The Three Ms of a Pediatric-Orthodontic Practice: Part 1 by Dr. Daniel Grob

SharePostShareShare
Start Discussion More by this author (7)
Categories: Marketing; Orthodontics; Pediatric; Practice Management, HR and Accounting;


The Three Ms of a Pediatric-Orthodontic Practice: Part 1

by Dr. Daniel Grob

If you are like me, visiting potential referral sources is often a pleasant way to spend some downtime or see how the community is treating orthodontists.

In addition to noting how many general dentists offer Invisalign with a sticker on their door or window, we now must contend with pediatric dentists offering orthodontics or employing an orthodontist. This is not a new concept or necessarily a bad thing.

Back in 2022, the Pacific Coast Society of Orthodontists’ Bulletin1 published the story of an orthodontist and his quest for employment in the 1980s. Inflation coupled with outsourcing of work from American factories made the job market for recent graduates of programs and residencies difficult to navigate. It was not a great time to be an orthodontist!

Young orthodontist Dr. Martin Thurston was one of those struggling. A graduate of a California residency program, he found himself looking for work without much success. Fortunately, he found a pediatric dentist willing to try something new.

Dr. Gordon Dixon offered Thurston the opportunity to work within a pediatric dental practice. At the time, this was not a proven or widely accepted method of practice. The rest is history, as a quick Google search of the practice will disclose a thriving business with the original partners and many others carrying the ball for the foreseeable future.

Currently, this practice model is ubiquitous, especially in hypercompetitive markets.

The benefits are almost too obvious when one takes time to think about the concept. Most patients and doctors appreciate the joint efforts, which include:
  • Continuity of care
  • Built-in referrals
  • Opportunity to collaborate
But not all pediatric/orthodontic practices are the same, with many versions currently in place across the country. These include:
  • Rent sharing
  • Employing either a pediatric dentist or an orthodontist
  • Dual training or spouses
  • True partnership business
  • Fresh start for both specialists
Dr. Dan Bills2 outlined the pros and cons of these arrangements during his address to the American Association of Orthodontists (AAO). The main concerns among all the models are:
  • Varying incomes between providers
  • Shared or separate staff training and utilization
  • Differing overhead between the specialists
  • Reputations of various providers
I have put together the three Ms of an orthodontic/pediatric practice:
  • Marketing: Get the patients
  • Mechanics: Do the work
  • Management: Performance metrics
These Ms do not necessarily eliminate the issues, but they expose them front and center and force the interested parties to address them and, hopefully, take preventive, proactive measures to ensure success.

Marketing
Marketing is the key to building all practices and is undoubtedly first on the list. With so many changing options available to the new practice, how you present yourself to your potential audience comes first in defining your practice. To do this, you need to identify your:
  • Treatment philosophy that guides your decisions
  • Physical facilities to support your philosophy
  • Staff culture
For years, Charlene White3 has identified five key targets of a marketing program that hold true to this day, modified, of course, with advances in social media. Some examples of events and promotions are included below:
  • Individual doctors and practices
    • Personal contact, lunch-and-learns, and the like
  • Parents
    • Promotions for parent treatment, involvement in charities, etc.
  • Patients
    • Sponsorships of events and activities
  • Community, including schools, teams, etc.
    • Visiting schools to explain oral habits while the pediatric dentist is talking cavities; mouthguard events
  • Staff, through team-building exercises and a reward system for advancing the needs of the practice
One might ask how an orthodontic practice appeals to the school-age patient and concerned parent. I have found that the topic of oral habits is a nice complement to the general or pediatric dentist who appears at the local grade or middle school offering tips on brushing teeth and flossing. It’s important to get the teachers, parents, and families involved to help spread the message that habits are a big reason for crooked teeth in the first place.

Collateral
For more than 20 years, I have utilized and written about the Treatment by Twelves (TBT)4 philosophy, which clearly delineates three distinct time points for treatment as well as the four elements of orthodontics responsible for malocclusion, treatment, and relapse.

It all started with a tooth eruption chart, captioned with the help of a pediatric dentist, which has morphed into a suite of brochures and related items that continuously emphasize these elements and facts.

This chart is utilized during the new patient exam, given to referring dental offices for use in the treatment rooms, and serves as an educational piece to explain the various stages of development to parents, patients, and doctors. It is a great training aid as well.

These charts are utilized daily to inform, educate, and hopefully gather the patients into the practice by being handed to patients upon their referral from the pediatric dental practice. In this day of digital everything, I still find many of these pieces valuable in the treatment process.

Systems are then put in place around this collateral, including:
  • Morning huddle with the pediatric practice, where common and future patients are discussed, as well as upcoming debandings and starts
  • Seven-and-up club to keep track of potential patients not yet ready for active care
  • Records that are shared between the orthodontic and pediatric practices
  • Continuous follow-up
I find that speaking in the TBT language helps to train, educate, and treat without confusion. Staff, patients, and other doctors quickly understand the time points of orthodontic care and the associated four elements of malocclusion. I also can’t emphasize enough the importance of a thorough new patient exam5 that reviews systems, findings, and proposed treatment now and into the future.

The Three Ms of a Pediatric-Orthodontic Practice: Part 1
Fig. 1: The delineation between Smile Bones and Jaw Bones is shown on an intraoral image with the teeth clenched. The mucogingival junction approximates this delineation.

The Three Ms of a Pediatric-Orthodontic Practice: Part 1
Fig. 2: Superior convergence is essential to understanding transverse discrepancies: A patient doesn’t need a crossbite to have one.

Mechanics
Now that the patients are arriving and requesting an exam, what to do? I don’t wish to get into the discussion of this appliance or that appliance, or twin vs. self-ligation, but instead mention some topics that will help to make your young-patient practice successful.

First, you need to be comfortable with early treatment, many times leading to what is known as “Phase I,” and the evolving importance orthodontists play in growth and development.

You also need a CBCT X-ray machine and to learn how to read the images and volumes!

That is not a given among practicing orthodontists and is quite rare among pediatric-only practices.

Authors and presenters such as Kravitz,6 Kazmierski,7 and others caution about the frequency and necessity of early or Phase I treatment and have also written editorials and updates regarding expansion, the rules for Phase I treatment, and the like. The public perception is not improved by sensational articles such as one in The Atlantic,8 which offers a one-sided version of palate expansion.

I have elaborated on my decision to make Phase I treatment9 an essential part of practice and have outlined the reasons in published papers.

The typical presentation of a young patient will usually show signs of:
  • Crowding
  • Impactions
  • Class II or III
  • Associated oral habits

The Three Ms of a Pediatric-Orthodontic Practice: Part 1

The Three Ms of a Pediatric-Orthodontic Practice: Part 1

The Three Ms of a Pediatric-Orthodontic Practice: Part 1

Fig. 3: Note the different appearance between siblings sharing the same parents.

Concepts that will help one to understand the etiology and treatment include the following.

The way to simplify for oneself and patients is to draw a distinction between the “Smile Bones” and the “Jaw Bones” (Fig. 1).

I explain that the “Smile Bones” are easily moldable by the patient and orthodontist and are responsible for the look of the smile. The “Jaw Bones” are the hereditary bones that make the patient look like the parents and siblings.

This concept derives from Rose,10 who explains that teeth are not too big, but jaws are too small, often a result of factors such as modern diet and habits.

The transverse dimension is the issue!

McNamara11,12 has detailed the importance of measuring in the transverse dimension.

Also, crossbites are not an indicator of transverse discrepancies! Miner13 described the concept of superior convergence of the posterior dentition, which explains how many transverse issues are not identified because of a lack of a crossbite (Fig. 2).

This feature in malocclusion completely turns upside down the concept of crossbites being a determinant of need for maxillary expansion, one that I subscribed to for years!

Angle’s 1907 textbook14 addresses airway and mouth breathing and helps to explain many of the findings discussed above. As I have indicated in past writings, his observations on airway are often overshadowed by his Class I, II, and III descriptions and in many respects are his most important contribution to the profession.

In my experience, the main role of early treatment, or at least early exams, is to identify and work to eliminate these oral habits. I have written15 about the importance of identifying oral habits as part of an initial examination and being aware of such habits as treatment progresses.

For example, note the images of three siblings, each presenting for an examination (Fig. 3).
  1. The first child is a mouth breather. You can see the narrow smile and empty buccal corridors caused by constant open-mouth posture.
  2. The second has a digit habit. Here, you can see the tipped central incisor smile caused by pressure from nail biting in the anterior part of the mouth.
  3. The third child has essentially no habits. This patient presents with irregularities of the dentition, but note the upright molars and level smile.
These three patients are a great example of the difference between the “Smile Bones” and the “Jaw,” or hereditary, bones.

In summary, early treatment for the most part is delivered or prescribed to:
  • Identify and eliminate habits
  • Correct the damage done from habits
  • Deliver an adolescent with essentially minor irregularities that can be managed in reasonable time with brackets or aligners
Class II and III treatment is done utilizing elastics, fixed correctors, or other mandibular positioners such as a twin block or aligners with bite blocks, bite turbos, or tabs.

The Three Ms of a Pediatric-Orthodontic Practice: Part 1
Fig. 4: The concept of a cosmetic smile is detailed by outlining the various components.

The goal of smile treatment, or Phase II following Phase I, is to create an aesthetic smile as described by Sabri16 and Pitts17 (Fig. 4).

The question is often asked whether this early/late treatment protocol adds to treatment time and expense or prevents later treatment.

In my experience, two-phase treatment may extend “active” care by about one-quarter to one-third, with a corresponding fee increase. However, the benefit to the patient and the resulting ease of completing Phase II care make it a price most patients, parents, and even orthodontists appreciate.

In Part 2, I will cover the third M, management, along with legal and practical considerations of various business arrangements.

References

  1. Panchura J. A pioneer of the pedo-ortho group practice model. PCSO Bulletin. Fall 2022:60–61.

  2. Bills D. Bulletproof your practice through the power of the ortho-pedo relationship. Presented at: AAO Annual Session.

  3. White C. Marketing the Orthodontic Practice [training manual].

  4. Grob D. Treatment by Twelves. Orthotown. October 2013:24–30.

  5. Grob DJ. The pediatric new patient exam. Orthotown.

  6. Kravitz N. Everyone gets an expander. Semin Orthod. 2023;29:171–173.

  7. Kazmierski R. Three conditions to determine the early treatment decision. Orthotown. May 2022.

  8. Engber D. The bones of children’s mouths are being wrenched apart. The Atlantic. January 2026.

  9. Grob D. Phase I treatment. Orthotown. January 2024.

  10. Rose JC, Roblee RD. Origins of dental crowding and malocclusions: an anthropological perspective. Compend Contin Educ Dent. 2009;30(5):292–300.

  11. McNamara JA Jr. Maxillary transverse deficiency. Am J Orthod Dentofacial Orthop. 2000;117(5):567–570.

  12. McNamara JA Jr. Early intervention in the transverse dimension: is it worth the effort? Am J Orthod Dentofacial Orthop. 2002;121(6):572–574.

  13. Miner RM, Al Qabandi S, Rigali PH, Will LA. Cone-beam computed tomography transverse analysis. Part I: normative data. Am J Orthod Dentofacial Orthop. 2012;142(3):300–307.

  14. Angle EH. Treatment of Malocclusion of the Teeth. 7th ed. S.S. White Dental Manufacturing Co.; 1907.

  15. Grob DJ. Oral habits. Orthotown. September 2025:30–37.

  16. Sabri R. The eight components of a balanced smile. J Clin Orthod. 2005;39(3):155–167.

  17. Pitts TR. Bracket positioning for smile arc protection. J Clin Orthod. 2017;51(3):142–156.

Author Bio
Grob Dr. Daniel Grob completed his dental, orthodontic, and prosthodontic training at Marquette University School of Dentistry and has practiced in Tucson, Scottsdale, and Peoria, Arizona, for more than four decades. For the last 10 years, he has worked in a combination practice with a pediatric dentist. As founder of ThePediatricOrthodontist.com, Grob educates orthodontists, dentists, parents, and patients on the benefits of early evaluation and intervention. He is a diplomate of the American Board of Orthodontics, a former editorial director of Orthotown, and a current member of its editorial advisory board.

More In Marketing
AI Marketing Blind Spots Costing Orthodontic Practices New Patients
AI Marketing Blind Spots Costing Orthodontic Practices New...
by Jeff Slater
September 2026
Google Analytics 4: What Dentists Need To Know Now
Google Analytics 4: What Dentists Need To Know Now
Dr. David A. Wank
CE Credits: 1.5
The Human Touch
The Human Touch
by Dr. Susan Blair
September 2024
Why Online Reviews Don’t Work as Expected
Why Online Reviews Don’t Work as Expected
by Tyson Downs
July/August 2026
More In Orthodontics
Are Clear Aligners an Unrecognized Source of Microplastic Exposure?
Are Clear Aligners an Unrecognized Source of Microplastic...
March 2026
Expand Your Reality
Expand Your Reality
Dr. Michael K. DeLuke
CE Credits: 1.5
From Burnout to Breakthrough
From Burnout to Breakthrough
by Dr. Ashley Kisling
December 2025
Phase I Treatment
Phase I Treatment
Dr. Daniel J. Grob
CE Credits: 1.5
More In Pediatric
Beyond OSA—Part 1
Beyond OSA—Part 1
by Dr. Michael K. DeLuke
March 2025
Sensory Processing Disorder and Dental Care: An Overview
Sensory Processing Disorder and Dental Care: An Overview
Lea Morgan, OTR/L
CE Credits: 2.25
The Three Ms of a Pediatric-Orthodontic Practice: Part 1
The Three Ms of a Pediatric-Orthodontic Practice: Part 1
by Dr. Daniel Grob
November 2026
The Tostado Take: The Waiting Years
The Tostado Take: The Waiting Years
by Dr. Julia Tostado
November 2026
More In Practice Management, HR and Accounting
Hiring and Developing Your Team the Right Way
Hiring and Developing Your Team the Right Way
Sheri Kay, RDH
CE Credits: 1.5
Poll: HR and Staffing
Poll: HR and Staffing
July/August 2026
Poll: HR and Staffing
Poll: HR and Staffing
July/August 2024
Real Estate: Real Issues for Starting (and Selling) a Dental Practice
Real Estate: Real Issues for Starting (and Selling) a Dental...
Charles Feitel
CE Credits: 1.5