Getting Up to Speed
On Friday, July 29, 1988, the Federal Deposit Insurance Corp. closed the First Republic Bank Corp. of Texas. Three days later, the bank reopened as an FDIC bridge bank under the name and control of NCNB, a large North Carolina regional banking corporation. This $40 billion rescue was the largest in FDIC history.
But even more amazing to me was that when the doors opened on Monday morning, every bank document and every check in all 113 branches carried the NCNB letterhead and the correct address. This fast-paced metamorphosis was achieved by Clark Check Co. Our daughter-in-law Carol, a middle manager for Clark, told us that high quality and competitive prices are no longer enough to guarantee success in bidding for such contracts. Those qualifications will merely allow you to enter the contest. NCNB's most important need was for speedy delivery.
This is not an isolated instance, but is symptomatic of a fundamental change occurring in American businesses. Citicorp of New York now approves home mortgages in 15 minutes, rather than three weeks or longer. General Electric has speeded up the delivery of custom-made circuit breakers from three weeks to three days. Motorola used to need three weeks to turn around an order for an electronic pager; now it takes two hours. Tom Monaghan, CEO of Domino's Pizza, says, "Our whole business is built on speed." And he furnishes his employees with track shoes so they can take stairs two at a time instead of using the elevator.
All these companies have discovered the competitive advantage of speed. Fast is no longer synonymous with shoddy. Quite the opposite--customers demand that the job be done right the first time, and with full efficiency.
But building an enterprise based on speed means more than simply stepping on the gas. Doing things the same old way, only more so and faster, burns up the equipment and the personnel. The emphasis on speed demands an entirely new qualitative assessment of how and why we do things, along with a new blend of strategy and organization.
Dentistry is not exempt from this consumer-driven revolution. Computer-aided design/computer-aided manufacture (CAD/CAM) have transformed American industry and will probably do the same for dentistry. Five companies are now developing CAD/CAM routines for constructing, in less than an hour, ceramic or metal crowns that fit within 10-15 microns and don't require impressions or models of the teeth. Contrast that to the usual two-to-three-week wait for a cast crown that may or may not fit, and you get a feel for the competitive advantage some dentists will soon gain.
Orthodontists would be wise to take heed, because it is clear that the traditional 18-to-24-month treatment time has deterred significant numbers of potential patients. Dr. Jack Sheridan of the LSU Orthodontic Department sums it up correctly: "If we could treat our patients in three to four months, they would probably pay us a fortune." Maybe not a fortune--but such rapid treatment would certainly enhance our appeal and uncover an entirely new population of patients.
Like manufacturers, orthodontists will have to develop new strategies: a treatment strategy that predicts what the patient and the improved occlusion should look like, and an organizational strategy that tells us how we can make it happen as quickly as possible.
In the past, we've had to rely upon abstract concepts based on mean measurements and a narrow view of "normal". Now, CAD/CAM spin-offs such as video imaging and holography hold the promise of showing the finished case in three dimensions, rather than our two-plane visualized treatment objectives and occlusograms. To me the biggest problem with the VTO, excellent as it is compared to other current diagnostic tools, is the inability to view the complete face.
I've treated several beauty pageant winners over the past 20 years. These truly beautiful young women showed an amazing lack of conformity to facial "norms". Some had such thin, flat lips that--from a cephalometric profile--you wondered how anyone could judge them beautiful. Yet when combined with other facial features, the thin lips didn't detract from the pleasing overall impression.
One of the factors that has slowed down our treatment is our insistence on fitting patients into a very narrow frame of "normal". Any concept of attractiveness based on measured averages simply won't suffice in the future. I'm betting that improved imaging techniques, such as the one described by Guess and Solzer in this issue of JCO, will eventually lead us to a new strategy of more reasonable, individualized treatment objectives and much shorter treatment times.
Certainly, there are some biological restraints to rapid orthodontic treatment, such as the time it takes to close extraction spaces and the control of growth. But when you consider the techniques already available--interproximal enamel stripping and the resulting increase in nonextraction cases; bonding from second molar to second molar; less reliance on permissive appliances and greater use of constant, positive forces such as magnets and nickel titanium coil springs and archwires; the vast improvement in orthognathic surgical procedures--then six-to-12-month therapies don't seem that unattainable.
Knowing exactly what we mean to do before we do it will take on increasing importance as speed becomes a value-added feature of orthodontic treatment. And right now it appears that computer graphics--which began as children's video games--will be the technology that leads us into this new era.