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With Great Parity Comes Great Responsibility by Dr. Andrew Sarpotdar

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Categories: Orthodontics;
With Great Parity Comes Great Responsibility 

Compare clear aligner options to discover what’s “right” for your practice

by Dr. Andrew Sarpotdar

Picture, if you will, the modern orthodontist, challenged to balance the goals of their practice with an increasing demand for aesthetic, convenient and affordable treatment solutions. All this must be done in an environment of increasing costs, downward price pressure and increased competition. Today’s orthodontists understand the benefits of clear aligner treatment and need little persuasion to accept it as part of their practice; however, which product to use continues to be a topic of debate, given the newfound parity in this space. In this article, I will share my experience with various aligner systems and make recommendations that will help you gain control over your practice, reduce overhead and scale your business using an aligner brand that fits your needs best.


 Starting with the big names

When I graduated from residency in 2013, clear aligner options consisted of either Invisalign or ClearCorrect. While I gave ClearCorrect an honest effort, I found it was light years behind Invisalign in terms of staging and ease of use—it simply wasn’t worth the cost savings, given the results I was able to obtain. To solve the cost problem, I was often encouraged to “sell” Invisalign to boost my status and achieve lower prices; however, I was unconvinced by the mathematics of this strategy. It is often cited that up to one-third of one’s Invisalign lab fee can be attributed to marketing, the rationale being that Invisalign sends patients to your door through its doctor locator. Similar claims are made about reducing chair time and the billable hours of an assistant to work it.

The unique economics of a startup practice, however, render these justifications rather weak. If my established competitor pays $1,100 per case, that would put his “marketing” portion at about $366, leaving about $734 as his “true” lab fee. Without a volume discount, my lab fee would be around $2,000. Subtracting out the same $734 “true” lab fee will leave me with a $1,266 “marketing” allocation per patient. This portion ultimately pays for marketing that pushes patients to a doctor locator in which I am at the bottom of the list. Put another way, newer offices pay almost twice as much toward Invisalign’s marketing campaigns, which benefit their largest competitors the most! Likewise, I am of the strong opinion that chair time is not expensive until one has maxed out capacity, a problem only a select few startup owners face.

Still, Invisalign is a known brand that patients ask for by name. Align Tech owns the most data of any aligner company and uses it to constantly innovate through the use of its “force-driven algorithm,” which uses pressure points and voids to induce tooth movement even as the shape of the aligner will not conform perfectly to the shape of the tooth or attachments. (This is a similar concept to placing a “dimple” in an aligner or retainer to induce tooth movement.) The company’s ubiquitous marketing also has, unfortunately, led some to believe they can trust the algorithm to make up for a paucity of their own clinical skills, which couldn’t be farther from the truth.

For those able to win at the volume game, lab fees can be quite justifiable; however, maintaining their status can result in pressure to oversell the product. Ultimately, I came to the conclusion that Invisalign makes the most sense for two types of practitioners: those who win at the volume game and achieve the highest statuses, and those who have a strong history with this modality and have mastered its nuances to the point that changing would be overly cumbersome. I encourage those who fall outside of these categories to consider some other options


 Testing new alternatives

By late 2018, I was becoming increasingly motivated to explore aligner alternatives when Invisalign stopped accepting scans from my Trios scanner. I was fortunate then to become an early adopter for 3M’s new Clarity aligner. This allowed me to cut my lab fees by one-third while using a product that was as effective as Invisalign for the mild to moderate cases I was treating.

Overall, I had an excellent experience with Clarity. The approver software was clean and efficient, but best of all it was web-based, so I could work from any computer in any location. (Invisalign has since developed a web-based “lite” version of ClinCheck as well.) Clarity uses a displacement-driven system in which aligners are formed by digitally sectioning teeth and incrementally moving them along their intended pathway. Aligner shape is identical to the shape of the teeth, a similar concept to “resetting” teeth on a plaster model and making an Essix retainer over it.

Clarity lacks optimized attachments and certain algorithmic functions proprietary to Invisalign, but this didn’t present a problem to me. I felt confident forgoing much of the algorithmic tooth movement to rely on my own knowledge of aligner mechanics instead. A newer feature of Clarity—and advantage over Invisalign—is the ability to use a more flexible plastic (“Flex”) initially, then switch to a more rigid plastic (“Force”) for finishing movements.

Overall, my experience with Clarity was one in which I felt little pressure to “produce” for 3M as we grew our brands together. I found that patients weren’t as married to the Invisalign brand as I had once believed and would easily go along with my recommendation of this alternative clear aligner. After years of monopolistic control by a single aligner product, it was refreshing to feel control gradually shifting back into the hands of orthodontists.


Keeping it in the (brand) family

In my practice, I primarily use Ormco products, including brackets, wires and instruments. So it was fortuitous when Ormco released its Spark aligner about a year after I adopted Clarity in my practice, and I was able to further increase my pricing advantage by combining my bracket and aligner volume discounts. This forever removed me from the hamster wheel of chasing status tiers, because I immediately qualified for an exceptionally low lab fee based on my bracket volume alone.

My first impression of the Insignia-based Spark Approver software was lukewarm because of the unfamiliar aesthetics and controls; however, I quickly grew to prefer it the more I practiced. The ability to view root position in three dimensions, for example, is a nice advantage that will continue to improve; Spark currently uses a library of root images but will soon have the ability to simulate actual roots with a CBCT image. Still, the fact that it was Windows-based when I used it presented a mild inconvenience over Clarity and Invisalign, especially for Mac-based practices. [Editor's note: Ormco later introduced a Mac-compatible version of this software.]

Results were comparable to those I’d achieved with Invisalign and Clarity; however, I thought Spark’s aligners were the clearest-looking ones (no striations). One of my favorite features was the flexible attachment template that “peels” off the teeth rather than “snapping” off, resulting in superior experience for both patient and assistant during bonding. Like Clarity, Spark also offers a more f lexible plastic (TruGen) for early movement, with a more rigid plastic (TruGen XR) for finishing movements. Support from Ormco has always been top-notch, which was a huge reason I’ve used the company for my supplies in the first place.


Trying in-office systems

In 2020, our office entered the realm of in-house aligners, first using Ortho Analyzer from 3Shape, then transitioning to uLab Systems in 2021. Being able to provide rapid turnaround cases for lab fees in the low hundreds of dollars was a true game-changer. We could now offer limited treatment to a category of patients overserved by comprehensive aligner packages. Ortho Analyzer was a natural entry point because the software was included with my scanner. Unfortunately, support from 3Shape was practically nonexistent because third-party distributors serve this function with inconsistent results. uLab, on the other hand, offered extensive one-on-one training at no additional charge, which greatly increased my confidence in the system and my willingness to prescribe it for my patients. I loved the ability to choose between printing in-office for decreased turnaround time or ordering aligners directly from uLab for better scalability.

With any in-office system, one must be prepared to invest time in learning, then training staff to set up and print cases. While uLab made the process rather painless by training my team, you should still expect a learning curve, especially if you plan to print in-house. There is also a financial cost to installing 3D printing hardware and the maintenance/supplies it will require. I strongly suggest anyone interested in taking this path observe an office that has successfully implemented this system, because it will save you weeks of frustration and experimentation.


5 keys to choosing the right clear aligner system

When learning from another’s experience, I find it more useful to examine how they arrived at their conclusions rather than what their actual conclusions were. Each of us is unique in our values and circumstances, so I recommend starting here:

  1. Define your practice identity by defining your values, goals, strengths and weaknesses. To what extent will your brand rely on those of the products you use? Do you have a competitive advantage that is favored by one product over another? For example, if you’re the largest practice in town, winning the highest Invisalign status could be advantageous to maintaining your edge. If you’re a startup with established incumbents, it may be better to keep overhead lower with newer brands like Spark or Clarity. If you value autonomy and are willing to invest time into developing in-house systems, uLab would be an excellent choice. A braces purchase history with either Ormco or 3M would also be considered a competitive advantage in that you can combine volume discounts.

  2. Observe those who have succeeded with similar goals. Once you have clearly identified your direction in concept, it is important to observe others who have implemented similar strategies. I highly encourage you to physically visit the practices of your mentors; this is the best way to pick up on details omitted in verbal discussions and to make stronger connections with them.

  3. Take courses to master your chosen technique. Aligner systems are, in the words of James Franco, “Same same, but different.” Much of our aligner CE is sponsored by manufacturers, which can present a myopic and biased message mixed with clinical techniques. While I find these CE courses valuable to mastering a particular product, I recommend supplementing these with more “agnostic” courses such as the Aligner Intensive Fellowship and Tipping Point Ortho that focus on broader concepts that can apply to any system.

  4. Trial and error. Taking your skills from theoretical to practical is a necessary step in the learning process. I recommend starting with enough simple cases to be challenging but not overwhelming—somewhere between five and 10 was the sweet spot for my practice. It is important to inform your patients of the product they are getting, especially if they were expecting Invisalign and you recommend an alternative. Many doctors will be surprised by the lack of pushback patients give to their recommendation. If you are a beginner with aligners, be sure to inform your patients that you will switch them to braces at no charge if satisfactory results can’t be achieved.

  5. Narrow your focus to one or two main products. Profitability and scalability require consistency and mastery. Once you’ve chosen the best product(s) for your office, focus your systems on their advantages and don’t look back. Learn to delegate as much of the process as possible and keep your systems simple for maximum efficiency.
With Great Parity Comes Great Responsibility

Conclusion

I hope that my experience has inspired you to explore and take advantage of increasing parity in the clear aligner market. Never has there been a greater opportunity to gain control of our practices by choosing an aligner system that works for the doctor, rather than the doctor working for the aligner company.

As exciting as this space may be, practice due diligence and never lose sight of the fact that we are, above all else, health care providers. Whatever decision you make, make it with clinical excellence as your highest priority, followed by practice management considerations. We are fortunate today to have choices in our clear aligner offerings, and with that ability to choose comes a responsibility to choose wisely for both our patients and our practices.
Author Bio
Andrew Sarpotdar Dr. Andrew Sarpotdar is a board-certified orthodontist in private practice with his wife, Dr. Jenny Sun, in the greater Phoenix area. He attended dental school at UCLA before earning his master’s degree in orthodontics from Columbia University in 2013. Sarpotdar is co-founder of the Orthodontic Pearls Facebook group, along with its corresponding annual meeting, the Mother of Pearls Conference, and is a strong advocate for collegiality and shared learning within the profession. In his free time, he enjoys traveling the world with his wife, working out and spending time with his twin puggles, Chief and Lexi.
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