulted in shorter treatment times and, more importantly, enhanced patient safety.

Figure 2: suresmile cloud-based total patient management system. Note: suresmile provides 3D printing services. Also STL files of models are available for remote printing at the practice or a laboratory

Principles and practice of error proofing

“We can’t solve problems by using the same kind of thinking we used when we created them.” — Albert Einstein

The strategic and tactical practices to error-proofing  patient care  against the 7 M’s that I present  are based on a bedrock of sound biomechanical principles and, when appropriate, are enabled with the use of 3D-imaging technologies such as CBCT, OraScan (Figure 1), and CAD/CAM technologies offered by the suresmile® total patient care management platform3 (Figure 2). These approaches are discussed below.

Figures 3A-3C: 3A. Note the CBCT image detects the bone fenestrations around the canines but not the gingival recession that can be seen on both the intraoral or OraScan image. 3B. 3D images can be navigated to allow the viewer to see multiple perspectives of the image and gauge depth. As a result, the “hidden” can be seen. Note that the second bicuspid is extruded. This is not seen on the intraoral visible in the intraoral images or from the occlusal perspective of the 3D OraScan. It is clearly visible from the lingual perspective of the OraScan. 3C. The panorex image does not show the dilaceration at the apex of the lower left central incisor. This is seen with the CBCT image

A) Error-proofing against Misdiagnosis

A major thrust of orthodontic diagnosis involves the understanding and delineation of the complex spatial interrelationships between the various anatomical components of the craniofacial complex. Misdiagnosis in orthodontics commonly occurs as a result of perceptual, measurement, and judgment errors. By using 3D images and 3D virtual models of a patient for simulations, such errors may be minimized. Clinical examples of the use of these tools follow.

High-fidelity 3D diagnostic imaging
2D images of patients, such as photographs or the panorex, are commonly used as aids in diagnosis. Unfortunately, such images lack depth and are also prone to projection errors.4 This limits the doctor’s ability to perform a thorough diagnosis for his/her patient. Misdiagnosis leads to incorrect treatment decisions and, as a result, treatment time is negatively impacted. 3D imaging helps overcome these issues. Examples of both the clinical “misses” resulting from 2D images and the benefit of using 3D images in these situations are shown in (Figure 3).

Many of our diagnostic decisions rely upon accurate and precise measurements of the dentition. We are often hampered both by the limitations of the tools we use and our perceptual biases. This is primarily due to a lack of operational definitions for the region of interest and having no common plane of reference to measure against. This leads to inaccurate, unreliable (inter- and intra-operator) measures that result in the incorrect diagnostic assessment of a patient. Autoanalytic tools overcome such limitations and allow for more reliable diagnosis.5 (Figure 4).

Figure 4: Autoanalytic tools offered by suresmile technology allow the automatic measure of various features of interest. Also feature points such as marginal ridges are automatically detected. The doctor can override their location and relocate the points. Also, the ABO discrepancy index and the Bolton tooth size discrepancy index are automatically measured

Interactive diagnosis with simdiagnostics
Currently, we measure the degree of severity of a malocclusion by measuring against a normative age/sex/ethnic-based sample. However, it is equally important to measure the degree of severity of a mal-occlusion based upon the amount and nature of tooth displacement required to achieve the treatment objective (Figure 5). Assessing this measure with conventional tools is difficult. For instance, the assessment of the severity of crowding is affected by a multiplicity of boundary conditions such as arch form, nature of tooth movement, midline, and anatomical constraints. Accounting for all these variables is beyond the capacity of the clinician. The ability to run multiple simulations on a patient’s virtual models and impose upon these models varying boundary conditions provides an elegant solution to this problem (Figure 6). I term this practice simdiagnostics. It is performed quickly and, most importantly, does not put the patient at risk as all the simulations are done virtually. An accurate assessment of the nature and type of planned orthodontic tooth movement allows the operator to design the appropriate appliance system that delivers the appropriate force system to move the teeth. This minimizes “round tripping,” which invariably adds to treatment time.

Figure 5: Simdiagnosis. This patient demonstrates a significant shift (asymmetry) of the mandible to the left. The severity of the dentoalveolar compensation in the lower left buccal segment is difficult to assess with conventional intraoral images. The nature of compensation can be the CBCT when compared to the right side. Quantifying its extent and the nature of the tooth movement to correct it require the ability to both simulate and measure the movement of the tooth to the desired state. In this situation, the lower right first molar was controlled tipped 15° with a center of rotation at the left of the crown tip. This is a difficult movement to accomplish and will take time to correct and require the creative design of a force-driven appliance. Recognition of this patient need can only be done with the aid of simdiagnosis
Figure 6: Simdiagnostics. Simulations allow a quick way to understand the impact of various boundary conditions on the resolution of crowding. In this situation, the impact of choosing the natural arch form (Figure 6A) versus the Damon arch form (Figure 6B) is being considered. Note the amount of intersections, a measure of crowding when using both arch forms, is similar. However, more tooth movement will be required to achieve the desired Damon arch form especially in the molar areas. The use of the Damon versus a natural arch form may well be driven by the esthetic needs of the patient but not by efficiency or stability of treatment

B) Error-proofing against Misplanning

Figures 7A-7E: Simplanning. 7A.This patient would have benefited from simplanning prior to the start of treatment. 7B. Note the simulation depicting the non-extraction approach to care clearly demonstrates that such a treatment would result in an bimaxillary protrusion with an anterior open bite This treatment strategy would not be in the best interest of the patient. 7C. Note the similarity between the non-extraction simulation and the clinical result. 7D.An extraction approach to treatment would have been a better approach to treatment. 7E. Mid-treatment the four first bicuspids were extracted. Although the bimaxillary protrusion is resolved, it is apparent that space closure has not been well controlled, resulting in forward tipping of the buccal segments and, especially, the lower right buccal segment. Practicing orthodontic care by a “fly of the wheel” approach is not right patient care and adds to treatment time as well

Misplanning is commonly a result of misdiagnosis and a misguided understanding of the impact of a doctor’s treatment measures on the course and outcome of care. I use two approaches to overcome these limitations.

Proactive care prototyping with simplanning
Prior to beginning active treatment on a patient, I run simulations that model different treatment scenarios to critically evaluate and validate the best “care flight plan” for the patient. This avoids wayfaring or midcourse retractions during the patient’s care journey, allowing for the promotion of patient safety and less wasteful practices. As a result, treatment time is compressed (Figure 7).

A very important aspect of care planning resides in a doctor’s ability to determine the prognosis of treatment. This requires that the clinician be skilled in forecasting the potential “fault lines” or risks associated with the treatment measures and the likelihood of a successful treatment outcome. Simulations provide a very useful method to assess the prognosis of treatment (Figures 8-10). Accurate prognostics again saves treatment time since it allows the doctor to proactively recognize the impact of his/her treatment regiments and design appropriate solutions to better  manage  patient care and therefore shorten the care cycle.

C) Error-proofing against Miscommunication

It is not uncommon to observe a dis-connect between the voice of the patient and that of the doctor in terms of treatment needs. Furthermore, this disconnect commonly extends into the larger concentric circle of the care team and interprofessional care collaborators. This leads to conflicting treatment goals and measures, placing the patient at risk, compromising the patient’s care experience, delaying treatment, and potentially hindering the quality of treatment outcomes. One common source of this angst lies in the high signal-to-noise of information shared orally or in the form of abbreviated text in the patient’s notes. Visual communication with simulations, complemented with both the oral and textual mediums, provides a realistic solution to overcome miscommunication.6 A brief description of the approach I use to better communicate among all the stakeholders is provided below.

Figure 8: High-fidelity diagnosis. 2D OraScan and the panorex images are inadequate in demonstrating the exact position of the roots. Note the upper right mesiolingual resides between the distobuccal and lingual root of the upper first molar root. On the panorex, the lower first bicuspid appears to show a root proximity problem with respect to the lower second bicuspid. However, when seen from multiple perspectives of the CBCT image, it is apparent that this is not the case; Figure 9: Simplanning and simprognostics. Correction of the rotation of upper second right molar at the crown level appears to be innocuous. However at the root level, one can clearly see that root collision will be a consequence of the derotation of the molar and put the patient at risk. Patient A.Z. clearly demonstrates that correct diagnosis, planning, and prognostics needed to be integrated in a sequential manner to serve safe patient care

Participatory communication with simcomm
To break the walls of miscommunication between the patient and the care team, a shared “blue space” for all the stakeholders is created. Real-time simulations are used to both design and explain treatment to the patient. This draws the patient into a “show and share” versus “show and tell” mode of communication with the doctor(s). Thinking out loud encourages both the patient’s “buy-in” in terms of his/her care needs and adherence to future requests made by the doctor, such as the wearing of elastics (real time). The virtual visual treatment plan established for the patient is accessible to all members of the care team, bringing concurrence in understanding the goals of care to all stakeholders involved in the care process (Figure 11).

Figure 10: Simprognostics. Alignment of the lower incisors leading to the appearance of black triangles was forecast prior to the start of treatment and discussed with the patient. She declined any more interproximal reduction than that which was required to correct the crowding between the incisors and accepted the black triangles. However, she was very satisfied with the results as she was made aware of this occurrence using simulations at the beginning of treatment and made a personal choice to accept the black triangles; Figure 11: Simcomm. Creating a shared interactive environment around the “blue space” gives the doctor the ability to actively input the patient’s preferences in the design of his/her occlusion. Additional tools for planning the surgical and restorative needs of a patient are used. This facilitates interprofessional communication. I often perform these consult sessions with webinars over the Internet

Orthodontic literacy with patient decision aids
Communication with patients is further facilitated by ensuring they have access to current disease-specific literature that is context-sensitive and caters to cultural diversity.

D) Error-proofing against Mismanagement and Misaction

Continuous active participatory care management with checklists, clinical pathway guidelines and patient care navigation maps with simtracking

A common challenge in managing patient care through the care cycle is that the care team loses sight of treatment goals, leading to clinical inertia or thematic vagabonding7 (Figure 12). This is commonly seen in practices that are busy, where work stress and intensity are high, and where the environment encourages safety violations8 (Table 1). As a result, treatment is delayed, and greater opportunities for failure emerge. Such unwanted practices are contained with the use of checklists and clinical pathway guidelines (Figure 13). Checklists are also used to minimize errors of omission and commission9 (Figure 14).

Figure 12: Thematic vagabonding. Patient has been in treatment for 16 months and shows little progress in treatment over this period
Figure 13: Checklists and clinical pathway guidelines are used to contain errors and prevent clinical inertia
Figure 14: Forgetting to engage an archwire is an error of omission. Not engaging an archwire properly is an error of commission. Checklists are used to engage such errors
Table1: Some factors that can enhance safety violations in an orthodontic practice. (Adapted from Croskerry and Wears, 2002) Croskerry P, Wears RL. Safety errors in emergency medicine. In: Markovchick VJ and Pons PT (eds.) Emergency Medicine Secrets, 3rd Edn..; Hanley and Belfus: Philadelphia, PA, 2002:29-37. Safety violations in practice

Another solution to care inertia involves the creation of patient care navigation maps (PCNMs). These visual simulations show a temporal sequence of the milestone-driven goals of the patient’s care journey. The care team and patient can use PCNMs to track treatment progress (Figure 15). I term this approach to care management simtrack. I also use simtracking to manage patient visits. Patients are provided their PCNMs and asked to self-monitor and assess their care progress against the map. Patients then schedule their care visits based upon the attainment of the planned milestones, allowing for just-in-time care scheduling. Simtracking results in fewer unnecessary patient visits, opening the doctor’s schedule up, decreasing the “busyness” in the clinic, and, in turn, minimizing the risk of operator-induced errors due to a decline in workload intensity. Patients are also encouraged to use PCNMs to detect any untoward or spurious tooth movement and may schedule an appointment immediately to rectify the presenting problem. Such care management practices help contain errors and, most importantly, encourage the patient’s enthusiastic and active participation in his/her own care. Indeed, patient cooperation is vital to achieve a successful outcome.


Orthodontic Misdiagnosis, Misplanning, Miscommunication, and Misaction impact the care cycle and, more importantly, put the patient at risk. Unfortunately, as a profession we have neglected to understand the influence of these care processes on the duration of orthodontic care and develop approaches to mitigate these “misses” consistently. Instead, the current  orthodontic marketplace has addressed the problem of reducing the care cycle by inundating the profession with promises of transformational technologies that claim to accelerate orthodontic tooth movement. Many of these technologies are sold on the basis of having a “biological” foundation to explain their superior performance. Furthermore, in my opinion, these claims are accentuated by marketing tactics that create an echo chamber populated by “the believers” whose ammunition consists of a few isolated clinical patient histories with insufficient documentation. Added justification comes from quoting research whose strength is justified by the fact that it was published by “independent” researchers from an academic center rather than on what really matters — the design of the study and cross validation of the results from multiple centers.

Figure 15: Simtracking. A patient-care navigational map is shown. Patients are encouraged to self-monitor their treatment progress by taking images of their own teeth during the course of treatment and matching it against the map. Care team members also have access to these maps to monitor treatment progress. Such practices create a flat-bed structure, allow for open communication between all stakeholders, and minimize errors

On the other hand, the “nonbelievers” also need to be held to the same standards as the “believers” and subject to the rigors of scientific scrutiny. It is not enough for the nonbelievers just to dismiss the other side without holding themselves accountable. It is my hope that the profession of orthodontics imposes upon itself the habit of self-reflection and recognizes that its sustainability will be driven by focusing on finding the problem first and then the solution rather than trying to fit a solution to a problem. This will also require that the opposing camps refrain from debating each other with the sole purpose of proving the other faction wrong and engage in meaningful conversation that seeks the truth supported by the bedrock of scientific evidence. Only then will we able to practice what I call authentic orthodontics where the interests of the patient supersede personal opinion.

In my next article, I will discuss how I manage errors related to orthodontic therapeutics.

Rohit C.L. Sachdeva, BDS, M Dent Sc, is a consultant/coach with Rohit Sachdeva Orthodontic Coaching and Consulting, which helps doctors increase their clinical performance and assess technology for clinical use. He also works with the dental industry in product design and development. He is the co-founder of the Institute of Orthodontic Care Improvement. Dr. Sachdeva is the co-founder and former Chief Clinical Officer at OraMetrix, Inc. He received his dental degree from the University of Nairobi, Kenya, in 1978. He earned his Certificate in Orthodontics and Masters in Dental Science at the University of Connecticut in 1983. Dr. Sachdeva is a Diplomate of the American Board of Orthodontics and is an active member of the American Association of Orthodontics. In the past, he has held faculty positions at the University of Connecticut, Manitoba, and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 90 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 160 papers and abstracts to his credit. Visit Dr. Sachdeva’s blog on Please contact to access information.


  1. Sachdeva R. Novus ordo seclorum: a manifesto for practicing quality care – part 1. EJCO. 2014;2(3):71-76.
  2. Sachdeva R. Novus ordo seclorum: a manifesto for practicing quality care – part 2. EJCO. 2015;3(1):2-14.
  3. Sachdeva R. Integrating digital and robotic technologies: diagnosis, treatment planning, and therapeutics, In: Graber ML, Vanarsdall RL, Vig KWL, eds. Orthodontics: Current Principles and Techniques. 5th ed. Philadelphia, PA:Elsevier/Mosby; 2012.
  4. Bouwens DG, Cevidanes L, Ludlow JB, Phillips C. Comparison of mesiodistal root angulation with posttreatment panoramic radiographs and cone-beam computed tomography. Am J Orthod and Dentofacial Orthop. 2011;139(1):126–132.
  5. Grünheid T, Patel N, De Felippe NL, Wey A, Gaillard PR, Larson BE. Accuracy, reproducibility, and time efficiency of dental measurements using different technologies. Am J Orthod and Dentofacial Orthop. 2014;145(2):157–164.
  6. Almog D, Sanchez Marin C, Proskin HM, Cohen MJ, Kyrkanides S, Malmstrom H. The effect of esthetic consultation methods on acceptance of diastema-closure treatment plan: a pilot study. J Am Dent Assoc. 2004;135(7):875-881.
  7. Aujoula I, Jacquemin P, RietzscheE, et al. Factors associated with clinical inertia: an integrative review. Adv Med Educ Pract. 2014;5:141–147.
  8. Croskerry P, Cosby K, Schenkel SM, Wears R, eds. Patient Safety in Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
  9. Gawande A. The Checklist Manifesto: How to Get Things Right.London: Profile Books; 2010.
  10. Cash AC, Good SA, Curtis RV, McDonald F. An evaluation of slot size in orthodontic brackets — are standards as expected? Angle Orthod. 2004; 74(4):450-453.
  11. Balut N, Klapper L, Sandrik J, Bowman D. Variations in bracket placement in the preadjusted orthodontic appliance. Am J Orthod Dentofacial Orthop. 1992;102(1):62-67.
  12. Eerkens JW. Practice makes within 5% of perfect: visual perception, motor skills, and memory in artifact variation. Current Anthropology. 2000;41(4):663-668.
  13. Sachdeva R, Bantleon H. Cantilever based orthodontic— biomechanical and clinical considerations. In: Sachdeva RCL, ed. Orthodontics for the Next Millennium. Glendora, CA: Ormco Publishing; 1997.
  14. Fontenelle A. Challenging the boundaries of orthodontic tooth movement.  In: Sachdeva RCL, ed. 14. Root Cause Analysis. Patient Safety World Health Organization. doc:1.10.A
  15. Vaughan D. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. London: The University of Chicago Press; 1996.

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