The Use of Clear Aligners for Orthognathic Surgery: A Systematic Review

Clear aligners, known for their esthetic appeal, are now increasingly utilized in orthognathic surgery treatment, offering preoperative and postoperative benefits. This systematic review aims to answer the research question: Are clear aligners as effective as traditional fixed appliances in achieving dental and skeletal changes, improving oral health, and enhancing patient-reported satisfaction in patients requiring orthognathic surgery?

We conducted a systematic review following a predefined protocol. We searched databases including MEDLINE, Web of Science, EMBASE, Scopus, and Cochrane's CENTRAL from inception until September 2024, with no language or date restrictions. Studies were included based on the Population, Intervention, Comparison, and Outcome (PICO) criteria, focusing on patients requiring orthognathic surgery (Population), the use of clear aligners (Intervention), compared with traditional fixed appliances (Comparison), and outcomes related to dental and skeletal changes, oral health, and patient satisfaction (Outcome). Inclusion criteria were clinical studies addressing the PICO question, while exclusion criteria were studies not involving human subjects or unrelated to orthognathic surgery with clear aligners. The risk of bias was assessed using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) and Cochrane Risk of Bias 2.0 (ROB.02) tools. Data extraction included publication year, study design, participant demographics, malocclusion type, surgical procedures, aligner specifications, treatment protocols, aligner utilization stages, treatment durations, and evaluated outcomes.

Our comprehensive search identified 765 studies, supplemented by 12 from manual searching. After screening, 34 studies underwent full-text review, and 16 clinical studies (375 patients) were included in the qualitative review: 2 randomized clinical trial, 2 prospective, and 12 retrospective studies. Four studies using presurgical aligners reported an increase in the incisor mandibular plane angle by 3 to 15° for Class III cases, while 2 studies on postsurgical aligners noted similar decompensatory movements, such as a change in incisor mandibular plane angle exceeding 10°. The remaining 7 studies used aligners before and after surgery and sometimes during surgery to create surgical splints. Comparative results between aligners and fixed appliances indicated no significant differences in dental and skeletal changes. Aligners had higher patient satisfaction scores (3 to 5 points higher on a 10-point scale) and better periodontal health outcomes. The Peer Assessment Rating score reductions were similar (60% for aligners vs 69% for fixed appliances). Overall, clear aligners may provide similar effectiveness to fixed appliances in orthognathic surgery while enhancing periodontal health and patient satisfaction. However, due to the low quality of evidence, these findings should be interpreted cautiously, warranting further investigation.

Based on the limited evidence available in our study, clear aligners may provide outcomes similar to those of fixed appliances in orthognathic surgery. They might also offer additional benefits in terms of periodontal health and patient satisfaction. However, it is important to interpret these findings with caution due to the limited quantity and quality of the studies. Further comparative research with rigorous methodology is necessary to confirm these initial observations and support clinical decision-making.