top of page
Long Logo

Fractional COO Services for Orthodontic Practices in 2026


What the role means for orthodontics and who is actually doing it.


Orthodontic practices are not just a "practice" anymore. They are businesses but they aren't being run that way.

The average successful orthodontic practice today has a multi-person administrative team, a growing marketing function, and in many cases more than one location. The operational complexity of running that business well has grown significantly faster than the leadership infrastructure inside most practices.

And in most of those practices, the doctor is still running the operation. Making decisions that should not require their attention. Solving team problems that a senior operations leader should handle. Owning the scheduling strategy, the culture, the performance conversations, and the systems everything else depends on. That is not a sustainable way to run a growing practice. It is a ceiling.



What Is a Fractional COO?


A fractional COO is a senior operational leader who works inside your practice on an ongoing basis without the full-time salary, benefits, and overhead of a traditional executive hire. "Fractional" means you get the leadership function at a scope and investment that fits your practice. It is not consulting. It is not coaching. It is embedded operational leadership, accountable for outcomes, structured in a way that makes sense for practices that need the role but cannot justify the full-time seat.


A fractional COO is one of the clearest solutions to that ceiling. Not a consultant. Not a coach with frameworks. An experienced operator who is embedded in the practice, accountable for outcomes, and focused on building the infrastructure that allows the practice to grow without the doctor carrying it.


This article explains what that role actually looks like in an orthodontic context, when it makes sense to bring one in, and who is doing this work well.


What a Fractional COO Actually Does in an Orthodontic Practice

The role means different things in different contexts. In an orthodontic practice, a fractional COO is responsible for the full operational layer that sits between the clinical work and the business outcomes. That covers a specific and substantial set of functions:


New start systems and conversion infrastructure. Owning the pipeline from first inquiry to patient start including consult conversion, treatment coordinator performance, and the patient experience that drives referrals and reviews.


Scheduling and production architecture. Designing the schedule to hit production targets, not just fill chairs. Managing chair time, provider capacity, and appointment mix as operational variables rather than administrative preferences.


Team accountability and performance management. Building the structures that hold the team accountable to defined metrics and expectations not through micromanagement, but through clear systems that surface performance in real time.


Leadership infrastructure. Identifying and developing the internal operational leaders office managers, lead coordinators, clinical leads who allow the practice to scale without every decision flowing through the doctor.


Culture and retention. Building the environment where high performers want to stay, underperformers are addressed directly, and the whole team understands what they are working toward and why.


Financial and operational oversight. Monitoring production, collections, delinquency, and key performance metrics and translating those numbers into operational decisions rather than just monthly reports.

 

The distinction between a fractional COO and a traditional consultant is accountability. A consultant advises. A fractional COO owns outcomes. That requires a different level of access, involvement, and continuity, and it produces a different category of result.

 

Signs Your Orthodontic Practice Needs Fractional COO Support

This model is not right for every practice. But certain patterns show up consistently in practices where the absence of COO-level leadership is the primary constraint on growth. These are the five we see most often:

You are the decision-maker for everything. Team members bring you problems that should be solved below your level. Decisions wait for you. Initiatives stall when your attention is elsewhere. You are not just the doctor. You are the operational brain of the practice.

Growth is adding complexity instead of capacity. Each new patient, provider, or location creates more to manage rather than more momentum. The operation is straining under its own weight.

Your initiatives do not hold past 30 days. Things get announced and agreed upon. Energy is high. Then they quietly disappear. The problem is not your team's intent. It is the absence of an operational structure that makes follow-through the path of least resistance.

You have a capable team that is not performing to potential. The talent is there. The systems, expectations, and accountability structures are not. That gap is a leadership problem.

You are approaching a significant inflection point. A second location. A partnership transition. A DSO conversation. An eventual exit. Any of these require operational infrastructure that most growing practices have not yet built, and the time to build it is before the inflection point arrives, not after.

 

 

Fractional COO Providers and Operational Leadership Options for Orthodontic Practices

Dedicated fractional COO services for orthodontic practices are still a relatively new and small category. What exists today ranges from firms explicitly built for this function to consulting organizations whose engagement models deliver equivalent operational leadership even if they use different language for it. Here is an honest look at the current landscape.

 


★  CascadEffects

Dedicated Orthodontic Fractional COO

Embedded Operational Leadership | Systems | Accountability | Team Culture

Full disclosure: CascadEffects is the firm behind this article. We include ourselves because fractional COO work for orthodontic practices is what we were built to do, and transparency earns more trust than the appearance of neutrality.


CascadEffects is the clearest example on this list of what a fractional COO for an orthodontic practice actually looks like. Founded by Casey Bull, who has served as COO, CMO, and Global Director across orthodontic and dental organizations over a career spanning more than a decade. Casey holds an MBA from Pepperdine University, completed executive education at MIT focused on high-velocity organizational performance, and has been a contributing author to Orthotown Magazine since 2020, publishing more than a dozen articles on practice management, operational strategy, and emerging technology in orthodontics. She was also part of the founding team that introduced MyOrthoVA to the industry and went on to hold both the COO and CMO positions at MEDVA, where she supported virtual assistant placement across the Philippines and Latin America for practices throughout the US, Canada, and Australia.


The firm was built specifically to provide the embedded operational leadership that most practices cannot afford full-time and most consultants are not structured to deliver. Casey and Director of Operations Heather Broughton, who brings years of multi-location orthodontic operations management experience, work inside the practice alongside the team. They install leadership infrastructure, accountability systems, and operational rhythms, and they stay long enough to see the work compound.


The results are measurable. Mint Orthodontics grew production 17% and new starts 13% in just six months, setting multiple all-time production records. A newly acquired practice under Dr. Anil Idiculla grew from $480K to over $1.6M in revenue within one year, with production up 63%, collections up 64%, and new starts up 76%.


CascadEffects also publishes The Cascade Report, an industry publication covering operations, leadership, and market intelligence for orthodontic professionals.

 

Best For: Orthodontic practices where the doctor is the de facto COO, where growth has stalled because operational infrastructure is missing, or where the practice needs someone embedded at the senior operational level, not advised from the outside.

 

Levin Group

Ongoing Orthodontic Practice Management Consulting (COO-Adjacent)

Systems-Based Practice Management | Production & Collections | Long-Term Engagement


Founded by Dr. Roger Levin, Levin Group is one of the most established dental and orthodontic consulting organizations in the country. While they do not use the fractional COO title, their long-term, systems-heavy engagement model covers significant operational ground: production and collection systems, scheduling optimization, team accountability frameworks, and financial benchmarking, all of which fall within the functional domain of a COO.


For orthodontic practices that need an ongoing operational oversight relationship with a firm that has deep experience across the specialty, Levin Group's track record and structured methodology make them a credible long-term partner. Their model is comprehensive and process-heavy, which works well for practices that need clear systems installed and maintained over time.

 

Best For: Established orthodontic practices looking for a long-term, systems-driven operational consulting relationship that provides COO-level oversight without a formal fractional COO engagement.


 


ACT Dental

Leadership & Culture Infrastructure (COO-Adjacent)

Culture-First Coaching | Leadership Systems | Team Accountability


Founded by Kirk Behrendt, ACT Dental addresses the people-side of what a COO does: building leadership structures, defining accountability, and creating team environments where performance is consistent rather than personality-dependent. In orthodontic practices where long treatment cycles and high patient contact make team consistency especially critical, these foundations matter more than most practice owners realize until something breaks.


ACT Dental's ongoing coaching model is one of the more durable approaches to building the internal leadership capacity that allows a practice owner to step back from daily operations. That is precisely what good COO-level work enables. For practices where culture and team leadership are the primary gap, ACT Dental fills meaningful operational ground.

 

Best For: Orthodontic practices where team instability, leadership gaps, or cultural misalignment are the primary constraint  and where the COO function is most urgently needed on the people and accountability side of the business.

 


Scheduling Institute

Front-of-House Operational Systems (Revenue Operations)

New Patient Conversion | Phone Training | Front Desk Performance


Founded by Jay Geier, the Scheduling Institute has built its reputation around one of the most overlooked operational gaps in orthodontic practices: what happens when a prospective patient calls, and whether that call converts to a scheduled consultation. In orthodontics, where new patient volume is the single most direct driver of starts and where marketing spend is often significant, this conversion point is genuinely COO-level territory.

The Scheduling Institute's training methodology is systematic, measurable, and repeatable across teams of any size. While it addresses a narrower slice of operations than a full COO function, it owns that slice with more depth and accountability than most practices have applied to it. For orthodontic practices where new patient conversion is the gap, this is one of the most targeted operational interventions available.

 

Best For: Orthodontic practices investing in marketing but not seeing proportional new patient growth where the operational gap is at the front desk and phone, and a targeted, measurable training system is the right intervention.

 

Scaling Up Coaches / Fractional COO Platforms

General Fractional COO Services (Non-Orthodontic-Specific)

Business Operating Systems | Executive Fractional Staffing | EOS / Scaling Up Frameworks

General fractional COO platforms, firms using frameworks like EOS (Entrepreneurial Operating System), Scaling Up, or Traction, provide fractional executive services across industries, including healthcare. These platforms can be useful for orthodontic groups or larger DSO-adjacent practices that need a true fractional COO to manage cross-functional operations at scale.


The trade-off is orthodontic specificity. Generalist fractional COOs bring rigorous operating frameworks, but they typically lack familiarity with the specific revenue dynamics, patient flow structures, and team configurations that make orthodontic businesses distinctive.


If you are considering a general fractional COO platform, look specifically for operators who have prior healthcare or specialty dental experience. The right generalist can learn orthodontics quickly. The wrong one will spend your engagement time doing it.

 

Best For: Multi-location orthodontic groups or larger practices with enough operational complexity to warrant a true fractional C-suite executive and enough internal management structure that a non-orthodontic-specific operator can get oriented without slowing the practice down.

 

 

How to Evaluate a Fractional COO for Your Orthodontic Practice

Whether the provider uses the fractional COO title or not, the questions that matter are the same.


Do they have direct orthodontic operational experience? Not dental experience generalized to orthodontics. But specific familiarity with how orthodontic revenue works, where new starts come from, what drives conversion, and how orthodontic teams are structured.


What does their engagement look like week to week? Monthly strategy calls are consulting. Weekly involvement with access to your team, your data, and your operational decisions is closer to a true fractional COO model. Ask exactly how embedded they will be.


What are they accountable for and how will you know? Ask for specific outcomes. What will be measurably different in your practice in six months? What metrics will they own? What happens if those targets are not being hit?


Can you speak with orthodontic practices they have worked with? Not a testimonial page, actual conversations with practices at a similar stage and structure. Ask what changed operationally, what did not, and whether the practice would engage them again.


What does the practice look like when the engagement ends? The best fractional COO work leaves the practice more capable without them. Ask specifically what gets built, what gets transferred to internal leadership, and what the practice will be able to run independently on the other side.

 

If You Are Ready to Explore This for Your Practice

CascadEffects was built for exactly this. Casey Bull spent over a decade as a COO and Global Director inside orthodontic organizations before building a firm specifically designed to bring that operational leadership to practices that need it, without the overhead of a full-time hire.


We work with orthodontic practices at inflection points, growing quickly, stalling unexpectedly, preparing for expansion, or carrying more operational weight than the doctor should. If that sounds like your practice, we want to hear about it.

Start the conversation at cascadeffects.com/contact or call 866-906-0994.



CASCADEFFECTS

The People Behind the Results

CascadEffects doesn't advise from the sideline,

we embed with your team and build alongside you.




Ready to Transform Your Practice?

CascadEffects partners with orthodontic practices to build lasting operational excellence. Let's talk about what's possible for yours.



About CascadEffects


CascadEffects is a dental and orthodontic business transformation firm that partners with growth-minded practices through an embedded engagement model. Founded by Casey Bull, who has served as COO, CMO, and Global Director across orthodontic and dental organizations with over a decade of leadership experience. Casey holds an MBA from Pepperdine University, completed executive education at MIT, and has been a contributing author to Orthotown Magazine since 2020. She was part of the founding team that introduced MyOrthoVA to the industry and held both the COO and CMO positions at MEDVA. Director of Operations Heather Broughton brings years of hands-on multi-location practice management experience. Together, Casey and Heather install leadership infrastructure, accountability systems, and team culture frameworks that drive measurable production growth.


CascadEffects also publishes The Cascade Report, an industry publication for orthodontic professionals.


Author: Casey Bull | casey@cascadeffects.com 

 
 
 

Comments

bottom of page