Surgically facilitated orthodontics with clear aligners for severe malocclusion and gingival recessions

Background: Gingival recession defects (GRDs) pose functional and esthetic concerns and may be associated with unfavorable tooth positions. Surgically facilitated orthodontic treatment (SFOT) with clear aligners can be a valuable option for adults with severe malocclusion and GRDs.

Methods: A 28-year-old male presented with severe dental crowding, Class III dental malocclusion, localized tooth crossbites, and tapered maxillary arch. He exhibited multiple gingival recessions type I up to 6 mm in depth, at least 2 mm of keratinized tissue throughout, and a thick scalloped gingival phenotype. Clear aligner SFOT was performed including buccal corticotomies and bone augmentation with demineralized allograft between the first molars on both arches, dental expansion, interproximal enamel reduction, and use of intermaxillary elastics. Progress of the aligners occurred every 3 days for the first 6 months; and every 5 days thereafter, for a total duration of 10.5 months.

Results: Clear aligner SFOT led to tooth alignment, Class I occlusion, and improvement in smile esthetics. Complete root coverage was achieved on 50% of the teeth and the mean root coverage was 81.6%, ranging from 1 to 6 mm, while residual GRDs ranged from 1 to 2 mm.

Conclusion: Clear aligner SFOT can be a valuable interdisciplinary approach for the management of adults with multiple GRDs and severe malocclusion.

Plain language summary: Recession of the gingiva creates functional and esthetic concerns and is often related to unfavorable tooth position and tooth crowding. A surgical procedure called "surgically facilitated orthodontic treatment" (SFOT) with clear aligners instead of metal braces is a valuable treatment option for adults with receding gingiva and unfavorable tooth position. This report presents a 28-year-old male with severe tooth crowding and narrow tooth arches. He had several areas with thick, receding gingiva on the upper and lower jaws. The surgery involved the creation of bony cuts in between the roots, followed by bone grafting over the roots and cuts, on both jaws. The orthodontic treatment was executed with clear aligners and elastics. The patient was switching aligners every 3 days for the first 6 months and every 5 days thereafter. The total treatment duration was 10.5 months. Eventually, clear aligner SFOT led to the alignment of all teeth and improved the appearance of the smile. Receding gingiva was completely reversed on 50% of the teeth and improved by a mean of 81.6% (1-6 mm gain in gingiva). This report exhibits that this technique can be a valuable treatment approach for patients with multiple areas of receding gingiva, unfavorable tooth position, and crowding.

Key points: This case is the first to illustrate the successful management of multiple and severe gingival recession defects along with severe malocclusion with clear aligner surgically facilitated orthodontic treatment and no soft tissue grafting. The orthodontic tooth movements and surgical procedures were digitally planned and executed while the frequency of aligner change was every 3 days based on the regional acceleratory phenomenon. Proper tooth positioning within the alveolar housing along with bone augmentation led to the reduction/resolution of gingival recessions without the need for soft tissue grafting.