Journal of Clinical Orthodonics
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Nonextraction Treatment in the Mixed Dentition

From time to time, the question arises whether small is better when it comes to the size and complexity of an orthodontic practice. The arguments in favor, which are usually made by operators of small practices, tend to cluster around the orthodontist's satisfaction. A smaller practice is held to be a happier practice because the orthodontist can give more personal and individualized treatment, with less administrative activity. The implication is that this will lead to a higher quality of treatment result, even though there is no evidence that the quality of care necessarily suffers in a large practice.

It appears to me that the question of which mode is better is impossible to resolve. The most that can be said is that they are different. One basis for the difference may be a conscious choice on the part of the orthodontist, based on the belief that a small practice is a more satisfying practice. More often, it may be the result of numerous other factors--inattention to practice building or inability in that area, poor practice management or indifference to it, continuing to practice in a dead or dying orthodontic locale, poor "people skills", unwillingness to delegate. Nevertheless, this does not rule out the possibility of an orthodontist preferring a small practice or becoming disillusioned with a large practice and making a conscious choice to downsize.

In the years prior to World War II, orthodontics was much more of a cottage industry than it is today. Most practices were small. Since state laws prohibited delegation, all of the work was performed by the orthodontist. He (it was almost always "he") made appliances from lengths or spools of wire and coils of band material, and it was also common for the orthodontist to trim models and make retainers and other removable appliances. Of this kind of practice, Vic Benton wrote, "Happiness is being a wire bender". Each orthodontist felt creative in the process of making appliances, but also in the process of making the appliances do his bidding. Since there were few orthodontists and lots of patients, a practice could grow with no special effort on the practitioner's part. The orthodontist became a power center within his small domain; his sense of satisfaction with an orthodontic practice was enhanced by an income beyond his wildest dreams and an independence of everyone and everything that sometimes encouraged and usually survived an indifference to patients and employees.

In that "small" environment, satisfaction could be diverse. For the tinkerer, innovation was a daily occurrence. For the warm personality, it was rewarding to sit with each patient, constructing or adjusting appliances. For the cold personality, it was satisfying that the practice grew without any effort to build relationships with patients and their families. Practice building was not essential, and management amounted to elementary bookkeeping. Orthodontic practice was strictly the practice of orthodontics.

No one thing has created the possibility of increased practice size. Changes in state dental practice acts that permitted extensive delegation of tasks to trained auxiliaries may have been the most important factor, although there is a chicken/ egg aspect to whether more patients caused more delegation or whether more delegation caused more patients. Both may be true, but they needed the permissiveness of the law to make the growth possible in the first place. Among other factors, improvements in technology certainly led to a reduction in patient visits and more predictable courses of treatment. Awareness of the need to organize and systematize practice administration, along with the computerization of all aspects of orthodontic practice, changed the orthodontist's job description from a hands-on solo entrepreneur to a chief executive officer. A cultural emphasis on youth and beauty contributed to an increase in the number of people seeking orthodontic treatment, including adults. The increase in the number of orthodontists was itself a factor, as greater accessibility and more aggressive competition resulted not only in organized practice building, but in various forms of advertising.

For orthodontists who choose not to compete or who are not suited to it, active practice building and management of a large practice are beyond consideration. For them, a small practice offers adequate income and the satisfaction of a more personalized and individualized environment. For competitors with the drive to build and manage a larger practice, there are greater financial rewards plus the satisfaction of being the driving force in a more complex business enterprise.

It is a mistake to argue that a smaller practice is better than a larger practice, or vice versa. Both are satisfying in their own ways to those who pursue them.

ELG

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Fig. 1 Case 1. 10-year-old female with crowding in both arches before treatment.
Fig. 2 Case 1. After 11 months of wearing mandibular lip bumper and eight months of maxillary removable appliance.
Fig. 3 Case 1. Intra-arch elastics from first molars to first bicuspids, worn with headgear to enhance distal drift of first bicuspids.
Fig. 4 Case 1. Elastic from cuspid hook on facebow to maxillary left central incisor and nickel titanium compressed-coil spring in area of maxillary right canine used for midline correction.
Fig. 5 Case 1. Finishing with maxillary .019" × .025" Quadcat wire and interarch elastics.
Fig. 6 Case 1. After 31 months of total treatment.
Fig. 7 Case 2. 11-year-old female with Class II, division 2 malocclusion before treatment.
Fig. 8 Case 2. After 18 months of treatment.
Fig. 9 Case 2. After 26 months of fixed appliance treatment.
Fig. 10 Case 3. 9-year-old male with skeletal Class II malocclusion before treatment.
Fig. 11 Case 3. After 11 months of twin-block appliance therapy.
Fig. 12 Case 3. Distalization of maxillary molars with headgear and removable appliance with finger springs.
Fig. 13 Case 3. After 10 months of using lower lip bumper to capture leeway space for crowded left canine and to correct midline; palatal bar refitted as anchorage unit.
Fig. 14 Case 3. Preadjusted .022" appliances combined with medium elastics across cuspid hooks and intraarch elastics from maxillary first molars to canines.
Fig. 15 Case 3. After 22 months of fixed appliance therapy.
Fig. 16 Case 4. 7-year-old female with skeletal Class II malocclusion before treatment.
Fig. 17 Case 4. Patient at beginning of Phase II, at age 11.
Fig. 18 Case 4. Palatal bar used to correct mesial maxillary molar rotations; lower lip bumper used to capture leeway space and encourage passive uprighting of buccal segments.
Fig. 19 Case 4. Maxillary removable appliance and headgear used to distalize molars.
Fig. 20 Case 4. Maxillary cuspids and bicuspids bonded after 21 months of Phase II therapy. Overjet reduced with intra-arch elastics from first molars to soldered hooks distal to lateral incisors; incisors retracted and intruded with elastics across cuspid hooks on Kloehn facebow.
Fig. 21 Case 4. After 30 months of Phase II therapy

REFERENCES 2

DR. EUGENE L. GOTTLIEB DDS

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