by Ari Y. Krug, DMD
The ideal layout solves the problems of traffic, ergonomics, and aesthetics
|Ari Y. Krug, DMD|
Clinical spaces in orthodontic offices are as unique as the providers who treat patients in them. The clinic is the central focus of the office, so many factors need to be considered when designing it to best suit each individual practice. Orthodontic offices are distinct from other dental facilities because orthodontists see a large number of patients with short average appointment lengths. Our patients tend to be younger and, because they may be accompanied by their families, many more people may be in the office than are actually scheduled. While a lot of procedures are done four-handed, there are a relatively large number of delegated tasks done two-handed. Due to these factors, special design considerations for orthodontists are mandated.
To evaluate a proposed design, you need to keep in mind dynamic flow patterns. There is a constant traffic pattern of patients entering and exiting. There are also separate traffic patterns of the clinical staff and orthodontist moving between patients, and of instruments being brought to and from sterilization. According to Joe Ross, an office design specialist at Ross Orthodontic Equipment, if these flow patterns are not coordinated, congestion can occur.1 Slowing down, even by a few seconds per patient, adds up to significantly reducing the number of patients who can be seen and creating potentially significant productivity loss.2
Location and Allocation
|Figure 1: Krug Orthodontics in Lakewood, NJ, uses five chairs in a row. All chairs have views of the full wall of windows. Half walls with frosted glass tops provide privacy for the seated patients while permitting Krug and his clinical staff easy viewing of the entire treatment bay.|
The location of the clinical work area within the overall office space is an important consideration. Ancillary services such as sterilization, laboratory, radiograph, and storage areas should all be within as few footsteps as possible. This can be reduced further by incorporating pass-through windows to the lab or sterilization areas.
Within the empty space that is an unbuilt office, the operatory chairs can be arranged in several configurations. Due to the fast pace of the orthodontic office, few orthodontists have selected to use separate operatory rooms as seen in most general dental offices, rather relying upon some variation of an open bay. The most common chair arrangement is parallel in a row. This design is an efficient use of space and permits the use of any delivery system. This design’s main drawback is that the operators are forced to walk greater distances between chairs; with five or more chairs, this inefficiency can become prohibitive (Figure 1).
A modification of this parallel design is to wrap it around a corner so that the chairs are along two legs of a right triangle; this can cut the distance between the two farthest chairs in half.1 Two parallel rows of chairs arranged back-to-back require more floor space than a single line of chairs, but allow more chairs to be within a reasonable distance (Figure 2).
|Figure 2: Two parallel rows of chairs in the Clarksville, Tenn, office of Cynthia Green, DDS, allow convenient access to the five clinical chairs. The central dispensary permits quick restocking of the chairside units and easy access to infrequently used supplies. A full height partition wall between two chairs gives patients a private treatment setting in these workstations while still permitting full view from the rest of the clinic and easy access for patients and staff.|
Another option is to use a circular arrangement. With this format, there is a central storage/workstation with chairs oriented around in either pinwheel formation or as spokes radiating out from the center. This design allows the operators to circulate within the central area while the patients’ traffic pattern is outside the circle. When the circle incorporates fewer than five chairs, the farthest distance between any two chairs is the least of any design. This design does, however, use at least 20% more floor space than a linear arrangement. With this arrangement there is also circular traffic flow around the feet of the chairs, so patients may have concerns about privacy and feel more exposed when lying back in the chair.1,3
Who’s on Deck?
Many practices incorporate an “on-deck” area to maximize the efficiency of moving patients in and out of the clinical area and to let the clinical staff know which patients are ready.4 It has been argued that the on-deck area has become obsolete; with today’s practice-management software, clinical staff know exactly when patients have arrived and in what order.5 Some design consultants still prefer an on-deck area to save clinical staff from having to retrieve patients from the reception area.1 Nontraditional on-deck areas, such as an arcade game room, can serve the same purpose (Figure 3, below right).
Keep the Flow Going
Unnecessary movements and tasks not only slow down the practice, but can also increase the operator’s fatigue and discomfort. Ergonomic structuring of the clinical work space is essential to maximizing productivity.
|Figure 3: The arcade game room in the Concord, Ohio, office of Aaron Lundner, DDS, MS, provides the benefits of an on-deck area without the tedium of a simple waiting area.|
The most common orthodontic tasks are between the operator and the instrument delivery system; selecting the most appropriate system is vital. Delivery systems can be located behind the operator (rear), to the side, or over the patient (front). Rear delivery systems accommodate both left- and right-handed operators. Unless exclusively doing four-handed procedures6,7 this setup requires the clinician to do a lot of unnecessary twisting and reaching, which are both very fatiguing types of movements.1 When examining patients for symmetry, many orthodontists prefer to sit at the 12 o’clock position, which is not possible with a rear delivery setup unless the entire chair is rotated.2 Although also ambidextrous, over-the-patient delivery systems provide relatively small work surfaces and require the operator to reach excessively for instruments.1,6 Side delivery systems are the most ergonomic and efficient use of space.1 Whether cantilevered from the chair or as a separate unit, the main drawback of these systems is that they are either right- or left-handed.2 Chairside carts may be floor-mounted or on rolling casters, which can be moved subtly for each operator’s comfort.
Seeing the Light
Up to 90% of fatigue in the dental office may be attributed to eye strain,8 so designing an appropriate lighting plan for the clinical space is imperative. Dental task lighting illuminates the mouth with 900 to 1,500 candle power (cp) illumination. While this provides a good, bright illumination of the mouth, switching constantly between this high-intensity light and low-intensity ambient lighting creates eye strain and fatigue.1,9 The ratio of intense task light to ambient light determines the degree of eye strain. Since intense light is needed for illumination in the mouth, the only way to reduce the ratio is to increase the ambient light intensity. Average office ambient light is only about 100 cp, which generates a very high ratio (9 to 15:1). Directed ambient fixtures raise the ambient light level to about 300 cp, so that the ratio drops to the ideal 3 to 5:1.1 Some authors have suggested lowering ceiling heights, using metal halide lighting, and increasing exposure to windows and skylights to achieve the same results.9
Don’t Get Up
Another major source of fatigue and slowdown is the need to get up and walk around during procedures. Chairside units should contain everything that is routinely needed for each patient, while central dispensaries in the clinical space should be limited to storing infrequently used supplies and extras needed to restock the chairside units.1,10 Admittedly, this requires material redundancy at each chair, but the initial material outlay cost is offset by the time savings. Central dispensaries vary greatly from round central islands to wall-side units, and are frequently combined with utility/wash sinks. Traditionally, the rule of thumb was one sink per two chairs,1 but with the increased use of waterless hand sanitizers and nonhydrocolloid impression materials, this number of sinks may be superfluous.
The technology you are using in the clinical area should be reflected in the design. Do you use paper or digital charts, models, radiographs, and photographs? How many computer workstations do you need? Are you doing chairside scheduling? Do you need a printer (or two) in the clinical area? Will the office use wired or wireless networking? The office should have a clear view of what technology is going to be employed in the clinical areas so that the space needed and wiring can all be included in the original plan.
|Figure 4: A frosted glass full-height partition provides Lundner with a private treatment area while still giving easy views of and access to the rest of the clinic bay.|
A practical, ergonomic clinical space must also be comfortable for the patients and have an overall aesthetic appeal. Several design decisions help create the environment that you want. An orthodontic clinic can be either carpeted or hard-surfaced. Carpeting provides a quiet and comforting feel for patients but allows dropped items to get lost or trapped. Hard vinyl, wood, or stone flooring looks clean and is easy to maintain; however, it is much harder on the feet for practitioners who are walking around all day long. If the clinical design calls for rolling chairside units, further consideration of the flooring materials is needed. Color choice in the clinical area goes a long way to creating the desired atmosphere. By selecting high styles and colors for areas that undergo wear and tear (flooring, wall coverings, and upholstery) and more neutral finishes for low-wear items, you can inexpensively change your look as high-wear areas age and ultimately need replacement.11
The orthodontic open bay design can make patients feel vulnerable, so many offices use partitions to divide the bay. Using partition materials such as frosted glass or glass bricks and keeping the height below eye level allows full light transmission and can actually add to the open feeling of the clinical room on the whole, while imparting privacy for the seated patient. All of the benefits of an open bay design are retained with these types of partitions.1 Some offices design cabinetry for partitions, thereby increasing their usefulness; however, access to these cabinets is limited while patients are seated.12 Strategic partition placement can create adult treatment areas and consultation areas within the open bay area. When using a circular chair arrangement, patient exposure is both toward the feet and to the sides; partitions are ineffective with this clinical setup (Figure 4).
Waiting Doesn’t Have to Be the Hardest Part
|Figure 5: Exchanging simple fluorescent light diffusers for sky scene diffusers gives Krug’s patients a view to watch while supine in the chair.|
Most orthodontic offices incorporate features to keep the patients busy and entertained while waiting in the seats and during procedures. This can be accomplished with something as simple as ceiling-mounted posters, or as elaborate as ceiling-mounted televisions, video games, or even eyeglasses-type virtual reality machines. Many offices also choose to have changing visual stimulus and increase ambient lighting by positioning the chairs against a wall of windows. Windows should not be relied upon entirely for this: unless they are facing north, there will be significant periods of sun glare. Consider the planned patient entertainment and decorations prior to finalizing any design, as it may require additional wiring or supports (Figure 5).
Some offices are very family-friendly and welcome accompanying parents, siblings, or friends in the clinic. Other offices prefer that the family wait in the reception areas, only allowing the patients themselves back to the clinical areas. Practices of the former type need clearly delineated areas for family seating so that this increased number of people in the clinic does not interfere with traffic patterns. Many offices use their practice-management software for chairside scheduling; if you plan to do this in your office, welcoming parents into the clinic and having seating for them is a must.
Planning patient flow patterns, ergonomics, technology, aesthetics, and patient comfort into a clinical design prior to construction contributes to a much more unified and functional outcome. If each of these aspects is not considered, efficiency and patient comfort can be unknowingly reduced, while the same work hours may generate much more operator fatigue. Clearly, an exhaustive evaluation is beyond the scope of this article, but understanding the basic design components of a highly functional and aesthetically pleasing clinical work area is essential to evaluating your current arrangement or future construction endeavor.
Ari Y. Krug, DMD, is in private practice in Lakewood, NJ. His areas of research have included curing lights, indirect bonding, distraction osteogenesis, dental bleaching, and chronic inflammation. He can be contacted at
- Author’s conversations with Joe Ross, orthodontic office design and ergonomics specialist, June 2008.
- Hamula W, Brower KA. The 30-second difference. J Clin Orthod. 1999;33:35–44.
- Hamula W. Orthodontic office design operatory. J Clin Orthod. 1978;12:445–450.
- Hamula W. Orthodontic office design on-deck area. J Clin Orthod. 1983;17:50–52.
- Hamula W, Schnaitter D. Computer technology and HIPAA. J Clin Orthod. 2003;37:533–540.
- Hamula W, Hamula DW. Rear delivery system. J Clin Orthod. 1994:28:547–555.
- Sands RH. Operatory design for four-handed orthodontics. J Clin Orthod. 1975:9:371–376.
- Kilpatrick HC. Work Simplification in Dental Practice. Philadelphia, W.B. Saunders, 1964:13.
- Hamula W, Hamula DW. Operatory lighting. J Clin Orthod. 1990;24:567–575.
- Hamula W. Operatory central islands. J Clin Orthod. 1989;23:415–419.
- Slizynski S. The power of image. Orthodontic Cyber Journal. www.oc-j.com/issue6/color.html. Accessed July 17, 2008.
- Hamula W, Hamula DW. Use of dividers. J Clin Orthod. 1995;29:101–105.