As I’ve mentioned in recent posts I’ve put a lot of thought into how Invisalign works in the marketplace and in my practice. After doing several hundred cases in and around 2006-2007 I stopped doing Invisalign cold turkey for 8 years due to many factors. Recently I talked about my decision to go all in with Invisalign because, frankly, Align has won the war for the heart and soul of Susie Q Patient. Anyway, as we implement and execute our plan to be THE Invisalign provider in our area I’m constantly asking for insight from Invisalign gurus and experts across the country. The most interesting topic discussed thus far is the subject of this blog: why don’t they do more aligner cases?

I know several people who do 1000-2000 starts or more a year and many of them are “all in” with Invisalign but, for some strange reason, the percentage of aligners they do hovers around 10-25%. It’s eerie how consistent the 10% mark is across the country and across the continent. It doesn’t seem to be planned, it just works out that way. So I’ve made a point to ask several people who do Invisalign why they don’t do more as a percentage of the cases they start. It’s a simple question but the answers are complex, varied and incomplete.

What answers do I get? I’m glad you asked. Here they are ranked by frequency (this is not a scientific poll)

1) I don’t know.

2) That’s just the way it works out.

3) Cost of aligners vs. brackets.

4) I don’t want to cannibalize my braces cases. (This is the one I’ve always identified with and it has a lot to do with #3)

5) Why would I want to do more aligners?

Now I’m sure there are other answers/reasons but these are the most common ones I’ve heard. (Feel free to comment with your reasons!) Anyway, I find it curious that we, as a profession, don’t do more aligners as a percentage of case starts and I want to understand so I make the right move in my offices. In that vein, I have a few more questions and would like you to help me answer them in order to find enlightenment.

1) Does every Invisalign case we sell take away a bracket and wire case? 

I would have said yes before but these days I’ve started to realize that there is a huge and untapped patient pool sitting in my waiting room already – parents! That plus my GP patients make it easy to see that there are lots of patients who I will never get brackets on but who might do aligners. As I mentioned in Fear only 1.5 percent of patients who consider braces actually get them. 

 2) Does Invisalign work? Is it a good product? Do we feel good prescribing it to patients and would we do it for our kids and spouse?

Yes is the answer here but it’s a matter of degree. Invisalign can certainly work to improve most cases and it can “correct” many. So if it works, why are we shy to prescribe it? Especially to adult patients. Forget perfection, it’s unattainable. Think enhancement in the way Ackerman talked about it in his text (way ahead of his time btw). Which is better? A patient who gets enough improvement from aligners to be satisfied or a patient who gets elective endo, crowns and/or veneers to get a better smile? No contest!! Aligners every time. So what’s the holdup? Why do we surrender these cases to GPs instead of doing them ourselves?

 3) Does being on the Invisalign doctor locator bring in new patients? Does Invisalign’s marketing do a good job in creating demand? What’s that worth?

Yes, yes and a lot! Again, I fought this for a long time but Align has won the war and it is what it is. Why not harness this for our practices? 

4) Are you willing to give up money and discount to start a case?

No? Really? Don’t you take Care Credit and give up 14.9%? Aren’t you a provider for some insurance company that reduces your fee? Don’t you drop the price for shoppers?? C’mon… Be honest. Isn’t the lab fee for Invisalign comparable to those discounts? Would you spend $1,000 dollars if you thought it would bring you in more cases and create visibility for you?

 5) Are you willing to drop your price to get people in the door? 

Sure you are. It’s called advertising cost and it reduces your profit margin just like discounting your fee does! Same goes for taking insurance in the hopes to be listed as “in network”. But there’s no comparison between the number of people who seek out Invisalign and those who look on the insurance website to see who’s in network. Plus our practice marketing just isn’t that good when compared to Align’s. 

Res ipsa loquitur.

I hate when my world and my beliefs are uprooted by the facts but once it happens I tend to run with it and get maximum bang for my buck when it comes to change. I’m very interested to see how this shakes out and what else I discover as we implement Invisalign in our practices. I’m working hard to dispel my belief possession and shed all the things I thought I KNEW about aligners in the context of an orthodontic practice. Learning and changing are a journey that can be painful but the rewards for those of us who are willing to take the necessary steps are far greater than mere financial gain. Help me hash this out. Tell me what I’m missing and why I’m wrong… But also be sure to consider what I’m saying here about the answers I’ve discovered.


8 thoughts on “Why Don’t We Do More Invisalign?

  1. Patient choice! All my new patients have the choice to be treated with Invisalign but it seems that only about 1 out of every 4 patients choose the clear aligner option for many reasons. But I would say that the top 3 reasons are: 1) pts feel they are not responsible enough to wear them or find it a nuisance to continually have to put them on 2) all my friends have braces and 3) they are skeptical that it works since they were told it doesn’t by a dentist/orthodontist or Dr Google! A start is a start and if they don’t come in asking for Invisalign why convert them to a more expensive option unless you want to be the Invisalign King of Arkansas! 🙂

  2. Ben,
    I’ve been in a private high end study club for quite some time, 4 members total all excellent orthos with top practices. We’ve debated these issues for quite some time. I’ll try to address your concerns one by one:
    1. No absolutely not, Invisalign has expanded the marketplace significantly. I tend to be an overhead hawk. When I criticized one of our members who does a ton of invisalign for his overhead going up several % points, he said would you rather have 50% of 4M or 53% of 4.5M, case closed.
    2. There is no question Invisalign works but remember not every braces case turns out to be a gold medal either. Carlyn Phucas, a speaker for invisalign (member of my group), taught me one key to exceptional movement and control, slow down the movement, this also allows for weekly tray changes. It makes no sense to add an acceledent and $500 to your cost. Slow down your movement by 1/3 (ask for 1/3 more trays). Have your patients change their trays once/week. Its a beautiful thing.
    3. Yes, we are listed first in our area, but low numbers. Maybe one/week.
    4. I think most people avoid Inv due to increased lab cost. If you don’t increase your starts you will sig increase your overhead. Having said that there is no question that Inv cases take considerably less chair time and fewer staff to complete. Also, much less training.

    One thing I’ve struggled with is taking the risk of putting myself out their as “the Invisalign” provider when I don’t have a proprietary product. You have addressed this many times. I don’t want to get into a pissing war with my ortho neighbors.

    All in all, my thought is that 10 yrs from now Inv (or a competitor) will make up a sig portion of our practices. Our suburban soft society wants the easiest path to any goal and inv is certainly easier for them in every way.

  3. I’ll tell you the one real reason most practices don’t do more Invisalign – because they don’t want to, and that’s because they don’t want to pay the lab fee. Question: if Invisalign aligners were free, would you do a higher percentage of Invisalign?

    As a modest one doctor one office practice, I am at 65% Invisalign, and I can tell you, the water is fine. My goal is 70%, and I don’t think its likely to get above 80% any time soon. For many reasons, my overhead is actually lower (lower is relative, it was too high prior – I have a great OM now, watching expenses). It is a cultural shift within the office, and of course it includes buy in from the entire team.

    Luis is right about pt. choice, however, in most cases it is very simple to remove the mental barriers that families have about it. I’m happy to share those.

    1. Yes. But so does a better bracket system. I pay more for Smart clip, and it pays me back in fewer wire changes, fewer visits, and shorter treatment times.

    2. I never compromise results. The more you do , the better you get. This happened with Smart Clip. I do not get great results in every case. About 3-5 cases/year end up in wires. We are still orthodontists and we know how to move teeth. Most of my staff and my entire family is in Invisalign.

    3. Yes, but as John stated, its not going to be your main driver. There is a new driver though: the mom’s on the soccer field who’s 2nd child had Invisalign and is now telling everyone how much better the experience was.

    4. Obviously. Be careful in your build up. There will be times when you really ramp up, and the monthly payments will lag behind. Cash flow will get tight.

    5. Obviously.


  4. Fair enough. I hadn’t considered that Luis. Thanks for the insight. Now the question is, “how much does the doctor influence patient choice?” Because I spent a lot of time and effort leading patients away from Invisalign for all the reasons we listed here. I’m just trying to figure out the answer to this question:
    If invisalign is profitable and a good idea for some patients then why is it not a good idea for most?

  5. You’re a great resource as always John. Thanks so much for the insight.

  6. Well stated sir. Thanks for lighting the way for us late adopters.

  7. I have been thinking about embracing this concept. Patients want it. I have tried to steer tens to braces, but later see them in Publix with Invusalign in. Someone will do it for them. For those who are heavily into Invisalign AND successful with it, how much do you charge down? If you were just ramping up, would you be nervous to charge less than the lab fee.


  8. Patients want it. That’s a fact.
    How much you charge and how much you want down is very market and practice specific and talking fees with a group of professionals is never a good idea.
    Let me know what you decide and how it goes. I think many find themselves in the same situation or will soon.

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