DERJ DERJ Dent Res J Dent Res J Dental Research Journal 1735-3327 2008-0255 Wolters Kluwer - Medknow India DERJ-22-37 00002 10.4103/drj.drj_251_25 2 Review Article Combined treatment approach: A review of using clear aligners in orthognathic surgery procedures Ahmadvand Atefe 1 Ebrahimi Hossein 2 dr.hosseinebrahimi@gmail.com Amiri Zahra 2 Besharatizadeh Parisa 2 Department of Orthodontics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran Department of Orthodontics, School of Dentistry, Shahed University of Medical Sciences, Tehran, Iran Address for correspondence: Dr. Hossein Ebrahimi, Department of Orthodontics, School of Dentistry, Shahed University of Medical Sciences, Tehran, Iran. E-mail: dr.hosseinebrahimi@gmail.com 09 2025 24 09 2025 22 9 37 13 05 2025 22 07 2025 03 08 2025 © 2025 Dental Research Journal 2025 This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License (http://creativecommons.org/licenses/by-nc-sa/4.0/), which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. ABSTRACT Background:

Clear aligner therapy (CAT) was originally introduced for minor orthodontic corrections. However, with technological advances and increasing patient demands for esthetic and comfortable treatments, its application has expanded into more complex cases, including orthognathic surgery. This narrative review explores the use of clear aligners across all phases of orthognathic treatment, such as presurgical, surgical, and postsurgical.

 Materials and Methods:

The literature from 2000 to 2025 was analyzed, identifying 34 relevant studies.

 Results:

Findings indicate that CAT can effectively manage dentofacial deformities such as skeletal Class II and III malocclusions, open bites, and craniofacial anomalies when used pre- and/or postoperatively.

 Conclusion:

Clear aligners offer significant advantages in esthetics, oral hygiene, treatment comfort, and quality of life. The combination of surgery and CAT has been demonstrated to reduce treatment time and increase patient satisfaction without compromising skeletal stability. Although there are some limitations, such as concerns about relapse and aligner rigidity in early postoperative phases, the results of occlusal stability, periodontal health, and patient satisfaction are promising. The increasing use of CAT in orthognathic surgery cases, particularly in digitally driven interdisciplinary treatment plans, is supported by this review as an effective and patient-centered alternative to fixed appliances.

 Key Words: Clear aligner therapy digital orthodontics orthognathic surgery surgery-first approach surgical splints OPEN-ACCESS TRUE INTRODUCTION

Fixed braces have been the orthodontic appliance of choice for over 100 years.[1] However, increasing patient demand for more esthetic and comfortable treatment options has driven interest in clear aligner therapy (CAT) in recent years. Despite growing popularity, the viability of clear aligners as a comprehensive alternative to fixed appliances remains a topic of ongoing investigation.[1,2] CAT involves custom-made transparent trays that apply gentle, controlled forces to move teeth. Its advantages – such as being nearly invisible, removable, and more comfortable – make it a popular choice for improved oral hygiene and dietary flexibility.[3] The development of CAT dates back to the 20th century, when dentists first explored the use of transparent plastic trays to realign teeth. They discovered that a sequential set of slightly modified aligners could progressively shift teeth into their ideal positions.[4] Initially, CAT was designed to address only minor tooth misalignments. While some systems continue to be restricted to treating mild positional issues, others have expanded their scope to include more complex malocclusions.[5] Over the past two decades, it has become a significant tool in managing malocclusions.[6]

In addition, individuals (generally adults) undergoing orthognathic jaw surgery are desiring for a speedy, clear, or invisible means of correcting their aberrant jaw and malocclusion problem.[7] With the growing popularity of clear aligners, it was a natural progression to explore their application in orthognathic surgery (OS) cases. In the current literature, there is not much research on the use of clear aligners in conjunction with OS. One of the earliest reports, published in 2005, described a case where clear aligners were used during the preoperative and postoperative phases, but the patient was switched to conventional fixed appliances shortly before surgery.[8] Given the digital nature of clear aligners, planning for surgical movements may be virtually performed, allowing for an immediate understanding of decompensation and appropriate customization of movements and the appliance versus an analog process.[9] Application of these techniques in OS allows optimization of the scope of indications and may increase case acceptance for surgical patients seeking esthetic and minimally invasive orthodontic options.[10]

This study aims to investigate the capabilities of clear aligners in different stages of orthognathic surgery and to investigate their effectiveness and efficiency in this procedure.

 MATERIALS AND METHODS

From 2000 to 2025, related articles were searched using databases such as ScienceDirect, Scopus, PubMed, and Google Scholar. All studies, published through March 25, 2025, were included in the study. The search keywords used are shown in Table 1. Relevant articles in the topic and abstract were assessed and included in the study.

Mesh keywords and synonyms

 RESULTS

An initial search was conducted using MeSH terms and related synonyms across databases, including ScienceDirect, Scopus, PubMed, and Google Scholar, covering 2000–2025. A total of 492 studies were identified. After removing 133 duplicate records, 359 articles remained for the screening phase. During this stage, 325 articles were excluded following a review of their titles, abstracts, and full texts due to irrelevance to the research topic. Consequently, 34 studies met the inclusion criteria and were incorporated into the final review. These included 17 case reports, 7 case series, 4 case–control studies, 2 randomized controlled trials, 3 retrospective studies, and 1 comparative study. Studies excluded from the review were those unrelated based on title, abstract, or full-text content, as well as review articles, including systematic reviews.

The included studies included data that included variables such as author (s), year of publication, study design, number and age range of participants, type of skeletal deformity, surgical intervention method, use of CAT, and reported outcomes. This information is summarized and compared in Table 2.

Overview of the characteristics, data extraction, and outcomes of the included studies

 DISCUSSION

OS is a combined orthodontic and surgical procedure used to correct dentofacial deformities that cannot be managed with conventional orthodontic treatment alone, such as severe Class II or III malocclusions, anterior open bites, and facial asymmetries.[44] These discrepancies often significantly impact facial esthetics, occlusal function, and overall quality of life, and their correction can greatly enhance patient self-esteem and psychological well-being.[45] The most commonly performed surgical techniques in OS are LeFort I osteotomy and sagittal split ramus osteotomy (SSRO),[46,47] which aim to reposition the maxilla and mandible for improved functional and esthetic outcomes.

Surgical orthodontic treatment requires close coordination between orthodontists and maxillofacial surgeons and often involves collaboration with other specialties throughout the diagnostic, treatment, and posttreatment phases.[48] A successful outcome depends on comprehensive planning and interdisciplinary communication. The orthodontic aspect of orthognathic cases is guided by a thorough understanding of malocclusion, particularly a differential diagnosis of its skeletal, dental, and facial components, as well as the limitations of current orthodontic approaches.[49]

To enhance the occlusion, orthodontic tooth movement is often started before surgery and continues afterward. In traditional protocols, fixed appliances are utilized to achieve this.[50] However, with the advancement of technology, clear aligners have emerged as a viable alternative. Their transparency, removability, and enhanced patient comfort make them especially appealing for individuals with high esthetic demands.[51] In orthognathic cases, the use of clear aligners requires meticulous planning for presurgical decompensation and postsurgical finishing.[52] As their material properties and clinical protocols have evolved, clear aligners have gained increasing popularity in orthodontic practices worldwide and are now considered a preferred treatment option in many cases.[53]

Treatment steps of clear aligner therapy in orthognathic surgery Presurgical preparation

Presurgical orthodontic goals should be clearly defined early on and may not require full arch leveling or ideal occlusion, as this phase determines the extent of surgical movements [Figure 1].[54] It typically lasts 12–24 months and addresses issues such as crowding, decompensation, and arch coordination. However, prolonged treatment may lead to complications such as gingival issues, root resorption, occlusal dysfunction, and psychological stress due to a worsened facial profile.[55,56] By eliminating dental compensations, orthodontists reveal the true skeletal discrepancy, enabling accurate surgical planning and better outcomes.[57]

Presurgical preparation in orthognathic surgery patients. The dentoalveolar decompensation process aims to reveal the true skeletal discrepancy by eliminating compensatory tooth positions. The black lines represent the occlusal relationship before presurgical orthodontic treatment, while the red lines illustrate the corrected position after decompensation. (a) Class II patients; (b) Class III patients.

Recent advances in OS aim to reduce the duration of preoperative orthodontic treatment and incorporate three-dimensional (3D) technologies into surgical planning to enhance precision.[58] One of the appliances that can be used in presurgical Preparation and decompensation is clear aligners.[11,21,24] Using clear aligners offers advantages such as reduced duration of preoperative orthodontics[35] and being an effective treatment.[8,11,34] Therefore, clear aligners can be considered a valid alternative for both pre- and postsurgical orthodontic treatment.[32]

 Surgical treatment

The orthodontist plays a key role in managing surgical-orthodontic treatment, especially during the preoperative phase, including arch preparation and creation of surgical splints.[59] While traditional OS uses brackets and wires for intraoperative splint stabilization, this is not possible with clear aligners.[23] For bimaxillary surgery, splints are used to achieve the final occlusion and stabilize the arches during healing.[60] In the clear aligner OS, tray splints are utilized, covering a greater portion of the dental crowns. Following surgery, clear aligners in combination with interarch elastics are used to maintain stability during the healing period. Unlike fixed appliances, clear aligners do not provide rigid fixation to the teeth; therefore, surgical management of the dentition and dental arches must follow a different protocol. Various fixation options are available, including bondable buttons, TADs, or a combination of both. Since interarch elastics require a stable point of anchorage, TADs are often essential during the presurgical phase to ensure adequate support.[61] The use of intermaxillary fixation screws facilitates precise surgical movements, accelerates the treatment timeline, and increases patient comfort.[62]

Clear aligners offer advantages such as precise seating of the dentition and quick fabrication through digital planning, although challenges such as high manufacturing costs and rigidity exist.[17] Clear aligner orthognathic splints provide full arch coverage, facilitating repositioning without wires.[17,41] Surgical splints are essential for stability in multisegmental surgeries, transverse stability, occlusal support when teeth are missing, and interdigitating occlusion in cases of worn or missing teeth.[63] The use of clear aligners in different types of OS is outlined below.

Maxillary surgery

Significant advancements have made maxillary surgery a safe and effective method for correcting midface deformities. Landmark studies have demonstrated that manipulation and segmentalization of the maxilla are safe, establishing this procedure as a cornerstone of corrective jaw surgery.[64] Patients with skeletal disharmonies and complex craniofacial anomalies, requiring multisegmented LeFort I osteotomies or asymmetrical movements, often undergo a psychologically challenging phase of presurgical orthodontic decompensation and segmental preparation using multibracket orthodontics. In this context, CAT presents a promising alternative, offering the advantage of a more aesthetic appliance and the potential for fewer appointments.[33] In addition, Xiao et al. found that LeFort I segmental osteotomy aided in decompensating the upper anterior teeth and reduced the duration of preoperative orthodontics when clear aligners were used.[35]

Mandibular surgery

Mandibular SSRO is a well-established procedure in craniomaxillofacial surgery, widely used to correct mandibular deformities such as retrusion, protrusion, deficiency, and asymmetry.[65,66] Its development marked a significant advancement in the field, as the technique allows broad bone contact for precise correction and effective spatial repositioning.[67] Boyd’s case report demonstrated that Invisalign could be used effectively alongside segmental or full fixed appliances immediately before and after surgery, and that in certain cases, like single-jaw mandibular advancement or setback, surgery was completed without buccal fixed appliances.[8] Similarly, Pagani et al. showed that in Class III cases, Invisalign provided precise results, improved esthetics, better oral hygiene, and high patient satisfaction, along with functional occlusal rehabilitation.[11]

Surgery first approach

The surgery-first approach (SFA) offers an alternative to conventional orthognathic protocols by eliminating or minimizing the presurgical orthodontic decompensation phase.[30] In this method, most teeth remain in their original positions at the time of surgery, and the goal is to achieve a treatable malocclusion postoperatively. To ensure success, orthodontists must be actively involved in the surgical planning to confirm the feasibility of managing the resultant occlusion. The skeletal and dental discrepancies are largely corrected through osteotomy, which simplifies the subsequent orthodontic phase, typically requiring only anteroposterior adjustments and minimal transverse or vertical movements.[68]

SFA offers several advantages, including earlier improvements in facial esthetics and dental function, reduced treatment complexity and duration[37,69] and increased patient acceptance.[70] By bypassing the lengthy presurgical phase, patients experience immediate enhancement in facial profile and a shorter total treatment time, approximately 5 months less than with conventional approaches.[71] In addition, the postsurgical period is characterized by accelerated orthodontic tooth movement, which further reduces treatment time and difficulty.[72] Overall, the SFA is seen as a valuable and efficient alternative for managing complex dentofacial deformities.

 Postsurgical finishing

Effective postsurgical management is crucial for achieving stable and predictable outcomes in orthognathic–orthodontic treatment. The main goals are to refine occlusion, maintain stability, and ensure long-term retention.[63] Postoperative orthodontics typically lasts 5–11 months, with no clear link to presurgical treatment duration.[73] Intensive monitoring is needed in the first 1–2 months to adjust elastics or mechanics, followed by extended intervals once stability is achieved.[63]

A multidisciplinary approach is often required for final adjustments.[74] CAT can begin shortly after surgery if the arch form is stable, although it may be more difficult in cases requiring maxillomandibular fixation due to nonrigid mandibular osteotomies.[61]

 Retention

Retention in surgical orthodontic cases typically involves a Hawley or wraparound retainer for the maxillary arch, chosen based on whether the case involved extractions, and a fixed bonded lingual retainer from cuspid to cuspid in the mandibular arch. Although many patients prefer clear retainers, they are acceptable as long as they do not interfere with occlusion.[75] When appropriately used, clear aligners can also serve as effective retainers. However, in cases involving maxillary expansion, more rigid options such as Hawley retainers or full-palatal-coverage Essix retainers are recommended to maintain transverse corrections.[76]

 Evaluation of efficacy, outcomes, and patient-centered benefits Efficacy and effectiveness

Based on the results of various studies, the use of clear aligners in the presurgical or postsurgical preparation stages can be effective.[8,11-13,15,17,21,22,26,27,33,34,43] While the use of clear aligners in the pre- or post-surgical preparation stages was considered very effective in a study compared to a fixed appliance,[36] another study found no difference between removable and fixed appliances.[32]

Nevertheless, clear aligners can be considered an efficient approach for the combined orthodontic and surgical treatment of skeletal Class II/III patients.[13,39] On the other hand, clear aligners as splints during the surgical process are also effective.[17]

 Oral Health-related Quality of Life

The removability of clear aligners facilitates better oral hygiene practices, potentially supporting improved dental and periodontal health during orthodontic treatment.[77] A 2023 systematic review by Kaklamanos et al. reported that CAT may be linked to improved oral health-related quality of life (OHRQoL) compared to conventional labial metal fixed appliances.[78] However, other studies have suggested that CAT may have a lesser impact on OHRQoL compared to conventional fixed appliances during the 1st year of treatment.[79,80]

Compared to conventional fixed appliances, patients treated with clear aligners following OS using the SFA demonstrated improved periodontal health and quality of life outcomes.[30,81] De Leyva et al. also reported that postoperative CAT with Invisalign in SFA cases leads to better periodontal status and enhanced quality of life.[30] This improvement in periodontal health in SFA cases was confirmed by another study.[36]

 Esthetic outcomes and patient satisfaction

Patient satisfaction with CAT has been reported to be very high, primarily due to the invisibility of the treatment and functional rehabilitation of occlusion.[11] The combination of SFA with clear aligners increases esthetic satisfaction, improves clinical outcomes, and reduces treatment time.[24] In addition, SFA treatment can enhance the facial profile, which is closely associated with increased patient satisfaction.[31,41] Studies have shown that clear aligners may be more effective than fixed orthodontic appliances in treating dental malocclusions.[17,29]

Due to their aesthetic and removable nature, clear aligners are considered a promising alternative to traditional orthodontics in OS,[26] as they eliminate the need for braces and wires[16] and reduce treatment time.[14,17,35,82]

 Occlusal outcomes

Clear aligners provide accurate 3D simulations for surgeons, essential for achieving optimal aesthetic and occlusal results in orthodontic–orthognathic combination treatment.[5] Kwon et al. found significant occlusal improvements with aligners, and orthognathic surgeries can be efficiently treated with them.[21] Zhou et al. demonstrated that early surgery for skeletal class III malocclusion improves facial profiles and functional occlusion with postoperative aligners.[31]

Li et al. confirmed that clear aligners offer similar skeletal stability to conventional methods.[37] Though some studies suggest that Invisalign cases may be more prone to relapse and that final occlusion can sometimes be less favorable, despite shorter treatment times.[83]

 Skeletal stability

The combined surgery-first and clear aligners treatment can achieve comparable skeletal stability to the conventional approach while also saving significant time.[37] The results of the Mangat et al. study demonstrate that skeletal relapse following OGS may not be affected by the mechanism of orthodontic therapy. Both fixed orthodontic appliances and CAT patients displayed minimal postoperative skeletal changes.[82] However, it is important to note that passive aligners may lack the necessary rigidity to adequately retain segmental movements in the immediate postoperative period.[84]

 Pain level, muscle soreness, and postoperative edema

While pain is a factor in orthodontic treatment, greater emphasis is often placed on predictability and technical outcomes, especially since pain differences tend to diminish after the initial months of treatment.[85] In the short term, CAT may cause mild tooth discomfort and masticatory muscle soreness, though these effects are generally limited. In addition, increased masticatory muscle soreness has been associated with frequent oral habits during CAT.[86] Almalki et al. reported that aligner-based orthodontic treatment can have varying effects on the masticatory muscles, often leading to an initial increase in symptoms that may improve over time.[87]

Patients that treated with Invisalign had significantly less facial swelling in the 1st postoperative week than those with fixed appliances.[88] In another approach described by Kankam et al., CAT was utilized in a complex triple-jaw OS (LeFort I osteotomy, bilateral sagittal split osteotomy, and genioplasty) case involving an Invisalign patient. The study found that perioperative outcomes and postoperative swelling were not significantly different compared to cases managed with traditional fixed appliances.[12] Based on the systematic review conducted by Rosenberg et al., it seems that CAT and fixed orthodontic treatment are comparable in facial swelling after OS.[89]

 CONCLUSION

CAT has emerged as a viable alternative to conventional fixed appliances in the context of OS. Multiple studies have confirmed its effectiveness in both presurgical and postsurgical orthodontic phases, demonstrating comparable skeletal stability and occlusal outcomes to traditional approaches. Clear aligners also contribute to shorter treatment durations in many cases, particularly with the SFA. Esthetic benefits, improved patient satisfaction, and better oral hygiene maintenance are notable advantages. Studies also show enhanced OHRQoL and periodontal outcomes in patients treated with CAT compared to those with fixed appliances. Despite these advantages, limitations remain. Passive aligners may lack the rigidity needed to retain segmental movements in the immediate postoperative phase. Some studies indicate a higher tendency for relapse due to the tipping movement mechanics of aligners. Moreover, while short-term discomfort, such as tooth pain or muscle soreness, is generally mild, aligner treatment does not significantly reduce long-term postoperative pain compared to fixed appliances.

Overall, CAT offers a highly aesthetic, patient-friendly, and efficient alternative for managing orthodontic-surgical cases, without compromising treatment quality or stability. With continuous advancements in digital planning and materials, its role in OS is expected to grow further.

Although attempted to cover a wide range of relevant studies by searching major databases, there is still a need for research with larger, randomized populations. Future research could also use standardized methods and a wider range of databases to conduct systematic reviews, providing stronger and more reliable evidence.

Declaration of AI-assisted technologies in the writing process

During the preparation of this manuscript, the authors used ChatGPT to improve readability and language. After using this service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

 Financial support and sponsorship

Nil.

 Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or non-financial in this article.

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