It’s been over five years since we started the experiment that is Smiley Face Braces in Orlando, Florida. A lot has happened – both expected and totally out of the blue – so we thought we’d post an update FWIW.
First, what went wrong?
We were wrong about several things:
1) It was not possible for us to do limited aligner cases. Patients heard what we said about the limited number of aligners, about the extra charge if they wanted more aligners beyond that, about the limited treatment goals… and they either didn’t understand, didn’t care or we were unable to manage the situation. The why really doesn’t matter. Doing aligners in this model was a bad idea. We should never have offered aligners at Smiley Face and we put an end to that within the first year. It was a great day when we finished the last aligner case!
2) We don’t like ceramic brackets! We no longer offer ceramic bracket cases for all the reasons orthodontists (and often patients) don’t like ceramic brackets. Life is better now. We even charge a substantial additional fee to remove ceramic brackets if someone wants to transfer to our practice and we hope it is a deterrent since we really don’t want to deal with them.
3) We should have hired experienced clinical assistants from the start. We had the idea that we would hire for attitude and train the clinical as we have done in the past. That was fine in a traditional practice growing from a startup as you have plenty of time. It’s not easy if you are running the Smiley Face Model and are going to do significant volume.
4) The pandemic – ‘nuf said.
5) We didn’t build the office with enough chairs so we added 4 more to go from 8 to 12 chairs and that is about right. If we work with two doctors in the office at the same time in the future we may need to add more and relocate the admin staff to another location but 12 is just right for us for now.
6) Ben’s Arkansas complications meant we had to bring in associates even though that was not the plan. That did not go well at first…. and then it did! Funny how sometimes a negative becomes a positive. We would likely never have brought in an associate to work at Smiley Face and we would have certainly ended the experiment after the first couple failures if we hadn’t been forced to utilize a non-owner doctor. The ultimate associate solution is both awesome and novel.
7) We have had several people emulate the “2998 low fee model” without understanding that the price is just part of what we do. This has caused a great deal of confusion and some failures. We get calls, texts and emails from people who tell us “we did the low fee model just like you guys but we modified and improved it”. We ask them how it’s going and usually they say “the model doesn’t work like you said it would and I don’t understand why, we are doing it just like you only better”. When we dig deeper we often find they have multiple fees, take on every case, use expensive bracket systems and appliances, they do aligners, they have iCAT and other expensive but unnecessary tech, their office is not set up for volume and on and on. We hate to hear these stories but don’t know how to prevent it other than to say, once again, Smiley Face is about much more than price. The model is set up to create a great lifestyle for a motivated owner/operator while increasing access to care but there are things you just cannot do at this price point. We know of a few other doctors who have 2998 models that are working as intended. If you ask any of these owner/operators who are successful at the model they will tell you that you have to dispense with traditional thinking if you want to succeed in this game. It is certainly not for everyone and we are not advocating anyone change what they are doing – if you are happy with your results why in the world would you ever change? That being said if you are unhappy with your results there has never been a better time to make orthodontics affordable and enjoy the fruits of doing so.
What was/is the outcome of the Smiley Face Experiment?
First let’s discuss the gritty details everyone wants to know:
Overall the practice did much better than we ever imagined it would and surpassed all our projections. We researched the psychographics/demographics, picked our location based on that and did a cold startup in an area where we knew no one. We started just shy of 1300 cases in our first 12 months spending about 10K a month in advertising. So we reasoned that if we doubled our advertising then we should do even better. We spent about 20K a month in the next twelve months and started just shy of 2300 cases (the 12 months not counting the two months we were closed for the pandemic – the next consecutive 12 months we were open). 2300 cases is not double the starts we did the first year but not bad. We have stayed at the 20 K a month advertising spend more or less since then and it’s gone well. We averaged just over 27 starts a day for almost 6 months after we were allowed to open after the pandemic forced closures. We believe this was a combination of pent up demand, free money from the government and the fact that we kept our team on at full pay while most other ortho offices fired all their employees during the pandemic so we were ready to roll when we could open while others struggled with staffing. We learned that 27 starts a day was too many and we couldn’t continue at that rate but we kept going until the demand slowed down. For those who are curious the most starts we have ever done in a day is 33 and we have done that 3 different days. Not what we prefer to do but one must make hay whilst the sun shines. The practice declined over the second half of ‘21 and all of ‘22 to the point that we were only averaging about 9 starts a day. Ben returned to the practice in January of 2023 and this year we have averaged just shy of 12 starts a day – sometimes it’s 18 and sometimes it’s 5. There is tremendous amount of variability in the Smiley Face model and has been from the beginning but the production is consistently solid. The practice is growing, the patients are happy and we have the best associate ever so there are zero complaints! From what we understand the entire industry is down this year so this explains at least part of the slowdown for us. We’d rather hit our goal of 17 starts a day but we just do the best we can for the patients that do come to see us and it seems to be working out. Life is good.
How often/how much do we work?
We see patients about 135 days a year. Our first patient appointment is at 9 am and our last is at 3 pm. Our last morning appointment is at 11:40 and there is no grace period for that appointment time (normally if a patient is less than 10 min late we will see them but not at 11:40) because we want the staff to get a lunch. No grace period for our 3 pm patients either. We seat patients at 8:50 am and 12:50 pm as discussed in past OrthoPundit articles and that makes a huge difference in keeping us running on time. Running on time is our prime directive at Smiley Face. Now for total transparency it must be said that on the days we started 25 plus cases we did pinch the lunch hour a bit and we would order something for the staff to eat on those days but anything under 22 starts a day is no sweat. We schedule about 230 patients a day and usually see about 190-200 patients who turn up for their appointments. We allow patients to change their colors as often as they like and they can walk in to do this from 8-8:30 am and 4-4:30 pm or make appointments at other times. We see color changes and comfort appointments on non-doctor days as well. We do very little early/interceptive/phase I treatment and about 58 percent of our patients are adults. We treat a lot of children still – probably more than most practices – it’s just that we treat a ton of 18-30 year-olds who were not able to get braces when they were kids because their parents couldn’t afford it. That’s basically who Smiley Face was built for!
We use .022 twin brackets and the wire sequence is 014(sometimes 012) niti 10-12 weeks, 018 niti 10-12 weeks, 20×20 niti 10-12 weeks, 19×25 TMA 8-10 weeks to finish. We will repo as necessary but prefer to bend the TMA wire to finish. We don’t use steel ties, we have three different types of elastics that are worn in one of 6 configurations, we use power chain to close space, we use Nance buttons when max anchorage is necessary in extraction cases and we do RPEs in growing children. We use eyelets to engage ectopic teeth and often engage them with small niti wires or elastic thread. Occasionally we use a 16×22 or 19×25 niti reverse curve wire in a deep bite or open bite case but it is rare. That’s it for 99 percent of our cases. We have two pan/ceph machines, two scanners (used only for RPEs and Nance buttons), we use alginate for impressions to make retainers and we do in house retainers on a biostar type machine. We use inexpensive instruments, use only what is necessary in order to limit the number of instruments per setup and we have a ton of setups (sterilization bags not cassettes) with a very efficient sterilization system to keep up with the volume of instrument packs we need. We only buy brackets that come already setup on cards as we don’t want to waste time doing that ourselves. We don’t use NOLA type retractors because patients hate them and we have a more comfortable alternative. We always defer to patient comfort whenever there are treatment options. Always. The idea that “patients can be uncomfortable for a few minutes but I have to do this all day” that is rife among orthodontists is not logically sound and not good for business. We do what we do extremely well but we also try to do it quickly as no one likes to be leaned back in a dental chair. Hopefully you’ve noticed that the patient experience is a big part of what we do and why – less visits, shorter visits, more comfortable visits with team members who are hyper-competent, happy in their work and good at what they do. It makes a big difference!
Our clinical staff get paid 32 hours a week, 52 weeks a year and we only need 2-3 of them at the office on non-patient days so they work out their schedule on non-doctor days. Before you object, read again the production numbers and see why we are happy to pay our team extremely well even when the industry as a whole is down. Clinical assistants are encouraged to have their cell phones and use them whenever they are not busy to keep in contact with their family members and friends. Generally they keep their phones in their pocket. They self-police this as well as all the other perks our clinical team members get because of how awesome, responsible, efficient and productive they are. “When you do, you get”, is our motto for the team at Smiley Face and boy oh boy THEY DO! The team is very particular about new hires and are heavily involved in the interview/hiring process. They will not tolerate a new team member who does not buy into the model or pull their weight. They refuse to let anyone mess up our good thing!
Our average contract value is about of $3700 and our default rate is between 20 and 25% depending on the time of year and what the economy is doing. Collection rates also vary depending on how good a job we are doing at staying on top of things. It’s our responsibility to remind people to pay – to think otherwise is foolishness. We don’t really know what the “baseline” for the practice is as we have been figuring out a novel model, growing like crazy, fighting off a pandemic, dealing with bringing in new associates, etc. from the inception. We know that 27 starts a day is not sustainable in our size office with one doctor (and probably not even with two doctors because chairs/staff is the limiting factor in that scenario). We know that if we book 40ish new patients a day then about 30 will show and roughly 22 will be ready and 13-16 will start (we don’t start anyone with caries, perio, unrealistic expectations, outlier/unpredictable cases like Brodie bites and impacted canines or anyone who is not a good fit at the office – we keep a couple stacks of dental and ortho referral forms handy). Add that to the roughly 5 scheduled bonds a day (of which 2-3 will show up) and you end up with our desired 17 starts a day. Seventeen starts is our ideal day and what we design the schedule for when we can get the number of new patients we want. We are having trouble getting 40 NP a day in the current economy and have been more in the 25 range thus the drop in starts to 12 a day. None of this is scientific it is just us sharing what we have seen and our experience with the Smiley Face Model. We know that the practice model and the demographic we serve are unpredictable as all consumers and direct to consumer businesses are. One never knows what will happen in a given day or why – holidays, weather, school being in/out, the economy, or unknown factors can impact our clinic day experience. The doctor and the team must remain flexible and maintain a great attitude of service! We are in the service industry after all so why wouldn’t we?
We have 12 clinical chairs, 13 chairside assistants, one clinical lead (who can also be in a chair in a pinch), one sterilization person, one lab person, three front desk people, 2 additional admin people, one TC, one office manager and two doctors (only one works at a time most days given the decreased start volume but the security is nice). We are onboarding an accountant to manage our systems and collections and it’s going great… a real, honest to god accountant who passed his exams and got licensed and everything! We know we need to shoot for 10 plus debonds a day to keep up with past starts and often times we do more than that because we have transfers and people who left us then come back. We do same day retainers which eliminates a lot of problems. We do same day starts (which are the norm for us) and same day debonds (also the norm) as well as scheduling both procedures when the patient wants that. We bond upper and lower arches at the same time 95+ percent of the time because otherwise you take one large appointment and turn it into two long appointments and that is not wise for lots of reasons but especially for patient comfort/happiness. We have the best clinical team we have ever seen by a long shot and we have seen hundreds of teams in action. This is not an accident! Our team is well paid, well treated and shown the utmost respect. At Smiley Face the clinical team is the top of the org chart and the rest of us (including the doctor) are here to support them. Let’s be honest – they do 98 percent of the actual work.
We charge $2998 for braces and offer Retainer Assurance, teeth whitening and gold braces as upsell options. However patients can pay only $2998 and get everything without any additional cost – bond, visits, repairs, removal and retainers are all included. It’s the best deal going by far! The down payment is $292 and the monthly payment is $123 but we offer options to match the payments to the estimated treatment time if patients so desire. We accept most insurance but only about 20% of our patients have orthodontic insurance. We allow patients to pick what day of the month they want to have their auto-draft or credit card charge fall on excluding the 23rd through the 31st and we follow up immediately should a charge or draft be declined. We communicate mostly via text but also by phone. We have automated text reminders for appointments. We work hard to make getting braces affordable and the financing easy. There is no credit check. Our new patient exam happens on couches in the middle of our open floorpan as you will see in the video at the end of the article. The patient is taken for a pano then seated on the couch with their family. The doctor has a look, prescribes treatment, answers questions and estimates treatment time then leaves it to the team. The whole process is quick, easy, fun and low stress. If the doctor and the patient are happy and ready to start then we start. If not then we make a plan to move forward that works for everyone or refer the patient elsewhere.
Sometimes things don’t go as planned and payment issues arise. We are happy to work with patients who have payment issues as long as they will continue communicating with us. Most people pay most of the time so we make policy for the norm and deal with the outliers as they arise. It’s not personal and we work hard to keep it that way. It is possible to enforce the rules while being kind and treating people with respect so that is what we do. Why wouldn’t we?
What’s the best part about the Smiley Face model?
1) Lifestyle. This is the entire reason for the model. This model is designed for a motivated owner/operator doctor. An owner/operator can do anywhere from 1000-2000 (or more) starts a year depending on motivation and NP flow on 135 patient days a year while being at the office from 8:30 am to about 4:00 pm. With an average contract value of about 3700 and even a 25% write-off you don’t have to be a math major to see the upside in time and financial rewards. As Imtiaz Manji told me years ago, “It’s good to do good while doing good”. At Smiley Face we increase access to care, provide excellent treatment with outstanding customer service, have a fantastic work environment and create plenty of family time while making a good living for the owner, doctor and the team.
2) No more negative/subservient dealings with dentists or hygienists. NONE. We don’t have to treat cases the way a dentist thinks we should for fear of upsetting a referral. We get to be perfectly candid with patients regarding the dental care they are getting and the dental treatment plans that are proposed to them. It’s orthodontics the way it’s meant to be practiced. Smiley Face is the source of patients and we don’t have to rely on anyone for patient referrals. In fact the script is flipped. Say goodbye to the dentist lunches, Christmas basket runs and lunch and learns!
3) Happy patients, happy team, happy family. Just check our Google Reviews if you want confirmation. We accomplish more work in less time with more joy than any office I’ve ever seen or even heard of. Again, it’s orthodontics the way it is meant to be practiced.
4) No after school appointment battles given we don’t offer any after school appointments, no combative moms, no abusive patients/parents, no unrealistic patients – we don’t tolerate any of this and at our price point we don’t have to. Another great thing about charging a low fee is that it’s easy to write a refund check when you make a mistake and let one of the above into the practice.
5) No need for an elaborate sales process, diva TCs with crazy commission structures, or tricks/tactics/gimmicks to get customers to buy. The quality treatment, the office, our reputation, the new patient experience and our happy team along with the $2998 price tag sell themselves.
6) Our overhead is not nearly as oppressive as a traditional office.
7) We can easily answer the most common question orthodontic offices get on the phone – What do braces cost? – because we only have one price and we plaster it everywhere. Sure makes life less complicated.
8) The orthodontic obsession with conversion rate and all the silly things orthodontic offices do to pump up that number (often times at the expense of the number of starts) doesn’t apply to the Smiley Face Model. We don’t worry at all about conversion rate. Of course a higher conversion rate is always better if all things are equal but they rarely are. We offer great treatment at a great price with outstanding service and we do what is best for the patient in front of us every single time. If they need to see a dentist, we send them. If veneers are a better option for them, we send them. If braces won’t address their chief complaint, we don’t treat them. It’s orthodontics as it’s meant to be. Providing truly patient centered treatment is an awesome way to live.
9) No aligner patients and no computer time setting up aligners.
10) No bonded retainers. Ever. For any reason.
11) Security. As the economy suffers we don’t feel it like a normal practice. We saw that during COVID and we are seeing it again now.
That’s about it. We love the way we practice now and wonder why we ever did it any other way. The demand is out there and we are willing to offer a great product at a great price with excellent service. Practicing this way is incredibly rewarding in and of itself but the fact that this is the most profitable practice we’ve ever had while working the least days and hours per day certainly doesn’t hurt. Smiley face is a Lifestyle Practice meaning the business fits into our ideal lives on our terms and within the time constraints we have set. The goal is to be intentional, set boundaries around the days and times you are willing to work and then defend those borders fiercely. This is only possible if you have a product/price/service combination that is more desirable than anything out there! If you manage to have something considered superior and uniquely desirable by potential customers they will buy from you on your terms.
In contrast the traditional Practice Lifestyle is the much more common. In a Practice Lifestyle every aspect of our lives is dictated by the needs of the beast that is an orthodontic practice and it will constantly expand to encompass every moment of our lives to the exclusion of our loved ones and anything else. Now that we have experienced both a Practice Lifestyle and a Lifestyle Practice there is no comparison!
PS Here’s a short video I took a couple weeks ago to answer a friend’s question about my “crazy uniform”. It will give you a little insight into the clinic in action.