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Surgical Orthodontic Treatment with Aligners by Dr. Mark L. McInnis

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Categories: Orthodontics;
Surgical Orthodontic Treatment with Aligners How one complex surgical case was resolved using aligners instead of braces.

by Dr. Mark L. McInnis

Introduction
Even an old dog can learn new tricks. Here is a case I recently completed, highlighting a dilemma I faced a couple of years ago. After the clinical exam and records review, I discussed the patient’s skeletal and dental issues in detail (Figs. 1–3). Her treatment options included braces, aligners, camouflage versus surgical correction, and the probable need for extractions. Each option’s pros and cons were thoroughly discussed.

The patient and her family were open to surgery, but she was adamant about being treated with aligners. I was not concerned about arch width or incisor proclination. I believed she was dentally constricted, and with proper posterior torque and interproximal reduction (IPR), I felt I could establish a good post-surgical occlusion.

My concern was that she had a posterior arch length discrepancy that would require extractions of the lower second bicuspids to give the lower second molars enough room to erupt.
Surgical Orthodontics with Aligners
Fig. 1
Surgical Orthodontics with Aligners
Fig. 2
Surgical Orthodontics with Aligners
Fig. 3

Surgical Orthodontics with Aligners
Fig. 4


Surgical treatment approach
I am comfortable treating surgical cases with aligners, provided extractions are not required. If minimal root movement is needed, I find aligners more efficient. Aligners offer two main advantages:
  1. They decouple the teeth, making it easier to decompensate.
  2. All movements are performed with the post-surgical occlusion in mind.
To clarify, my practice primarily uses fixed appliances, not aligners, as I believe braces offer more control with most types of tooth movement. If this patient required extractions, I explained that I would need braces instead of aligners.


Challenges and solutions for surgical setups
When performing presurgical setups with braces, I inadvertently add arch width and torque forces that are not beneficial. The more I conduct surgical scans and model review appointments, the sooner I can address inappropriate tooth movements to improve efficiency. All aligner setups are designed with the arches positioned in the post surgical position.

Aligners don’t easily allow for post-surgical guiding elastics.

To solve this, my surgeon adds four tads to allow for elastics in the weeks following surgery. Furthermore, I will bond a lingual temporary retainer to the upper and lower incisors to stabilize them just before surgery. The posterior teeth can settle without aligners or retainers worn for eight weeks post-surgery.
Surgical Orthodontics with Aligners
Fig. 5


The deciding factor
My primary concern was the patient’s posterior arch length discrepancy. I initially believed extracting the lower second premolars (L5s) would be necessary. If L5s were extracted, braces would be required and future extractions of the upper second molars (U7s) would likely be needed.

After I consulted with my surgeon (Dr. Jim Howell from Carolinas Center for Oral and Facial Surgery) and expressed my concerns about the posterior arch length discrepancy and the need for L5 extractions, he suggested that the issue would be resolved with surgery, as it would increase the length in the retromolar area by 8 mm. This perspective had not occurred to me, and I do not believe it is a common consideration among orthodontists.


Patient consultation and decision
I discussed this option with the patient and her parents, offering them the choice of attempting non-extraction treatment with aligners or what I would consider a more traditional approach with extraction of L5s and treatment with braces. I explained that if there was insufficient space to clean the second molars properly, we could either extract the second molars, switch to braces, extract the 5s, and close the resulting space post-surgery.

After deliberation, they chose to move forward with aligner treatment and a BSSO advancement to be performed at 15 years of age.


Outcome
She was treated with two sets of aligners before surgery to allow for the BSSO advancement, which was done at 15. Her pre-surgical setup took 12 months. I performed approximately .3mm of IPR upper 6-6 and .5mm lower 6-6 (Fig. 6).
Surgical Orthodontics with Aligners
Fig. 6

After surgery, we waited eight weeks before a refinement scan was taken. I incorporated her lower second molars into her last two refinements post-surgery.


Results
Post-surgery, the posterior arch length discrepancy was significantly reduced. Her profile and post-surgical occlusion improved. Her dental arches were uprighted, and her incisor proclination was within normal limits.

I have included a series of panoramic radiographs that show the retromolar changes. I have requested the oral surgeon reshape the bone distal to the lower right second molar (LR7) to improve the retromolar tissue, as it still was not ideal at the end of treatment. (Figs. 7–15)
Surgical Orthodontics with Aligners
Fig. 7
Surgical Orthodontics with Aligners
Fig. 8
Surgical Orthodontics with Aligners
Fig. 9
Surgical Orthodontics with Aligners
Fig. 10
Surgical Orthodontics with Aligners
Fig. 11
Surgical Orthodontics with Aligners
Fig. 12
Surgical Orthodontics with Aligners
Fig. 13
Surgical Orthodontics with Aligners
Fig. 14
Surgical Orthodontics with Aligners
Fig. 15


Conclusion
Aligners can be an efficient tool for treating surgical cases that don’t require bicuspid extractions. BSSO advancements are a positive factor in reducing and potentially eliminating posterior arch length discrepancies.
Author Bio
Dr. Mark L. McInnis Dr. Mark McInnis is a native of South Carolina and has practiced orthodontics in the upstate area for more than 25 years. He earned his BS at Francis Marion University and his dental medicine degree at the Medical University of South Carolina. He then completed his orthodontic residency at the University of Missouri, Kansas City. McInnis stays on the cutting edge with the latest orthodontic technology, offering stateof- the-art braces and aligners. He has an on-site lab to create efficiency and quick turnaround on aligners, retainers and various appliances. He is the past president of the South Carolina Association of Orthodontists and the AAO’s component advocacy liaison for the state of South Carolina.


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