After successfully convincing the Chinese populace about the importance of dental aesthetics with a Silicon Valley mindset, this American brand has experienced a slowdown in growth in recent years. Additionally, it needs to confront increased local competition and ethical challenges.
By Yiyue Wang, Simin Wen
Zhou Yanheng’s first encounter with Invisalign was in 2000. As the Deputy Director of the Orthodontics Department at Peking University, he was sent for training in the United States and encountered this recently marketed clear aligner, which was braceless. Patients wore a set of transparent aligners that matched the shape of their upper and lower teeth. These aligners, colloquially known as “braces,” had several irregularly shaped “attachments” adhering to the teeth, interacting with the aligners, moving the teeth to achieve orthodontic effects.
Zhou Yanheng remembered observing several cases back then. Though simple, the outcomes were not satisfactory. “The teeth were crookedly arranged, some roots were still on the outside,” leaving him an impression that “this technology didn’t seem promising.”
Upon returning to China, Zhou continued his work at the Orthodontics Department of Peking University. In 2010, he was promoted to the Head of the Orthodontics Department. Towards the end of the same year, a company named Align Technology approached him. Align Technology is the parent company of Invisalign.
Zhou Yanheng became a pivotal figure in promoting Invisalign in the Chinese market. At that time, he was searching for a new technology that could serve as a hallmark for the Orthodontics Department at Peking University. The continuously improving efficacy of Invisalign over the past 13 years presented an opportunity. “In the past, we always lagged behind others and lacked the capability to develop tools. So, could we bring in the tools and create a good technical system?” Zhou Yanheng told CBN Weekly.
Under his leadership, Peking University School and Hospital of Stomatology organized a special seminar on Invisalign in 2011. The seminar invited orthodontists, including committee members of the Orthodontics Professional Committee of the Chinese Stomatological Association and directors of orthodontic departments in over 95% of the university-affiliated stomatological hospitals and specialized stomatological hospitals nationwide. The purpose of the seminar was to introduce Invisalign’s braceless invisible correction technology to the orthodontic community. Subsequently, many universities followed up with research.
The increased academic recognition and the unveiling of subsequent research results laid the groundwork for Invisalign’s further entry into hospitals.
In 2011, the China branch of Align Technology was formally established, at a near-perfect timing. Around 2010, China was at the beginning of a wave of consumer upgrades. The younger generation of consumers had higher requirements and more budgets for personal appearance. Consequently, there was substantial market demand in the field of oral health and dental aesthetics, which had long been overlooked by the Chinese population. The Consumer Confidence Index and a report jointly released by Kaidu Consumer Index and Tmall, titled “Grasping the Upgrade Route of New Generation Consumers,” indicated that in 2017, the sales of electric toothbrushes increased by 63%, and mouthwash sales increased by 48.6%.
The high-cost, medically intervened orthodontics market subsequently exploded. Data from 2018 revealed that orthodontic cases in China increased at a rate of approximately 12%, accounting for about 24.7% of the national oral healthcare services market. The flourishing mobile internet and social media accelerated the dissemination of various oral health knowledge, related products, and services. Searching for “orthodontics” on Little Red Book (a social media platform) yields over 100,000 notes. For adults regretful about their teeth during their growth stages, although more expensive, invisible aligners that do not affect appearance, are relatively comfortable to wear, and offer flexible follow-up appointments have become a new option. As this generation becomes parents, they are more attentive to the oral issues of the next generation.
With Invisalign entering China, Align Technology quickly achieved rapid growth in this emerging market. Between 2013 and 2017, Align Technology’s revenue in China had a compound annual growth rate of 102%. By the fourth quarter of 2019, this U.S. company had over 950,000 users in Asia, with China becoming Align Technology’s third-largest global market after the United States and the Netherlands. It was the only overseas market with factories, design centers, and commercial teams. In some instances, Invisalign even became synonymous with invisible orthodontics in China.
Two Technologies, Two Value Systems
In 1997, Zia Chishti, who had just completed orthodontic treatment and had a background in computer software, envisioned combining computer imaging technology to simulate tooth movement effects. He used this simulation to model the production of various transparent aligners for different treatment stages. This idea led Chishti and four partners to establish Align Technology in Redwood City, California, USA.
Although similar transparent aligners had appeared as early as 1945, they were primarily used for short-term retention and minor adjustments post-orthodontics. In comparison to fixed braces using brackets, commonly known as “metal braces,” the invisible aligners significantly improved the wearer’s experience and greatly mitigated issues like mouth irritation and food entrapment.
Conventional fixed braces emerged in the early 20th century and were introduced to China in the early 1990s, evolving into various techniques such as straight wire, rectangular wire, and self-ligating brackets. Brackets can be made from metal or a more aesthetic ceramic material. They can be attached on the buccal side (toward the lips) or the lingual side (toward the tongue). However, their biomechanical principles remain fundamentally the same—attaching brackets to the center of the tooth crown, securing different elastic and rigid wires to the brackets, and using wire deformation and elasticity to achieve tooth movement. On the other hand, invisible aligners, made of transparent polymer materials, encase the entire crown of the tooth. They generate forces on teeth and attachments through the deformation of the aligner itself.
The fundamental change lies in the treatment philosophy. Traditional orthodontics typically follows four stages: alignment, leveling, closing spaces, and refinement. However, the advent of invisible aligner technology breaks away from this fixed sequence. Digital aligner design allows teeth to align, level, and close gaps simultaneously. “With this approach, we don’t have to align the teeth first; we can immediately start closing gaps. It has changed the entire way of thinking,” said Zhou Yanheng.
Fixed braces heavily rely on the doctor’s personal experience, judgment, and manual skills to a certain extent. In contrast, the treatment plan for invisible orthodontics is digitized, where a significant amount of calculation and outcome prediction is delegated to computers. This digitized system continually enriches its database and self-optimizes as more cases are accumulated, although the doctor still remains a core component in the process.
The production of invisible aligners takes place in factories, freeing doctors from tedious tasks like bending wires at the chairside. However, it also demands a higher level of capability from doctors in terms of pre-designing treatment plans and conducting digital operations. “With fixed braces, adjustments can be made at each visit, but with invisible aligners, they are produced once. We have to anticipate potential issues during the process. If the design is flawed and the teeth don’t move correctly, we might need to restart, prolonging the patient’s treatment,” explained Hao Zeliang.
Older or more conservative doctors, familiar with fixed orthodontic techniques, might find it challenging to embrace the mindset of new technology or adapt to operating digital software. As a result, the main proponents of invisible orthodontic technology are mostly young doctors aged between 30 and 40. They rapidly mature in their profession with invisible aligners, even achieving significant career advancements. In this sense, the new technology acts as a catalyst for the younger generation’s careers, motivating them to invest time in researching and promoting the technology in treatments.
In October 2017, Align’s Invisalign System had a total of 40 early patents expiring in the US, leading to the expiration of corresponding patents overseas from 2018 onward, providing an opportunity for new entrants in the market.
In China, domestic brands like Angel Align and Smartee have emerged, targeting the lower-priced market segment and possessing more advantages for local competition.
In 2019, the orthodontic brand Ormco, under the dental giant KaVo Group, became the second American brand to enter China’s invisible orthodontics market. Its high-end product line, Spark, directly positioned itself against Invisalign. Moreover, both adopted similar marketing strategies to enter the market.
Key figures in opening up the market Since the inception of the product was not from medical professionals but from a bold attempt by an orthodontic patient, Align Technology, from the start, placed significant emphasis on consumer-facing brand education. Therefore, Invisalign globally promoted itself as a consumer product rather than traditional medical equipment, allocating substantial budgets for extensive advertising and consumer education.
However, medical services belong to the professional domain, where trust is crucial given the severe information asymmetry. As a device manufacturer, Align Technology wasn’t able to directly engage in sales. Doctors remained the most critical intermediary, which was one reason why they approached Zhou Yanheng in 2010.
At that time, one of Zhou Yanheng’s suggestions to Align Technology was to alter its strategy of collaborating with general practitioners (GPs) in the US market and directly promote the technology to professional orthodontists. “Align had previously faced challenges in the US market, as general dentists had limited knowledge of orthodontic technology,” Zhou Yanheng mentioned.
Apart from his role as the head of the orthodontic department in a public hospital, Zhou Yanheng personally established a private dental clinic, Sunny Dental, in 2007, mainly operated by his students. Consequently, Zhou Yanheng became the first certified doctor for Invisalign in China, leading two parallel teams in public hospitals and private clinics to advance clinical research.
Zhou Yanheng and his team chose common East Asian cases involving tooth extraction and skeletal issues as entry points. After five years, when both studies concluded, according to Zhou Yanheng’s estimates, Invisalign’s applicability for Chinese individuals increased from 20% to around 60%.
After stepping down as the head of the orthodontic department in 2015, Zhou Yanheng shifted his focus to clinic operations. In the same year, Sunny Dental received authorization from Align Technology, becoming the Invisalign China Center.
In addition to the Invisalign showrooms designed by Align, doctors at Sunny Dental could also try out the latest Invisalign products. For complex cases and new technologies, Invisalign’s clinical team frequently provided exclusive training to Sunny Dental doctors, such as treating the movement of posterior teeth forward or utilizing new attachment kits suitable for extraction cases.
To summarize the methodology of the non-bracket invisible orthodontic technology system, Sunny Dental held internal sharing sessions every two weeks and, together with Invisalign, organized the Great Wall Academic Forum annually. “Invisalign’s adaptability expanded to over 90% through continuous research,” Zhou Yanheng remarked.
Cooperation with Private Clinics and Doctors
On a Sunday in November 2020, the Invisalign Experience Center in Shanghai’s Xintiandi was hosting a seminar. Orthodontists were demonstrating facial changes resulting from orthodontic treatment to several consumers and provided each person with a brief facial examination.
The experience center serves as a direct point of contact between consumers and Invisalign. On four rows of display shelves inside the store, real photos of cases like deep overbite, retrognathism, and open bite were exhibited, along with the complete set of actual invisible aligners used for each case. Various Invisalign aligner boxes were arranged on the display table near the floor-to-ceiling windows. Here, Invisalign focuses on promotion without direct sales, directing final treatment decisions to doctors, such as scheduling onsite consultations at nearby clinics.
“Orthodontics lies between traditional healthcare and medical aesthetics, so we need to possess both the medical and professional qualities of traditional healthcare and conduct extensive marketing efforts similar to the medical aesthetics industry, managing the entire patient process,” former Align Technology employee Chen Bing told CBN Weekly.
Chen Bing further explained that Invisalign doesn’t just sell products to clinics but values long-term collaboration with them. The most common collaborations include providing promotions, planning marketing activities to attract new clients, and managing the retention of existing clients. Apart from clinic managers and frontline orthodontists, Chen Bing also interacts with marketing department staff, receptionist consultants, and even medical assistants.
Dentistry has relatively low entry barriers in the medical industry and is one of the earliest market-oriented specialized medical fields in China.
In the 1990s, dental chain brands like Jiamei, Baibo, and Rui’er were established, targeting the middle to high-end market. However, due to difficulties in standardizing treatments, their replicability was relatively low, with most stores concentrated in economically developed areas such as Beijing, Shanghai, Guangzhou, and Shenzhen. Around 2000, the dental industry formed a nationwide but regionally concentrated market pattern, which persists today. According to the “China Health Statistics Yearbook,” in 2003, China had 196 dental hospitals, of which only 37 were private, accounting for 19%. By 2018, the number of private dental clinics had increased to 624, accounting for 79%.
Private dental clinics are catching up with, and in some aspects surpassing, public hospitals in terms of medical technology, talent resources, equipment, and patient experiences. High-value-added services like orthodontics, implants, and dental cleaning have become the driving force behind the business growth of private dental clinics.
Hao Zeliang, who practices in both hospitals and multiple clinics, observed that while invisible orthodontics accounts for only around 10% to 20% in public hospitals, it can reach 40% in private clinics. In some clinics specializing in invisible orthodontics, the rate can even exceed 90%.
Generally, the sales of invisible aligners are mainly negotiated based on the material cost with private clinics, which is the fee charged by the brand. She Min, the Marketing Director at Dentexcel, a private dental clinic in London, told CBN Weekly, “Pricing primarily depends on the clinic’s positioning. High-end private clinics will set higher prices than public institutions. Additionally, Invisalign provides discounts based on the number of cases treated by doctors each year. The more cases, the higher the discount, resulting in lower costs.”
However, this is just the most basic aspect. “Invisalign is not only our supplier of aligners and software but also a strategic and market cooperation partner. They have a very close relationship with the clinics,” expressed She Min. Before the early stages of new product development, Invisalign’s regional managers gather opinions and demands. Following product development, they conduct training for clinic personnel, including attending physicians and market managers. “They frequently conduct regional market promotions, consumer training locally, and bring us along,” She Min added.
This methodology of collaborating with clinics has been carried over to China. Chen Bing informed CBN Weekly that depending on the level of collaboration, Invisalign provides different service levels at a brand level – from offering academic conference support and consulting training services to even streamlining internal processes with clinics to improve operational and digital efficiency in treatment.
The volume of case submissions and approved production is the most critical evaluation for sales performance. “Doctors submit more cases, and sales are generated only after the brand’s technical team approves the orthodontic plan,” stated Chen Bing, highlighting the importance of strengthening connections with doctors for invisible aligner brands.
Hao Zeliang occasionally receives updates from several leading invisible orthodontic brands, informing him about recent product launches and inviting him to training sessions.
Align Technology also replicated the Invisalign doctor training and certification system in China, establishing training centers in Chengdu and Shanghai. Doctors hoping for certification submit cases to Align Technology, participate in training sessions, and, after theoretical and case instruction classes, obtain Invisalign certification to begin treatment. Certified doctors have opportunities to attend company-organized courses, lectures, and more. With a higher number of accumulated cases, certified doctors can reach higher certification levels and may even be recruited as Invisalign lecturers.
By the end of 2019, approximately 96,000 doctors worldwide had received Invisalign training and handled cases in the past year. In the fourth quarter of 2019, over 3,200 new Chinese doctors joined training sessions. The substantial number of certified doctors serves as the first point of contact with patients, constituting one of the barriers for Invisalign in its current stage.
Market Competition and Ethical Challenges
According to an industry insider close to Align Technology, in recent years, there has been increasing pressure on Invisalign’s sales to meet performance targets. “Starting from 2019, Invisalign’s growth in China fell below expectations. Although the anticipated growth rate for 2019 was 70%, it might have only achieved 30% to 40% growth,” revealed the industry source to CBN Weekly. Align Technology’s annual report also indicated that after reaching a revenue growth of 91% in the Chinese market in 2018, it dropped to 26% in 2019.
The U.S.-China trade tensions in 2019, combined with consumers tightening their spending on non-essential goods during an economic downturn, have impacted overseas, especially American, brands operating in China. Simultaneously, the competition in China’s invisible orthodontics market has intensified, with various brands not only upgrading their product technology but also engaging in a battle involving pricing, the number of doctors, and consumer awareness.
The total price paid by patients includes the material fees charged by orthodontic device brands and the treatment fees levied by orthodontic institutions. Presently, the material costs for domestic orthodontic devices range from 3,000 to 10,000 yuan, while imported devices cost around 10,000 to 15,000 yuan.
Due to widespread promotions by brands offering lower prices to attract new customers, the overall charges for orthodontic treatment using high-end brands have decreased by more than 10,000 yuan in recent years. The reduction in fees for lower-end brands is even more noticeable. “A few years ago, using domestic orthodontic brands cost at least 20,000 to 30,000 yuan. Now, in some medical beauty institutions, it can be done for just over 10,000 yuan,” stated the aforementioned source.
One distinguishing characteristic of the demand for orthodontics among Chinese consumers is their exceptionally high pursuit of aesthetics. Individuals of East Asian descent often have slightly protruding jaws, whereas the current aesthetic preference leans toward a straighter facial profile resembling European or American individuals, where the line connecting the upper and lower lips sits a bit further back. With social media promoting the cosmetic effects of orthodontics, consumers generally expect orthodontic treatments to result in a more attractive side profile.
Apart from a slightly protruding front tooth, Zhang Xiaoye’s dental issues are not very noticeable to others. However, she decided to undergo orthodontic treatment because she is concerned about her slightly recessed chin. “Most East Asians have somewhat retrusive chins. Orthodontics can solve my retrusion problem, align the upper and lower teeth lines, and will definitely make my chin stick out, making my face look better,” she explained.
After conducting thorough research online, Zhang Xiaoye specifically chose an internationalized private dental clinic and selected an orthodontist who graduated from a prestigious institution and had experience studying abroad. Her orthodontic treatment is estimated to last about a year and a half, requiring around 40 sets of aligners, with a switch every 10 to 14 days.
“Some even desire a facial profile as slightly recessed as Yang Mi’s (a celebrity of China),” stated an orthodontist from a private clinic to CBN Weekly. She and her colleagues regularly follow the Chinese Journal of Plastic Surgery, both as a professional requirement and to aid communication with consumers.
Under this mindset, many Chinese consumers directly approach medical beauty institutions for orthodontic treatments. According to industry sources, several top brands have ventured into the medical beauty sector in recent years, signing bulk purchase agreements with large-scale medical beauty institutions to offer relatively lower supply prices, provided they ensure a certain annual purchase volume.
Unlike specialized dental clinics, medical beauty institutions employ a low-cost strategy by positioning dental services as a customer acquisition tool. Once they attract traffic, due to the lengthy orthodontic treatment duration and frequent follow-up visits, these institutions might entice consumers to spend on other medical beauty procedures during this time, thus securing long-term revenue.
Meanwhile, Smile Direct Club (SDC), established in the United States in 2014, introduced a Direct-to-Consumer (DTC) model, allowing patients to create teeth molds themselves, send them to the company, and receive customized aligners at a lower price, bypassing intermediary steps.
However, SDC’s business model triggered industry controversies due to its lack of medical professionalism. Align Technology’s relationship with SDC remains intricate. Align Technology previously sued SDC for patent infringement but later, in 2016, announced the supply of non-Invisalign aligners to SDC. They acquired a 19% stake in SDC and established a referral program to transfer complex cases performed by individuals to certified Invisalign doctors located in the patient’s area.
In 2017, the American Association of Orthodontists (AAO) filed lawsuits against SDC in 36 states, leading numerous orthodontists to question Align Technology’s role as a supplier. In November of the same year, Align Technology launched its first offline experience store in the United States, attempting to establish direct contact with patients. SDC accused Align Technology of imitating its business model and, in 2018, filed a lawsuit against Align Technology for violating non-compete clauses. On December 31, 2019, after the supply agreement expired, Align Technology ceased supplying aligners to SDC.
Similar controversies are replaying in China. In July 2020, a domestic clear aligner brand, FourSmile, positioned as a counterpart to SDC, claimed to have official supply ties with Invisalign. They even used phrases like “Invisalign decentralization” in press releases, which led to a dental community backlash. Align Technology swiftly released a statement asserting, “We have no association with any company or platform directly selling clear aligners to patients.”
On the other hand, Align Technology’s significant investment in direct-to-consumer marketing in China has created overwhelming brand awareness, elevating the personal brand influence of some doctors while making others feel that their professional value is being challenged. “Many patients come directly asking for Invisalign, and after comparing prices, they choose cheaper doctors. This makes doctors question their own relevance,” mentioned Chen Bing, who has observed a conflicting mindset among some doctors. They feel as though they are working for the brand while benefiting from it.
Globally, orthodontics is a postgraduate specialization. In other words, only graduates in orthodontics with master’s or doctoral degrees or those who have completed over a year of specialized orthodontic training at university-affiliated dental hospitals are recognized as orthodontic specialists. General dentists lack such specialized experience.
Initially, the growth in the number of certified aligner doctors came from conversions among orthodontists. However, as the market demand continues to grow and with a large number of young orthodontists getting certified, the brands have started focusing on general practitioners and even medical beauty doctors.
To compensate for the lack of knowledge among these doctors, aligner brands often offer them regular training and assist in treatment planning. The planning centers, based on big data, help doctors devise treatment plans, and the company’s in-house clinical teams aid in solving complex cases.
However, challenges arise accordingly. “While treatment planning has a foundation in big data, sometimes the designs for individual cases fail to meet clinical needs, requiring intervention and modifications by the doctors. If a doctor lacks professionalism or experience, it can affect the outcomes,” mentioned Hao Zeliang.
Zhou Yanheng also emphasizes that good outcomes rely on personalized treatment plans. “Despite having millions of cases and direct 3D printing from the data, everyone is different. Depending solely on the first version generated by big data isn’t adequate; doctors need to create multiple versions for modifications.”
With numerous non-orthodontic specialists entering clear aligner treatments, the risk of problems arising due to inadequate skills or judgment in approving initial plans unavoidably increases. As the brand scales up, the real issue of limited supply of orthodontists in China becomes increasingly apparent.
All those interviewed by CBN Weekly from the orthodontists, clinic staff, to brand sales personnel emphasized that dental orthodontic treatments cannot bypass the involvement of a doctor. There is a significant risk in proceeding with clear aligner treatment without the diagnosis and follow-up of a doctor. “Whether it’s fixed braces or clear aligners, the appliance is just one way to achieve the goal; the treatment outcome still relies on the doctor’s judgment and expertise,” emphasized Hao Zeliang.
It all comes back to the doctor. Following several controversies, Align Technology emphasized in its 2019 annual report that “doctors are at the core of everything we do.” However, amidst consumer enthusiasm for both beauty and health, there are more interests to be explored in the clear aligner market. The balancing act between medical aesthetics and medical treatment will continue as clear aligners seek equilibrium between the two.