How to Sell an Orthodontic Practice in 2026

Orthodontics is structurally different from every other dental specialty when it comes to selling a practice. The issue is simple: when a patient starts a $6,000 braces case and pays $1,500 up front with 24 monthly installments afterward, the orthodontist has collected cash but still owes the patient 18-24 more months of clinical work. That treatment-in-progress liability is the single biggest issue in every ortho practice sale, and if you don't understand how it gets allocated between buyer and seller, you will either leave money on the table or accidentally promise free work to hundreds of patients.

Orthodontics is also a DSO-heavy market. The ortho DSO space has consolidated aggressively since 2018, and as of 2026 there are roughly a dozen active PE-backed platforms paying 7-11x EBITDA for quality practices. Here's how to sell an ortho practice without getting crushed on the accounting mechanics.

The Active Orthodontic DSO Buyers

The DSO and PE buyer landscape for orthodontics:

• Smile Doctors (Linden Capital Partners) — the largest ortho-specific DSO in North America.
• OrthoFX — backed by Greenbriar Equity.
• PepperPointe Partnerships — partnership model popular with owner-orthodontists who want continued clinical autonomy.
• Benevis — multi-specialty including ortho.
• Specialized Dental Partners (Quad-C Management) — multi-specialty DSO including ortho.
• Orthodontic Partners — PE-backed platform focused exclusively on orthodontics.
• Dental Care Alliance — multi-specialty DSO with ortho division.
• Heartland Dental (KKR) — primarily GP but selectively acquires ortho.
• MB2 Dental (Charlesbank) — partnership model, includes ortho.

DSO multiples for orthodontics have settled into a range of 6-8x EBITDA for bolt-ons, 8-11x for multi-location platforms, and occasional outliers higher for strategically important assets. Single-location practices under $600K EBITDA typically sell to individual orthodontists at 1.5-2.5x SDE, similar to general dental practice multiples.

Treatment in Progress: The Deal Issue Nobody Warns You About

Here is the core mechanical problem in every ortho sale. Your practice management system (Dolphin Management, Cloud 9 Ortho, topsOrtho, OrthoTrac, or Ortho2 Edge) tracks every active patient and how much of their treatment has been delivered versus how much has been paid. The math typically works out something like this:

• You have, say, 600 active treatment patients.
• Total contract value across those patients: $3.6M.
• Collected to date: $2.1M.
• Remaining to be collected: $1.5M.
• Treatment completed to date (clinically): approximately 55% — so you've delivered $1.98M of clinical work and collected $2.1M, meaning you are $120K ahead of delivery on average.
• Remaining clinical work to deliver: $1.62M at contract prices.

The buyer is inheriting the obligation to finish treatment on those 600 patients. They will collect the $1.5M remaining balance but also incur the clinical and overhead cost of delivering $1.62M worth of ortho work. So the buyer's view is: "I'm inheriting a net liability here — I need to be compensated for that." And they will adjust the purchase price accordingly.

There are two common ways to handle this:

• Carry-forward method — the buyer assumes the treatment-in-progress liability and applies a purchase price reduction equal to the estimated cost of delivering remaining treatment (typically calculated as remaining clinical work value multiplied by the practice's overhead ratio). This is the most common approach in DSO deals.
• Cash allocation method — the seller and buyer agree on a dollar amount of collected-but-unearned revenue (a deferred revenue liability), and that amount is deducted from the purchase price. This is cleaner but requires a robust data pull from your practice management system.

Either way, the mechanics typically reduce the purchase price by $400K-$1.2M on a typical mid-sized ortho practice. If you're not ready for that conversation, you'll think the buyer is trying to re-trade the deal. They're not — they're doing basic TIP accounting.

Pull the TIP Report Before You Go to Market

The single most important document in your sale prep is a Treatment in Progress (TIP) Report pulled from your practice management software. You want this report to show, for every active patient:

• Treatment start date and projected completion date.
• Total contract amount.
• Collected to date.
• Remaining balance.
• Percentage of treatment completed (clinically).
• Estimated months remaining.

Dolphin, Cloud 9, and topsOrtho all have standard TIP reports. If yours is inaccurate — which it probably is, because most orthodontists don't audit the "percent complete" field — spend 3-6 months cleaning it up before selling. Have your treatment coordinator review every active patient and update the completion percentages based on actual treatment progress. An accurate TIP report can be worth $200-500K in the deal because it avoids the buyer assuming the worst.

Invisalign vs. Braces Mix

Buyers look closely at your Invisalign vs. traditional braces mix for several reasons:

• Invisalign margins are tighter — Align Technology takes a meaningful cut per case, so a high-Invisalign practice has lower per-case gross margin than a braces-heavy practice.
• Invisalign drives consumer demand — a practice that's capturing Invisalign cases is attracting the demographic that drives new patient flow.
• Direct-to-consumer competition — SmileDirectClub's 2023 bankruptcy reduced the DTC threat, but the category still exists (Byte, NewSmile, AlignerCo). Buyers price in the continued DTC risk on simple clear aligner cases.
• Invisalign tier status — Diamond, Diamond II, Diamond+ status drives rebates. Document your tier and your 12-month case volume history.

New Patient Flow and Marketing Spend

Ortho practices are heavily dependent on consistent new patient flow. Buyers want to see:

• Monthly new patient exam count for the trailing 36 months.
• Case acceptance rate (exams that convert to treatment starts).
• Marketing spend as a percentage of revenue (healthy practices run 4-8%).
• Referral source breakdown — GP dentist referrals, parent/word-of-mouth, digital marketing, community marketing.

If your new patient flow is trending down, buyers will flag it immediately and reduce the multiple. Two flat or declining years is a red flag. One year of decline with a credible explanation is manageable. If you see declining new patient flow, fix it before going to market — this is something digital marketing can move quickly with practices like Smile Savvy, HIP Creative, or People & Practice.

Associate Retention and Owner Dependency

Like other dental specialties, ortho practices have owner-dependency risk. If you're the only orthodontist, the practice is deeply tied to you. DSOs will typically require an employment agreement of 3-5 years post-close at market-rate compensation (typically 30-35% of personal production for orthodontists). If you want to retire shortly after selling, you need to have recruited a replacement associate at least 12-18 months before sale so the buyer sees transition-ready clinical capacity.

Staff retention matters too. Treatment coordinators, ortho assistants, and your office manager drive operational continuity. Document their compensation, tenure, and any at-risk relationships. Buyers will include key staff retention as a closing condition.

EBITDA Normalization for Ortho

Standard add-backs in ortho deals:

• Owner compensation to market — typically 30-35% of personal production.
• Real estate rent — adjusted to market if you own the building.
• Family member payroll — spouses on payroll at above-market rates get stripped.
• One-time items — equipment purchases, EMR conversions, legal settlements.
• Personal expenses — auto, travel, meals that ran through the practice.

Buyers will NOT add back legitimate marketing spend, legitimate staff compensation, or capital expenditures tied to ongoing operations. For more on what flies and what doesn't, see adjusted EBITDA add-backs.

Advisor Selection

Do not sell an orthodontic practice without an advisor who has actually closed ortho deals. The TIP liability mechanics alone will trip up any generalist broker. Experienced dental/ortho M&A advisors include Professional Transition Strategies, Menlo Transitions, Paragon Dental Practice Transitions, and the specialty practice groups at healthcare-focused middle market banks.

For broader preparation steps, review how to prepare your business for sale at least 18 months before you plan to transact.

The Bottom Line

Orthodontics is a good market to sell into right now. DSO buyers are active, multiples are reasonable, and the specialty's cash-pay mix protects it from most reimbursement risk. But the treatment-in-progress mechanics will ambush any seller who doesn't understand them in advance. Pull a clean TIP report, audit your active patient completion percentages, understand how the buyer will allocate the liability, and negotiate with full information. The orthodontists who walk into these deals prepared get paid. The ones who assume it's just like selling a GP dental practice get surprised at the closing table.