The world is a wondrous place. I wonder about a great many things, all the time. Questions like, “How much longer will Align continue to permit orthodontists to take advantage of the mega brand recognition that Invisalign has built over decades of spending tens of millions a year in marketing?” are especially haunting of late. “Why has Invisalign allowed unfettered access to leads they own for so long?” is another vexing question. These questions are not scary to me personally as I saw the writing on the wall and did a personal/professional 180 on Invisalign about a year ago, but I am afraid for my friends and colleagues who don’t see the big picture. These particular questions have come to the forefront of my mind recently because of two events:

  • I just attended Invisalign Summit in Vegas and had more than a few very interesting conversations with peers and friends.
  • There has been a great deal of talk about SmileDirectClub and Invisalign on the Facebook groups of late. Well, complaining and outrage are more accurate descriptions than talk.

Why should you care? Why do I?

Well, I care because I want to positon my business to ride the prevailing winds in our industry – to take advantage of market forces much larger than my practice and my sphere of influence rather than being ridden down by them. I care because I think many of my friends and colleagues are underestimating the penetration of the Invisalign brand, unaware of what SmileDirectClub will become in the future and overconfident in the groupthink ideals that the vast majority of orthodontist subscribe to when it comes to how things should be done. This is dangerous for individuals and for the profession. You should care if you want to continue to grow and prosper over the next couple decades. Decades that will see more change than we saw in the entire history of orthodontics to this point. Yes, yes, you are very smart and you are doing great and you’ve always done it the way you have and you’ll probably be just fine doing what you do. It’s your choice and you can think and practice and do whatever you like. But isn’t it smart to know why you do what you do instead of just following the herd and nodding your head and going along with the way we have always done it? Don’t you want to know what is happening around you? Don’t you owe it to your family and your employees and your patients to at least try and see the big picture before wholesale rejecting anything you don’t like or approve of?

On to the point. I wonder how much longer Invisalign will allow orthodontists who push braces to every single patient that darkens the door of their practice to have access to their patient base? Oh yes, make no mistake, Invisalign owns a patient base. A very big one. They just haven’t asserted themselves when it comes to defending it because we think it’s ours and we make a lot of noise whenever someone does something we don’t like. But unless I am out of touch or miss my very educated guess, this will not be the case for much longer. I suspect that at some point in the near future Invisalign will be involved in the decision making process for leads (patients) they attract through their marketing channels when it comes to every aspect of treatment. Everything from choosing a doctor to initial contact with the practice to the new patient appointment to appliance selection and even the retainer selection and delivery will be influenced by Invisalign at some point in the future. I suspect that Invisalign will tire of the current and constant pushback and griping from orthodontists and, at some point soon, they will risk the ire of orthodontic specialists to defend the patient base and brand they have grown through decades of deliberate, direct to consumer market penetration. I expect that when this happens, many orthodontists will be up in arms and there will be a great deal of talk about how “someone should do something” but based on our past performance when it comes to anyone doing anything it won’t go much past talk and Align knows that. I also suspect that instead of backing down like they did with the case requirements, this time Invisalign will stand their ground and force orthodontists to play by their rules if we want access to Invisalign’s leads and use of their brand.

“They can’t do that! Those are my patients! I won’t stand for it. I’m a doctor and they are an evil corporation. Braces are the gold standard and you can’t do most cases with Invisalign” I can hear many of you saying.

“I can’t afford the lab fee! No way I can be profitable paying 1800 dollars a case. That’s crazy” others will cry.

“I’m going to call the state board and report them. You’ll see. Organized dentistry won’t stand for this” some will say.

I used to say the same things. How do you think I know what you’re thinking? I would ask you to consider a few things:

  • The hard, cold truth is that Invisalign can handle almost any case that braces can these days if you develop your plastic skillset to the degree you’ve honed your braces acumen. That’s just a fact. If you don’t believe me let me introduce you to a few of the Invisalign studs who convinced me that I was wrong in believing “braces are better”
  • Patients want Invisalign
  • You only have to pay the lab fee on people who want Invisalign and if you aren’t willing to give patients what they want and deliver Invisalign to Invisalign leads then you won’t get those patients in the future. Plus, the more cases you do, the lower your lab fee is. Which is better, all of nothing or part of something? You’ll have to decide but Invisalign, Medicaid and Insurance are all the same to me.
  • Patients want Invisalign.
  • State boards and organized dentistry are toast. You can no longer count on them to defend dentistry’s unfair monopoly.
  • Patients want Invisalign
  • Would you allow another person to utilize your brand or your name that you’ve worked hard to develop? Under any circumstances? What if they used it to their advantage while taking advantage of you? I think not…
  • The point of this article?? I don’t know anything for sure but I’m speculating that you won’t get access to the Invisalign leads unless you give patients what they want. No matter your reasons for doing so. No matter how right you think you are. No matter how unfair you are sure this is.
  • Of course there is a chance that I’m wrong and you’re right… Time will tell. But I’ll remind you, once more, that PATIENTS WANT INVISALIGN.

Still don’t believe me? Still think you don’t care and don’t have to care? That’s cool. You can do what you want but perhaps you might consider this?

  • Align will do over a billion dollars in revenue in the next 12 months. They aren’t dumb and they are getting smarter.
  • Align has a history of overcoming obstacles and resistance to their product. Remember when orthodontists refused to use Invisalign back at the turn of the century? How did that work out for us? We gift wrapped Invisalign for the PCDs is what happened.
  • Want a modern day comparison to 2000? Here you go – Most orthodontists are doing the minimum number of Invisalign cases they can do to get the level they want on the doctor locator. Orthodontists are pushing Invisalign leads to do braces. Orthodontists are even doing bait and switch on Invisalign leads and putting them in other clear options… so what does Align do to overcome this? Invisalign took a stake in SmileDirectClub to have a seat at the table at what will become the largest delivery channel in orthodontics (yes, you heard me, the largest). This will enhance their direct to consumer options and make sure they aren’t made obsolete by evolving models. Of course orthodontists are outraged – mainly because they don’t understand SDC, their target demographic, their delivery system and because they haven’t read the book The Innovator’s Dilemma but also because they think a publicly traded company like Align should act in the best interests of orthodontists instead of shareholders. (Also, let’s not forget that Align CEO Joe Hogan sued SDC first but that didn’t win him any applause from orthodontists so he made a smart business move, did a 180 and took a stake in SDC).
  • Someone was going to get in bed with SmileDirectClub and if we orthodontist were smart we would be thankful that it wasn’t some mega pharma company with no ties to orthodontists and no restraint.
  • The next logical step, from where I’m sitting, is for Align to clamp down control on THEIR brand and THEIR patient base and serve those orthodontists (and dentists) who feature Invisalign as an equal alternative to braces – or a superior one when appropriate.

I’m not asking you to agree. I don’t care if you think this is right or fair. Where I live, fair comes to town once a year… I am asking you to become aware of the market forces at play in your profession and suggesting that you understand why publicly traded companies do what they do so you have some inkling of what lies ahead. If you do so then you’ll be better prepared to succeed in an ever changing world! We all have choices and we all must live with the consequences of those choices. I make a point of owning my decisions. Do you? I’m pretty sure Invisalign is about to do what they do best – change with the changing world to deliver effective products to patients who want them while providing maximum benefit to their shareholders. That’s what good, publicly traded companies do. The good news is that this fact makes them fairly predictable.

PS I saw this at the Invisalign summit and I think this photo tells it all. There are two kinds of people, those who think this is crazy and those who think this is likely. Which are you?


Oh, BTW, if you haven’t read this book then, honestly, you can’t have an informed opinion on SmileDirectClub. READ IT. It’s tiny. If you want I’ll send you a copy just send me your address.


20 thoughts on “Is Invisalign Crazy?

  1. Hi Ben. I’m onboard with Invisalign and feel comfortable treating most cases if the patient wants it, but what do you say to those of us who have practices that are 75-80% adolescents or younger who, when we offer them braces or Invisalign as equal modalities, either say, “No, I want braces and colors like my friends,” or mom says, “There’s no way he/she will wear or keep track of his/her aligners. Let’s do braces.”? This happens all the time in my and my colleagues’ practices. We just had a discussion about it at a study club this week. I imagine Invisalign has a plan to make those kids/parents choose plastic, because they’re not doing it on their own right now in my area.

    1. Agreed. I’m all about giving patients what they want. If they want braces then that’s what they get.

  2. I may be crazy but after over 600 cases studied before and after( I am an academic and like not to be ultra efficient like my peers) , I fell that Align is actually getting better than braces.
    The whole 3D environment is a revolution, not an evolution.
    I made the leap this week end inVegas listening to a few great Aligner providers. Aligners or 3D appliances will be my first treatment modalitiy and will be complemented by braceswhen needed, not the otherway around anymore.

    1. Can’t argue with you. To my way of thinking Invisalign being “better” has as much to do with the non-clinical attributes as it has to do with the case finishes. Thanks for sharing.

    1. Time will tell. I’ve been wrong many, many times! Thanks for reading and joining the conversation.

  3. Ben, What if Align hires “providers” as salaried employees? I make no distinction about “providers” because there are enough PCD’s in the elite and 1% tiers providing care now. Why pay for an extra degree or specialized education? Imagine Invisalign Super Centers providing clinchecks by licensed employees, scans and delivery by minimally trained but licensed dental assistants and satellites of those super centers that provide care to outlying areas where scanning and delivery occur, but clinchecks are handled off-site (think local shopping mall or large strip center). The next step being direct to consumer SDC exclusively; computers and algorithms treat all patients from a 3D scan provided via smartphone. Align keeps everything “in-house” and no longer refers anything outside. I hope this NEVER happens and it remains an unrealized possibility. But, like you, I’ve seen the writing on the wall. “Braces are Done! Invisalign treatment is the new standard of care.” Don’t get me wrong, I still believe there is a place for fixed appliance therapy. However, it is becoming the second option in a quickly evolving orthodontic landscape.

    1. We have a very interesting future ahead of us. I think there will always be a place for orthodontists who understand the market and can deliver what their clientele want.

  4. You refer to developing a plastic skill set. To me, part of that recognizing the movements, few as they, where Invisalign still lags behind and in my opinion always will. I start 250 cases a year and don’t think in the 10-15 years I hopefully continue to practice I will ever fail to incorporate braces. Invisalign has to strive to be “the standard of care” or “as good as braces” but I don’t go for such generalizations or catagorizations. I am orthodontist, not an Invisaligner or Braceser.

    1. That’s one way of thinking about it. I think braces will always have a place in the market. I do think that, as the book The Innovator’s Dilemma will teach (if you read it) we orthodontists provide a product that far exceeds the wants or needs of our patients. We orthodontists want better, faster treatment when what we are doing exceeds expectations of 95% of patients and faster doesn’t really help unless you’re getting paid more for it.

  5. Would you send me a copy of Innovators Dilemma?
    Loved your article. I am a 1% provider and am completely on board.
    Thank you.

    1. you bet. just friend and message me on Facebook and give me your address and I’ll send it to you.

  6. I agree with MOST of your article/commentary but I always wonder what motivates such an article.
    I honestly think Invisalign is great and I think we can all agree that it has really come of age in the last 3-5 years. Probably why you are a recent convert to the technique.
    Yes Invisalign is a corporate giant with huge “star” power with respect to internet searches and marketing genius. But I don’t buy the argument that Invisalign has got to where it is, all on its own internal investment and development.
    There was a time (years ago) when the orthodontists who were Invisalign pioneers went to bat for Invisalign in consult rooms all over North America. Trying cases that they or Invisalign really didn’t know would work. Displaying unproven confidence to their patients and discounting fees to “some how feel better” about the fact they were kind of experimenting on these patients.
    Orthodontist are the ones who have taught Invisalign what could and could not be done in the real world (the mouth) rather than just on a computer. Today the “studs of the plastic game” as you call them continue teaching the Invisalign techs and more importantly the Invisalign computers how to do the clin checks and advanced orthodontics tooth movements. Don’t ever for a second think they aren’t developing algorithms in side the Invisalign computers to phase out the techs and do “set ups”without our input.
    You talk of “leads”. I assume a lead is a potential patient who has gone online or another marketing medium and been sold on Invisalign and subsequently called an orthodontic officers get the treatment. I agree that does happen but let’s not discount the “unaware” persons that gets steered to Invisalign by is orthodontists. Orthodontists still have a fair bit of “draw” and also provide “leads” the other direction for Invisalign.
    You speak of the “big picture” and make it sound like the future health and stability of our families, our staff and our practices relies on us using Invisalign.
    I do not agree that using more Invisalign in our practice’s is the road to solving the problems facing orthodontists in 2016.
    I live in Canada and our urban orthodontist are facing a myriad of problem of which Invisalign is one of the biggest but certainly not the only. I will come back to that statement as I go forward.

    I will tell you what I feel is the big picture in Orthodontics.


    This is the root of many of the issues in dentistry in Canada. DENTISTS in urban centres are struggling to pay there bills. There are no places to set up a practice. Sellers are demanding giant money for their practices. New grads are strapped with huge school debt. Dental schools keep pumping out new grads.
    Our governing bodies (at least in Canada) know that this overall situation puts dentists in a peculiar ethical dilemma. Walking the line between ethical proper treatment and maintaining financial stability. Kind of “catch 22” that we don’t know how to handle.

    How is Invisalign involved in this?
    The Invisalign reps are calling-on and promoting Invisalign to the general dentists. So if you are “not so busy” dentist and you are struggling financially …..doing your own ortho, endo, surgery and keeping the money in-house sounds pretty good. Almost a necessity!!
    Now Invisalign is very smart. Dentists don’t know a lot about ortho. So in comes ” Invisalign Assist”. A brilliant strategy!
    Invisalign as you have stated has no real allegiance to us orthodontists. Our reps love us but the moments they are out our offices they move onto their real job which is selling and promoting Invisalign, which again is their job. You can’t fault them or dislike them for that. They are well trained and good at it. My rep is great!! Love the guy. Unbelievably knowledgable and helpful.
    So we all agree Invisalign in a public company driven by share holders. The bottom line is the real driver of their strategies. As it should be. We would all do the same!!! It’s the same thinking we all use to run our little practices every day, just on a smaller scale.

    In Canada using a scanner is an “uncontrolled act”. We could train anyone to scan. You need a sterile environment (which is easy) and a pair of gloves.
    Invisalign owns the scanner that is arguably the best and most popular on the market . Another great corporate move. Owning or taking a stake in the Smile Direct Centres, again another fabulous move.

    This is really scary. So why not scan in tanning salons, kiosks in malls, independent hygiene clinics, SDC’s manned by “non dental” staff? All legal. All possible. Again I don’t like it but hey it doesn’t matter what I like.
    Non of the above options has to worry about the cost of buying the scanner. Invisalign could put the scanners in place on a lease, a rent to own scenario or just give it to the operator to use. Again a brilliant strategy and I don’t fault them for it. Again I don’t like it and maybe we would all do the same.
    I do worry about the public, but that’s just my old school thinking.
    Yikes …scary stuff. Now teeth are getting aligned with the entire profession of “dentistry” being bypassed.
    Now we know that not all patients will go to these “non dental” alternatives, but certainly some will and that lessens the pot for us orthodontists and dentist.
    Now, if Invisalign goes that direction? Do we hate them and boycott them? Would be hard to do because as you say “patients want Invisalign”! We are stuck between a rock and a hard place. Maybe there will be a competitor we will use instead if we are mad at Invisalign!?? Hard to know the answer to that situation.


    This is my pet peave!!
    So we as orthodontists go to school for 10-11-12 years and do a mountain of studying, take on a ton of debt, stress our families and spouses and gather a ton knowledge. Our grad schools do research on many orthodontic topics and present it to the world.
    Now we are out of school working and some management company, or Invisalign, or your accountant or a colleague tells you to “separate your practice” from the others in your city or town by doing complimentary exams. Sounds great until everyone else does the same (which others kinda have to do). Now you are all looking around at your staff saying “well that didn’t work”!
    Patients love it.
    Let the “price shopping” and “tire kicking” begin.
    Endodontists don’t do this. Oral surgeons don’t do this. Plumbers or lawyers don’t do this.
    I don’t get it!!!
    Is all our hard work and knowledge not worth something?
    Why does every city or town have a guy doing full ortho or Invisalign for $1500-2000 less than the rest of us? Why do we do that? Makes the guys charging a normal fee look like crooks!

    So I will end this rant now!

    Some of my orthodontist friends have urban practices that are down 50-60%. Oh and by the way, that’s why the Invisalign lab fee is an issue. They are laying off staff. Renegotiating leases. Adjusting their lifestyles.
    Orthodontists are now worrying about their overhead like no their time in their careers? It’s scary!!
    But not half as scary as that new grad who is popping out of ortho school with a $300,000 debt looking forward to a bright future in Orthodontics.

    This is the “BIG PICTURE” in our profession. Let’s not make it all about Invisalign.
    Sorry for being a bit of a downer and again I really really like Invisalign and I think it is a great way to do most cases and the ONLY way to treat some cases.

    I also truly love the specialty of Orthodontics.

    1. Dude you’re entitle to your opinion but honestly your desire to engage in price fixing, limit access to care and to charge for initial exams kinda puts us at odds – like diametrically opposed when it comes right down to it. That’s cool but let’s be clear. Question my motives all you want but this is just one of many topics I write on and I’m crystal clear about my affiliations. Also, I assume you didn’t know this but I did 6-700 cases back in 2006-2007 then stopped cold turkey so I have an idea about the history of Invisalign. Thanks for taking the time to write all this. I know you feel passionately about these issues and in Canada you can get away with a lot more of this Paternalism than you can here in the US. I’m sure you’re doing fine and will continue to do so. All I was advocating in this article is that orthodontists should be aware of what is going on. What you do with that knowledge is totally up to you!

  7. Didn’t want to challenge or offend anyone or you but there is a lot of frustration in our profession these days. I am on the 17 th fairway of my career and I just feel sad that the profession is changing so quickly. Guess that is the way of the world. I do think we are all doing the best ortho we have ever done at this time due to the new technologies.
    It will be an interesting next few years.
    I also am against price fixing. Dentists in Ontario have a fee guide. We don’t as orthodontist. It’s left to our discretion.
    Anyway thanks for your opinions and I did like your article and the dialogue it provokes. Makes us all think!

  8. Fantastic article Ben! I completely agree and have been following these trends, particularly since the purchase of my own practice in 2014, previously I was an associate for several years in a very nice practice but one fairly stuck in their ways. I have seen that practice shrink to some degree based on reluctance to give patients what they want and in their reluctance to accommodate the future. Paradigm shifts are difficult, accepting and adjusting will be the key to success. Here’s a curious thought I had after the Invisalign Summit; given the nearly unlimited finances of Align, at what point will we see an intraoral scanner, whether its Itero or not, in every Walgreens or Walmart allowing patients to simply scan themselves (with simple on screen directions of course), pay accordingly and have their aligners delivered to them??? Of course I assume this will depend on what Align’s pucker factor will be in regards to unsupervised care, it seems they are testing these waters already. Thoughts in this?

    Cheers ,
    Bret Johnson

    1. I think this absolutely will happen at some point. You’re not wrong at all. Scanners and 3D printing will revolutionize orthodontics but I don’t think it’s clear exactly how. Imagine every large employer or church or social group owning a scanner and a 3D printer and contracting with an orthodontists to provide doctor directed care as a benefit for their members and employees. Then what happens when the algorithms get so good that orthodontists are no longer needed? We will see more change in the next 10 years than we have in the entire history of the profession.

  9. Hi, I had Wilckodontic surgery May 2017 followed by two rounds of Invisalign. For a variety of reasons, I decided to chronicle this adventure, In the last year, I have noticed a good number of women over 50 pursuing Invisalign, mostly at the advice of their dentist rather than orthodontist.

    I have learned a lot through my experience, which was positive, not the least of which is that people should work with specialists when it comes to their teeth especially if over a certain age. So I decided to write on this topic. My research led me down a different path than I expected as I became familiar with Align’s marketing strategy. That is how I found your blog.

    If you feel inclined, I would love your opinions on the following:

    1) I am wondering if Align’s strategies may ultimately be bad for some of the ultimate end users, the patients. As an ex car dealer, I am more familiar than the average person with the consequences, good and bad, of incentives. Align offers incentives by reducing lab fees and providing a higher rating on their website based on number of cases. It appears they have also attempted to establish quotas. And I suspect, but do not know for certain, that profit margin is greater with Invisalign. Since every business owner must have a focus on the bottom line, are you concerned this will encourage providers to push orthodontics in general and Invisalign in particular, to untapped markets like the over 50 crowd? Am especially concerned about dentists who aren’t as well versed in the complications. Are you seeing this as well in your areas? I think Invisalign is great in many ways, but orthodontic work over 50 or more complex cases at any age has a lot of potential complications. As an aside anyone (other than the simplest of cases) who does orthodontic work through the SDC has to have their head examined.
    2) And on a separate subject, how many of you have provided orthodontics for patients who have gone through Wilckodontics or AOO? Have any of you never heard of it? Approve or disapprove of it?


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