Forty years into his career, Jeffrey Miller, DDS, sold his successful large practice to MyOrthos. He spent his career championing cone beam CT and mentoring the next generation to ensure the profession’s longevity and stability.
By Alison Werner | Photography by Jake Ferentz
Two words come to mind when looking at the career and passions of orthodontist Jeffrey Miller, DDS: longevity and stability.
Over the past 40 years, he has simultaneously built a thriving large orthodontic specialty practice in Maryland with 13 locations and six doctors, while also developing a significant commercial real estate portfolio. And as he looks to the future, he is hard at work advocating for cone beam computed tomography (CBCT) as a superior orthodontic diagnostic tool and mentoring the next generation of orthodontists—all with an eye to ensuring the longevity and stability of the profession as a specialty.
Building a practice and a commercial real estate business
It all started in 1984. Miller was finishing his residency at the State University of New York at Buffalo and wanted to return to his native Maryland to work in the Baltimore area, a region oversaturated with both dentists and orthodontists coming out of local programs—Georgetown University, Howard University, and, Miller’s dental school alma mater, the University of Maryland. The pickings were slim, and he found himself interviewing at several dated practices that did not align with his treatment philosophy. But it was an eye-opening experience at a practice that Miller considered a good fit for him that solidified his path to opening his own practice.
“The orthodontist there told me what he was paying his chairside technicians—between $35,000 to $40,000 a year. Back then, that was a lot of money for a tech. Then I asked him what the starting salary was for me, and he said $25,000,” Miller recalls. Startled by the disparity, Miller asked why the techs would be making more than the doctor. Without hesitation, the practice owner told him the techs were more valuable to the practice than a new doctor just out of residency.
At first, Miller didn’t know what to think. But he knew that he wanted more for his career than settling and feeling undervalued. A fortuitous encounter with a local dental sales rep who knew about an available office space in a good location for an orthodontic practice led Miller to take the first steps to opening his own practice.
Miller signed the lease with the landlord and picked up shifts at a few local practices to supplement his income to afford the buildout and rent on his new practice. He soon opened a second location, renting space from a prosthodontist who only used his office one day a week.
He added an additional three offices after Dr Aaron Schaefer, “of blessed memory,” an older local orthodontist interested in a partnership, contacted him. “Dr Schaefer was worried that if he got sick, there would be no one to cover his office. So, he said, ‘Would you be interested in doing something together?’” said Miller. The two partnered with nothing more than a handshake.
“Dr Schaefer was a mentor to me, such a kind gentleman, and always dressed in a sport coat and tie,” Miller adds.
With his practice growing, and some money in the bank, Miller was able to take advantage of the real estate liquidation resulting from the late 1980s savings and loan crisis, buying a former bank building at a discount. This purchase marked Miller’s first foray into commercial real estate.
Miller’s real estate purchases have been strategic, serving the growth of both his orthodontic practices and commercial real estate portfolio. As he acquired properties, he would sometimes open an orthodontic office at the location, while leasing the remaining vacant spaces. This is primarily how his practice, Orthodontic Associates, grew to 13 locations in Maryland.
Initially, the real estate was managed partially by some of the orthodontic administrative staff that switched “hats” depending on what needed to be done that day. Today, the commercial real estate company has grown to an independent enterprise completely separate from the orthodontic practice. As the real estate company grew, in-house contractors were hired, which has made renovating and opening new orthodontic offices more efficient. And Miller has expanded his real estate interest to Florida, this time working with his son Adam Miller, DDS, who started his own orthodontic practice. The younger Miller now has four offices in the Tampa Bay area, which he operates independently.
Selling to an OSO
Last year, Miller made a major transition, selling his practice to MyOrthos, an orthodontic support organization or OSO. The decision was a practical one. Soon to turn 68, Miller is looking at his next chapter. For now, that still includes direct patient care, but he wanted to have a solid plan for the successful continuation of the Maryland offices. With several orthodontists in the family—including his son, nephews Ben and Joey Fishbein of Fishbein Orthodontics in the Florida panhandle, his niece Katelyn Owen, who currently works at Orthodontic Associates Maryland, and his nephew Zack Miller (currently an orthodontic resident), the assumption would have been for one of them, or one of the other four doctors in the practice to take over. None, however, were interested in taking on the 13-office practice and Miller did not want to break it up and sell it piecemeal.
The MyOrthos transition was fairly seamless, according to Miller, in large part due to Orthodontic Associates’ size. The practice already had an outstanding CEO, T.J. Ross, and had centralized much of its non-clinical operations (centralized administrative functions and sterilization) years before. Normally, once a practice joins an OSO, the existing management would report to an OSO regional director. However, because Orthodontic Associates had a CEO in place and because of its size, the practice’s CEO became the equivalent to an OSO regional director dedicated to the 13 Maryland Orthodontic Associates locations. All the doctors and staff stayed on and became employees of MyOrthos.
Now, there were some changes. Before the sale, for example, if the practice needed a new scanner, they would simply order it that day; now there is a process. But overall, as Miller puts it, “Things are really more the same than they are different.”
And that includes patient care. Miller is aware of those in the industry who claim corporate ownership negatively impacts patient care and he refutes that claim. The claim that the day before selling to an OSO/DSO, it was a quality practice and the day after it is sold, the patient care becomes compromised is untrue, he says. “The quality of the care lies in the hands of the doctor. It’s not the DSO. I still enjoy practicing; I see patients; and I’m still doing what I was doing before I sold. I’m motivated,” he adds. Not to say that there aren’t doctors who check out once they get the check, but that is their choice.
CBCT as an orthodontic diagnostic tool
For Miller, a key component of ensuring both quality patient care and differentiating the orthodontic specialty from the general dentist providing orthodontics, is the use of cone beam CT as an orthodontic diagnostic tool for treatment planning and evaluating finished results.
Opponents of cone beam CT have their arguments. One often heard: It exposes the patient to too much radiation. But Miller, who frequently lectures on the topic, calls that view outdated. “The machines all have low dose settings, and that low dose setting is absolutely fine for all orthodontic purposes. You can even reduce the field of view to further reduce the radiation exposure,” he says, adding that the amount of radiation is comparable to taking a digital pan/ceph.
And then there are those who say the technology is redundant and fail to use it as intended—ie, using new technology to recreate an old 2D technology output. “The majority of orthodontists who are new to cone beam will use it to reconstruct the two-dimensional panorex and cephalometric radiographs which they use to diagnose and treatment plan their cases,” explains Miller. “There’s no benefit in doing that because you’re not really utilizing the diagnostic benefits of a cone beam.”
As Miller describes it, cone beam CT is about looking at individual teeth and the bone housing that supports those teeth. It is not, in his opinion, an extension of cephalometric analysis; it is a different discipline. And it is not about “treating to some average statistical measurement based on a certain homogeneous population of patients.” Instead, it allows the orthodontist, for the first time, to properly visualize the anatomy of the alveolar housing, which, Miller believes, gives the orthodontist the ability to prevent long-term damage by at least attempting to maintain the tooth root within the alveolar housing.
“A cephalometric and a panoramic radiograph are inadequate to properly assess not only the pre-treatment alveolar housing anatomy that supports the tooth root, but also to evaluate the root position of our finished cases,” he says. “So, if we treat a case and think the clinical crowns all look well aligned, but we take a cone beam CT and see they’re well aligned but the roots are out of the bone, what are the consequences of that long term?”
As Miller explains, “Yes, keeping the roots centered in the alveolar housing adds a level of complexity to our treatment planning because it is another consideration, although not new, that could not be visualized using 2D radiographs. For example, if the lower anterior teeth are de-crowded by expanding the intercanine width, changes to the cephalometric angle of the lower incisors may be minimal. A cephalometric/panoramic evaluation is not capable of evaluating canine expansion.”
And for those orthodontists who believe that cone beam CT is a waste of money and time, Miller points out that as orthodontic specialists, “We do not practice in a vacuum. Our patients are mutually shared with other dentists.” Although an orthodontist may not believe CBCT is necessary, his or her patients are likely to have a CBCT taken by the general dentist or other dental specialist. Orthodontic dehiscence pattern is easily recognized on CBCT examination.
“I believe the point is, whether or not the orthodontist believes CBCT is necessary, his or her finished cases are likely to be evaluated by CBCT at some point in the future,” he says. “If you’re evaluating [a case] with 2D, you can have horrible results with a general pattern of dehiscence, and it will look fine from 2D radiographs. You can’t hide it with a cone beam.”
CBCT adoption among orthodontic specialists is on an upward swing. Prices have come down and purchases have gone up. Five years ago, about 10% of orthodontists had a cone beam in their practice, according to Miller’s statistics. Today, it’s about 25%. “I think cone beam CT is what is going to be the diagnostic tool that returns orthodontics back to the specialty arena,” says Miller.
And to do that, Miller believes education around CBCT usage needs to be improved. According to Miller, residency programs generally have an oral maxillofacial radiologist teaching the residents about cone beam CT from a pathology perspective. With few exceptions, says Miller, the use of CBCT as an orthodontic treatment planning tool is not discussed.
Championing mentorship
Miller is passionate that mentorship should be a path after orthodontic residency graduation. Residency alone cannot teach an orthodontist everything. Moreover, as products and technologies emerge and evolve, an orthodontist is always learning and evaluating their treatment philosophy.
Orthodontic learning is a lifetime endeavor. Miller believes the goal of orthodontic residency should be to develop solid foundational principles from which to grow. These fundamental principles along with proper mentorship, can help guide the younger orthodontist to a more successful career, while hopefully avoiding or minimizing common practice mistakes.
“If you ask me what the orthodontic community needs, I think they need a better system of mentoring the younger orthodontist,” he says.
Currently, Miller holds a weekly Zoom call with residents and orthodontists. These sessions focus on discussing all things orthodontics including literature review, treatment planning, and long term stability. Miller says there is an emphasis that treatment decisions are grounded in science.
Miller laments the use of the term “evidence-based treatment” within the orthodontic community, pointing out that the term “wouldn’t exist if non-evidence-based treatment was not prevalent.” But that, he contends, is what has happened.
As Miller explains it, orthodontists are very intelligent people. But the danger is that an intelligent person can figure out a rationalization to pretty much support anything they do, whether appropriate or not. Coupled with this is the confirmation bias that can be found in online peer groups with similar thinking. They enter an echo chamber.
For new orthodontists, navigating all these competing philosophies and opinions can be overwhelming. Add to this the fact that many leave their residencies having heard competing ideas from full- and part-time faculty. Instructor A will tell them to extract the bicuspid, while instructor B will tell them to expand, not extract in reference to the same patient. Normally, residents quickly figure out which instructor to work with in order to assure a certain treatment plan.
“These residents are confused about who’s right and who’s wrong. They’re not sure how to evaluate,” says Miller. And while manufacturers and Facebook groups can have their place, this is where experienced doctors who are interested in evaluating cases and the literature one-on-one or in a small group with younger doctors can be invaluable.
Miller knows the benefits of a mentor firsthand. He is extremely grateful for the mentorship of Dr Schaefer early in his career. He was more recently reminded of the role they can play when he took up beekeeping to relax on the weekends at his Pennsylvania farm.
“I didn’t know anything about bees. So, I joined the York County Beekeeping Society, and I applied for a mentor,” he shares. His mentor is a banker by profession, but he has taught Miller the ins-and-outs of beekeeping. More importantly, Miller can call him when his bees start dying or he’s not getting the right honey yield.
As Miller sees it, the younger orthodontist needs a mentor just as much as the novice beekeeper. How else will the profession and the bees achieve longevity and stability?OP
