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If You Build It, Will They Come? by Matthew Fortna, DMD

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Ever wonder why some places seem have an abundance of orthodontists, while others do not? If you are not in a city with the reputation of a provider on every street corner, you've certainly heard about them. Why are so many doctors drawn to the same area? Does it really matter where we locate our business? The average orthodontist seems to be doing alright. Forbes Magazine ranks orthodontists in the top five best paying jobs in America. U.S. News & World Report ranked orthodontist as the top, yes numero uno, hidden gem career. According to author Marty Nemko, there are many reasons this is true. Orthodontists get to see their patients over the course of many months or years, and thus can build a relationship with them. He also cited the average annual salary of more than $200,000, according to the Bureau of Labor Statistics. You won't find many orthodontists who disagree with the fact that they have a great job. Few professions allow one to impact a patient's health and self-confidence the way orthodontics does. I believe one frequently overlooked reason for our profession's high rate of satisfaction and success is our thought processes when it comes to planning. We are, by nature and by training, very careful planners. We've carefully mapped out our lives: education, practice location and our lifelong goals. We think a lot. We think about the tiniest of details on a daily basis. One big detail is where exactly to plant ourselves and build a practice that will allow us to deliver a great service, support our families, our interests and hobbies, and make us proud of what we do.

Winning Demographics

We know some of the demographics that are known to support orthodontic practices: population, median income, family size, schools, commercial and residential growth, children between the ages of 11 and 14, large employers with great dental benefits and general dentists who can refer patients to you. These are proven to provide ample support to your practice. We know them. Companies know them. But will the lack of ideal conditions mean you won't be able to build a successful practice, and thus a fulfilling life?

Demographics definitely matter. It makes sense to locate your business in a market that can support your product. Companies make a living on providing demographic studies of localities throughout the world. There's a reason you won't find a BMW dealership in economically challenged areas. They've done their homework. Most companies do. And orthodontists are no exception. We look for areas to sustain our business, and allow it to flourish.

In an interesting study in the American Journal of Orthodontics and Dentofacial Orthopedics, the authors put together a model for evaluating certain key demographics. Using their model, they were able to plug in these zip code characteristics, and make an educated guess if there were orthodontic practices there. They looked at 30,000 zip codes and were correct over 90 percent of the time. They noted that the most key demographics were number of general dentists and population size.

Work Where You Want to Live

Would it be wise to disregard demographic studies and live where you want? It depends on what you desire in your personal and professional life. Fortunately, our motivation is not solely the financial aspect of the business. We deliver healthcare. We are human outside of the office. Many of us have families, and like to enjoy all the things life can offer away from brackets and wires. If people live there, there is a need for orthodontics. Will our services be affordable to everyone? Not by a long shot. But for every bustling city with multiple providers per mile, there are very successful practices beyond city limits, and even beyond the suburban sprawl.

Small towns are terrific supporters of orthodontic practices. You may not find that BMW dealership in my small town, but you will find caring parents who want to give their children the very best life they can. There are not tens of thousands of people banging down the door for braces or aligners. No overflowing upper class. Not an excess of disposable income. But there are plenty of people who want excellent orthodontic care for themselves and their families. They want to be treated well. They appreciate the investment of time and money and are willing to go the extra mile out of their way to get to you. They want what most every parent wants: for their children to benefit from all their hard work and enjoy a better life. If you work diligently and focus your energy on every potential patient, you can very successfully enjoy practicing in a rural area.

Our profession affords us the ability to change lives for the better. Like it or not, your appearance influences your potential. A winning smile can open many doors of opportunity. A great smile is part of a successful interview, whether it be for college, a job or even on a blind date. Right or wrong, the smile is a front door to opportunities for success. Do you think people living outside the city limits want to lead successful lives? Of course they do. We are lucky to be able to provide improved esteem and aesthetics, which can contribute to that success.

If I Buy It, Will They Come?

Purchasing a practice certainly has its advantages. Patients are already coming in and cash flow is appealing. Referral patterns are in motion. The location is likely already known by most everyone in the community. The office is already staffed and fully equipped. To a recent grad or a relocating seasoned doctor, this can be a most attractive option. You can hit the ground running. There are always concerns about the continuation of the success that another doctor has enjoyed for years, but systems are already in place to help you in the transition.

There are disadvantages to this system of practice purchase as well. We've all heard stories of associate orthodontists planning to buy an existing practice, and somehow the relationship falls apart. Plans were made from the outset of the associateship, but details (or egos) got in the way. The outgoing doctor changed his mind. Or the drastically reduced retirement portfolio changed his mind for him. Or the practice valuation process seemed only loosely based on reality, and now the practice sale price is overly inflated. Real estate values can fluctuate as well. Anticipated practice growth may have faltered. Large businesses which were currently supporting the practice well in the past, have relocated operations to another state (or country). Many scenarios exist in which the practice sale, despite contracted, did not happen.

Even if the purchase goes smoothly, there is no guarantee the patients will continue to come. You may be entering referral patterns that have been in place for decades. Sounds good, but these referrals were made to the outgoing orthodontist, not to you. In a smaller locale, personal relationships can become more emphasized. There is a good chance the retiring doctor treated multiple generations, and is even somehow related to some of the population. You are more likely to get the who is this new guy response from the GPs and the parents. You may have to carefully honor existing relationships, and more slowly establish practices and approaches to the community that make you comfortable in your new role.

The Alternative

Building a practice can have some advantages over practice purchase. You are fully in charge of the practice location and all that goes into it. You may choose to rent before you buy with respect to real estate. Certainly in a more rural location, property will be less expensive. Wherever you decide to begin a practice, you might want to start small and make sure the practice will take before building that stand-alone office of your dreams. You can pick and choose the layout of the office, the logo, all the décor, the staff, the chairs, the carts, the technology, the materials … and the list goes on and on.

One big disadvantage is, frankly, that the list goes on and on. There's a lot to manage. Our orthodontic programs, while great for educating us, really fall short in training business managers. How little we actually know about running a practice can be a real eye opening experience. The systems that should be in place for a smooth operation are up to you to create. Fortunately, practice management has become big business. There are many companies fighting each other for the opportunity to make your business more successful. These professionals see the potential in what you do for a living. They know you can be profitable. It is up to you to delegate some practice decisions to others, and focus on what you were trained to do best.

The Bottom Line

What do you do with all of this information? Should you purchase an existing practice? Start your own? Well, it depends on what you want out of your career and your life. If you've chosen your desired place to live, and a practice is for sale, it makes sense to pursue a purchase. If there isn't a practice for sale, then maybe you should create one. If there isn't a practice at all, but the demographics suggest the area can support one, then maybe you should break ground on a new building later this afternoon. And, even if the demographics don't predict traditional success, the location can still be an option. Fortunately, orthodontists all over the United States have chosen all of these pathways and are doing quite well. While this may only cloud the waters of decision-making, I believe it removes some of the pressures of making such a monumental decision. It's going to be fine, whichever road you choose. Now that's a comforting thought.

For me, the opportunity to build a life near family and away from the city won out. My wife and I did our homework regarding the demographics of our town. Most of the numbers suggested that we go elsewhere to be successful, but it depends on your personal definition of success. Forbes and U.S. News & World Report placed strong emphasis on salary in their rankings. In our decision, some intangible statistics entered the picture. We chose a small town that we knew. We knew the people, the places, the potential life we could build. We moved from the hustle and bustle of suburban life to a small town. No longer am I stuck in traffic on the way to work, or stuck in the office every day. We are serving a population that might not otherwise be served with orthodontics. I am really able to get to know my patients and their parents. I see patient smiles at the grocery store, the little league fields, dance recitals, and on stage in the high school musicals. My staff and I are making a difference in this town, and the parents appreciate the care we give and the life changes we help create. My schedule allows me some free time to stop and smell the roses, so that's what I'm doing. Remember, it takes work and is not easy, but if you build it, they will come.


After completing his dental training and residency from the University of Pennsylvania, Dr. Matthew Fortna moved from a Philadelphia suburb to rural Western New York. He established a practice in Fredonia, NY, in 2007. Dr Fortna, his wife, and their four children spend their free time enjoying all the benefits of being part of a wonderful small town community.

Orthotown Magazine
September 2025
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