Management of the anterior open bite using clear aligner therapy and surgery-first: Case example and scoping review of the literature

The anterior open bite is challenging skeletal facial discrepancy and often requires a combined orthodontic and surgical approach to treatment. Traditionally, such approaches have involved use of conventional fixed orthodontic appliances in-preparation, followed by orthognathic surgery, and subsequent refinement of the occlusion with orthodontic treatment after surgery. Surgery-first approaches to treatment of skeletal facial discrepancies exist and have been demonstrated to provide excellent treatment outcomes with often shorter overall treatment times. The use of clear aligner therapy rather than conventional fixed orthodontic appliances has also been described in the treatment of various skeletal facial discrepancies. As providers offer surgery-first and clear aligner treatment options more frequently, a review of the available literature regarding the combination of the two modalities is needed, particularly for treatment of the anterior open bite. The primary objectives of this report are to systematically review the available literature regarding the use of clear aligner therapy and a surgery-first approach to treatment of the anterior open bite and to provide a case example. Advantages of using clear aligners versus conventional fixed orthodontic appliances will also be discussed. Articles included for review were studies addressing patients with an anterior open bite and the use of a surgery-first approach as well as clear aligner therapy. PubMed and Ovid were queried using the terms “clear aligners” AND “von Willebrand OR open bite”; “clear aligners” AND “surgery-first”; and “clear aligners” AND “orthognathic.” Additional references relevant to the review were obtained from the reference lists of available articles ultimately deemed appropriate for inclusion in the review. A recent example case of a patient with hemifacial microsomia and an anterior open bite undergoing a combined orthodontic and surgical approach to management is presented for consideration. A scoping review of the literature was undertaken for evaluation of available literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR). Insufficient evidence exists for significant analysis of clear aligner therapy directly compared to conventional fixed orthodontic appliances in patients undergoing surgery-first, as was the strategy used for the case presented. A review of the available literature with reference to updated literature regarding management of patients with an open bite specifically undergoing surgery-first and clear aligner treatment yields one two case series. The results indicate that further study of the subject in question is warranted, but currently available literature demonstrates positive outcomes with no reported sequelae for patients with anterior open bites specifically. The available literature supports the use of clear aligner therapy and surgery-first treatment approaches for patients with anterior open bite. In such patients, clear aligner therapy may be as effective as traditional fixed orthodontic appliances. Evidence already exists that clear aligners can be effectively used to manage the anterior open bite non-surgically in select patients. Based on the review of the literature, there is growing support for the combination of clear aligner therapy in the setting of surgery-first. Newer techniques for orthodontic and surgical approaches to patient management may allow for the expansion of procedures that can be safely considered in patients with anterior open bites and additional skeletal facial discrepancies.