The Use of Clear Aligner Therapy for Orthognathic Surgery Patients: A Cross-Sectional Survey Among Saudi Orthodontics and Oral and Maxillofacial Surgeons

Study design and setting

This cross-sectional study was conducted using a closed-ended questionnaire designed online using Google Forms. It was distributed among orthodontists and maxillofacial surgeons practicing in Saudi Arabia. The survey was conducted between April 1 and May 31, 2023.

Sample size and population

According to recent data from the Saudi Commission for Health Specialties and regional workforce reports, there are an estimated 900–1,100 orthodontists and 400–500 oral and maxillofacial surgeons actively practicing in Saudi Arabia.²² Our sampling frame of 278 clinicians was drawn from professional networks and academic institutions, covering a cross-section of these specialties. The sample size was calculated based on the number of orthodontists and oral and maxillofacial surgeons practicing in Saudi Arabia, as stated by the Saudi Commission of Health Specialties, with a confidence level of 95% and a margin of error of 5%. The sample size was calculated to be 278 participants, and the survey was distributed via emails and social media platforms.

A non-probability convenience sampling method was used, which is appropriate for exploratory research involving geographically dispersed professional populations. Given the niche focus on surgical orthodontics and CAT, targeted sampling via professional channels was necessary to reach experienced clinicians. While convenience sampling may introduce selection bias, it remains an accepted approach in preliminary, perception-based clinical surveys.

Certain inclusion criteria were set for the selection of the study population: orthodontists and oral maxillofacial surgeons practicing in Saudi Arabia of both genders, with or without previous experience in the use of clear aligners for orthognathic surgeries. Likewise, exclusion criteria were also set: practitioners unwilling to participate in the study, incomplete responses, and general dentists. A visual flowchart of the recruitment and inclusion/exclusion process is provided in Figure 1, illustrating the total number of professionals contacted, eligibility screening, and final response count.

Figure 1. Flowchart of participant recruitment and selection process.

This figure illustrates the sampling method, survey distribution, inclusion and exclusion criteria, and the final sample of orthodontists and oral and maxillofacial surgeons who participated in the study.

Data collection instrument

The questionnaire comprised four sections. The first section includes demographic data. The second section was related to the current experience in orthognathic surgery and CAT. The third section addressed the knowledge of CAT used in orthognathic surgery patients. The fourth section was related to CAT practice in orthognathic surgery patients.

Validity and reliability

The content validity of the questionnaire was assessed by two subject-matter experts an orthodontist and an oral and maxillofacial surgeon who evaluated each item for clarity, relevance, and alignment with the study objectives. Based on their feedback, minor linguistic modifications were made, and two items were reworded to eliminate ambiguity, particularly regarding post-surgical treatment steps. No items were removed, as all were deemed essential to the study scope. To assess reliability, the questionnaire was pilot-tested with 20 participants, who completed the survey twice, one week apart. Responses were compared using Cohen’s Kappa statistic, which demonstrated substantial agreement (κ > 0.70), confirming good test–retest reliability of the instrument.

Ethical consideration

This study involved the collection of data from human participants (licensed clinicians), and as such, adhered to all ethical standards for research involving human subjects. Ethical approval was obtained from the Institutional Review Board (IRB) at Riyadh Elm University (Approval No. [FUGRP/2023/303/929]), in compliance with the Declaration of Helsinki. All participants were provided with detailed information regarding the study’s objectives, procedures, and data confidentiality protocols. Informed consent was obtained electronically from each respondent prior to survey participation. Participation was voluntary, and respondents were assured that their identities would remain anonymous and that data would be used solely for academic purposes.

Statistical analysis

Descriptive statistics were used to summarize participant demographics, current experience in orthognathic surgery and CAT, the knowledge of CAT used in orthognathic surgery patients, and CAT-related practice in orthognathic surgery patients. The frequency, percentage, mean, standard deviation (SD), and association (chi-square test) were calculated. Associations between categorical variables were tested using the chi-square test. Incomplete responses (n = 4) were excluded from the final analysis. Only fully completed questionnaires were retained to ensure data quality and consistency. No imputation methods were applied.

To compare the knowledge levels between orthodontists and oral and maxillofacial surgeons, a Mann-Whitney U test was performed using average knowledge scores derived from relevant questionnaire items. A p-value of 0.59 indicated no statistically significant difference between the two groups.

A univariate linear regression analysis was performed to examine the relationship between each demographic variable (age, gender, and professional experience) and the usage of clear aligner therapy (CAT) among orthodontists and oral and maxillofacial surgeons. To validate the regression model, the assumptions of linearity, independence, homoscedasticity, and normality of residuals were evaluated. The model yielded an R² of 0.38, indicating that age explained 38% of the variance in CAT usage. While this suggests a moderate level of explanatory power, the model’s purpose was exploratory rather than predictive. The adjusted R² was also reviewed to account for model complexity, further supporting the model’s suitability for hypothesis generation in future studies. Adjusted R² was also reviewed to account for the number of predictors and model complexity, supporting its appropriateness for hypothesis generation in future studies.

Given the number of statistical comparisons conducted, the potential for Type I error inflation is acknowledged. Although no formal correction (e.g., Bonferroni) was applied due to the exploratory intent and limited sample size, p-values near the threshold were interpreted cautiously.

The statistical analysis was performed using the Statistical Package for the Social Sciences Software (version 27, SPSS, Chicago, IL, USA).

Overview of findings

While traditional fixed appliances have long been the standard in pre and post-surgical orthodontic treatment, there is growing interest in the application of clear aligners, especially given their aesthetic appeal and enhanced patient comfort. However, the survey revealed a range of opinions on the suitability of CAT for managing complex skeletal discrepancies often requiring surgical intervention. This study offers initial insights into how Saudi orthodontists and oral and maxillofacial surgeons perceive the integration of CAT in orthognathic cases.

Out of the professionals surveyed, 46 responded, yielding a response rate of 16.5%. Respondents represented diverse regions and included proportionate representation of both orthodontists and oral surgeons. The results revealed general awareness of CAT and its emerging role in orthognathic cases within the surveyed Saudi sample, while also highlighting uncertainty regarding its practical application. The Mann-Whitney U test indicated no statistically significant difference in overall CAT knowledge between orthodontists and surgeons (p = 0.59), suggesting similar levels of understanding across specialties.

Although our survey had a low response rate, it is consistent with similar studies performed in other countries, which have reported both higher and lower participation rates.^23,24 One comparable study reported a 19.5% response rate from 233 participants, most of whom practiced in England, with a majority using CAT in their clinical workflow.²⁵ Invisalign was the most frequently prescribed system, and respondents often adjusted digital treatment plans due to discrepancies in final tooth positioning. These comparative findings place our response rate within an acceptable range for survey-based exploratory studies.

Knowledge and attitudes toward CAT

A significant proportion of respondents reported challenges with pre-operative positioning, leveling, and space-closing with CAT. Most agreed that the type of malocclusion affects the choice between CAT and a fixed appliance, with opinions divided on whether CAT outcomes are comparable to fixed appliances, particularly in post-surgical occlusion. Notably, some clinicians expressed concern about CAT’s predictability in complex surgical setups.

Regional variation in responses may reflect differences in population density, clinical training, and access to CAT systems. In South Korea, where computer-assisted orthognathic surgery (CAOS) is more established, clinicians report more advanced integration of CAT into surgery-first workflows. However, even there, broader clinical use is constrained by cost, the need for validation, and specialized training.²⁶ Globally, while enthusiasm for CAT is rising, systematic reviews suggest continued caution in surgical applications due to unresolved concerns about long-term stability, workflow complexity, and lack of standardized protocols.^27,28

The absence of significant knowledge differences between orthodontists and surgeons aligns with literature showing both groups have similar exposure to CAT protocols, especially in digitally supported workflows like 3D planning and simulation.²⁹

Comparative knowledge across specialties

This reflects global literature showing that both groups have similar exposure to digital workflows, particularly where interdisciplinary planning is emphasized.³⁰ According to published literature, while orthodontists and oral and maxillofacial surgeons agree on the benefits of CAT particularly for patient esthetic and comfort they also remain critical of the stability and control during IMF, as well as the accuracy of postoperative occlusion.^10,28 Particularly in surgery, first workup, digital planning along with coordination of appliances are challenging and require greater interdisciplinary collaboration.²⁹

Local clinicians have expressed high confidence in static CAOS tools for CAT, but have only limited adaptability to the full integration of such systems because of the cost and education base.²⁶ Long-term evidence and universal protocols remain insufficient, reinforcing the need for cautious optimism.²⁷

Awareness across populations

The awareness and perception of health professional graduates regarding the use of clear aligners in orthodontics ranged from moderate to low.³¹ Furthermore, several other studies have evaluated awareness of clear aligners among various groups, including dentists, dental graduates, the general public, and orthodontists. For instance, a study in Saudi Arabia examined dentists’ knowledge of clear aligners, revealing moderate awareness, with most respondents not opting for this treatment option for their patients.³² Another study performed in India, found that 93.5% of dental interns and 83.6% of dental undergraduates were aware of clear aligners,³³ while another study was performed in Saudi Arabia and reported that only 19.6% of the general public, out of 934 respondents, were aware of clear aligners.³⁴

Besides, CAT is considered as a popular treatment choice among many orthodontists, however not a common treatment for orthognathic surgery patients.

Attitudes toward CAT vs fixed appliances

A study performed in Canada and almost half of the orthodontists (47%) combined CAT with fixed appliances.³⁵

Across regions, CAT is generally perceived as more comfortable and aesthetically appealing than traditional fixed appliances. In East Asia, for example, social media influence, digital marketing, and cultural emphasis on facial harmony contribute to higher aligner demand, especially among younger adults.³⁶

In areas with an emphasis on precision of the treatment (e.g., parts of Europe and North America), clinicians continue to be skeptical of CAT’s capacity to address complex orthodontic mechanics. This concern is especially prevalent in the area of surgery, where clinicians expect outcomes to be highly predictable, and are slow to embrace aligners in the absence of clearly defined protocols and long-term success rates. Here, traditional braces remain more common due to their lower cost and widespread familiarity.

Demographic trends in usage

This is attributed to their exposure to digital workflows and CAT protocols during training, increased comfort with new technologies, and responsiveness to patient demand for esthetic and metal-free treatments. These clinicians are especially confident using CAT in mild to moderate adult malocclusions, where case complexity remains manageable.²³

Conversely, in parts of the Middle East and Asia, CAT use is more common among experienced clinicians. Here, senior practitioners often dominate surgical orthodontics, and their adoption of CAT is shaped more by clinical judgment and accumulated experience than by early exposure during training. Still, adoption among younger practitioners is rising, driven by evolving patient expectations, improved curriculum, and broader access to aligner systems.

Across all regions, adults remain the primary demographic for CAT, particularly working professionals who prioritize aesthetics and convenience. Studies also highlight increasing use of CAT in adolescents and even children for dentoalveolar changes, although evidence for skeletal correction is less conclusive.³⁷

Clinician experience also directly affects treatment outcomes: those using structured case selection protocols or assessment tools like the CAT-CAT index report improved predictability and fewer refinements.³⁸ Emerging technologies such as machine learning models that predict treatment refinement needs are poised to further assist both novice and experienced practitioners in case planning.³⁹

Socioeconomic factors also influence usage trends. In high-income countries, access to advanced 3D printing and aligner software enhances usage across age groups. However, in low-resource settings, cost and access barriers can limit the use of aligners, even among trained professionals. Multinational providers and mobile digital scanning platforms have helped expand aligner availability globally, yet disparities in access remain, particularly in underserved or rural regions.

Regional and global public/Professional awareness

Our study’s findings regarding professional awareness among Saudi orthodontists and oral surgeons appear to align with the limited public awareness reported in prior regional research. A recent study by Alsaeed et al. (2023) reported that only 19.6% of the general Saudi public were aware of clear aligner options for orthodontic care.¹⁵ This figure contrasts with awareness levels among Indian dental interns, which were as high as 93.5%, suggesting that educational exposure during undergraduate training may significantly enhance familiarity and confidence in CAT.

This discrepancy underscores a potential gap between rising aesthetic-driven patient demand and limited public awareness. Unlike in digitally-saturated markets, consumers may be less likely to proactively seek CAT unless informed by a clinician, suggesting a need for targeted public education campaigns and greater integration of CAT discussions during consultations. Bridging this gap may require collaboration between dental professionals, academic institutions, and aligner manufacturers to promote evidence-based awareness and ensure patients receive comprehensive treatment information.

Clinical challenges and workflow uncertainties

Respondents in the present study did not have a clear stance regarding whether CAT takes longer pre-surgical time or not. They believe CAT pre-surgical outcomes are similar to those of fixed appliance treatment. Respondents’ uncertainty regarding whether CAT requires more time before surgery. This may be attributed to differences in the complexity of the case and the treatment goals of the patient. Compared to fixed appliances that have a long history of treating a wide variety of complex malocclusions, CAT is still new, and its effectiveness may vary considering the malocclusion type, requirement in tooth movement, and the orthodontist’s experience in using technology.⁴⁰

A few clinicians stated that CAT can lead to pre-surgical lag because of the repetitive modifications of digital treatment plans, or challenges associated with achieving final tooth position where aligner refinements are required. Moreover, patient comfort and compliance in terms of aligner wear, which can vary widely, can affect these time perceptions.^10,13,14

In our Saudi orthodontists and oral maxillofacial survey, many of the respondents expressed anxiousness about workflow interference which has been blocking the best integration of the CAT with the orthognathic protocols. Critical factors were pre-surgical treatment delay, phase II with multiple aligner fits and aligner mechanics’ limitations in masking complex skeletal discrepancies.

These results confirm the observations of international literature where it is underlined how contemporary CAT systems are frequently unable to make sufficiently complex orthognathic cases without the adoption of hybrid protocols. For instance, 3D digital planning workflows integrated with computer-aided technology (CAT) custom titanium plates have been performed by North American surgeons has improved surgical predictability and postoperative management.²⁹ Although promising, these approaches need dedicated software, additional coordination at the chairside, and higher costs, which diminishes their applicability under low-resource settings.

In Europe, similar challenges are addressed through adjunctive techniques, such as temporary anchorage devices (TADs) and segmental surgery, to supplement CAT in treating skeletal Class III deformities and asymmetries, especially in surgery-first approaches.^27,28

Our results supported this global trend that CAT is a promising but technically challenging modality that demands interdisciplinary teamwork, strong digital infrastructure and flexible case-by-case planning.

Practice preferences and treatment decision factors

The current study highlights that clinicians in Saudi Arabia prioritize case complexity, patient demand, and comfort when selecting between Clear Aligner Therapy (CAT) and traditional fixed appliances. Survey responses showed that esthetic-driven demand, particularly among younger adults, plays a growing role in treatment planning. Nevertheless, clinicians remained cautious about using CAT in complex skeletal cases, especially those requiring precise post-surgical occlusion and long-term stability.

Although final refinements post-surgery were not widely reported as problematic, achieving ideal occlusion remains a key concern. Factors such as patient cooperation,¹¹ treatment cost and duration,¹² and coordination with oral surgeons often influence treatment selection. Some clinicians opt for hybrid protocols, combining CAT with fixed appliances or adjunctive tools like Temporary Anchorage Devices (TADs) in post-surgical phases.¹⁰

Skepticism toward CAT for skeletal discrepancies stems from its original design for dental malocclusions rather than orthognathic correction.⁴ Limitations in tooth movement control, especially without mid-course corrections, and short-term clinical experience further compound uncertainty.¹³

Globally, similar patterns emerge. In Europe, clinicians often adapt to patient demands for removable appliances even in less complex cases, balancing esthetic preferences with biomechanical viability.^41,42 In contrast, Asian clinicians emphasize predictability and long-term outcomes, favoring fixed or hybrid options for skeletal corrections.^26,29 These regional nuances underscore that CAT adoption is shaped by clinical culture, economic context, and patient expectations.³⁶

Implications for clinical protocols and training

The results of this investigation highlight an urgent need for evidence-based, standardized clinical protocols for the application of Clear Aligner Therapy (CAT) in orthognathic procedures. The present clinical ambiguities, particularly case selection, treatment sequence, digital treatment planning, and appliance modification in surgery-first protocols, reveal notable deficiencies in defined criteria and predictable results.

And this gap is not specific locally. Others overseas report similar struggles, and in places like North America and Europe, hybrid models of providing care are slowly starting to take off. These commonly incorporate 3D surgical planning, Temporary Anchorage Devices (TADs) and segmental surgeries to enhance predictability, stability and control for CAT-based interventions.²⁹ Even though there has been progress on this field, the lack of standardized protocols is still a big limitation; and especially for more complex skeletal deformities. Overcoming these implementation barriers will require major training reforms.

Orthodontists and oral & maxillofacial surgeons should have catered CATs in their postgraduate training. They should expand on digital workflows, aligner biomechanics, and technology integration, and allocate time to the importance of interdisciplinary cooperation, clinical sequencing, and the utility of hybrid approaches when CAT alone may prove inadequate.

Given global inconsistencies in CAT clinical protocols and persistent uncertainties in complex case outcomes, Saudi orthodontic and surgical training programs would greatly benefit from adopting standardized, interdisciplinary CAT education frameworks, ensuring better alignment with future-ready, evidence-based, and patient-centered treatment models.

Limitations

Despite providing valuable insights into clinician perspectives on clear aligner therapy (CAT) in orthognathic surgery, this study is not without limitations.

First, the sample size was relatively small, with only 46 responses obtained out of 278 invitations, resulting in a response rate of 16.5%. While this rate is comparable to similar professional surveys, it may limit the statistical power of the study and affect the generalizability of the findings across the broader population of orthodontists and surgeons in Saudi Arabia.

The low participation rate also raises the possibility of non-response bias (selection bias), where clinicians more familiar with or interested in CAT may have been more likely to respond. Although a formal non-responder analysis could not be conducted due to participant anonymity, this potential self-selection bias should be acknowledged.

Nevertheless, the statistical methods employed such as chi-square testing and univariate linear regression remain valid for exploratory analysis, and the model showed acceptable explanatory power (R² = 0.38), supporting preliminary associations. Future studies with larger, randomized samples are necessary to confirm and expand upon these findings. The study employed a non-probability convenience sampling approach, which, while pragmatic and commonly used in exploratory healthcare research, limits the representativeness of the sample. This constraint may affect the generalizability of findings to the entire population of orthodontists and oral and maxillofacial surgeons in Saudi Arabia.

Second, while the study draws on international comparisons to contextualize findings, these should be interpreted with caution. Variations in aligner systems (e.g., Invisalign, Clarity, AngelAlign), digital infrastructure, and regulatory environments can impact workflows, confidence, and adoption, complicating direct cross-country comparisons.

Third, the study relied on self-reported data, which may be subject to recall bias or overestimation of familiarity and competence with CAT protocols. This is particularly relevant in areas where structured CAT training is lacking or inconsistently delivered.

Despite these limitations, the study adds to the global understanding of CAT implementation and highlights important educational and clinical gaps that can be addressed in future research and policy reforms.

Given the complex, multidisciplinary nature of surgical orthodontics, ongoing collaboration and mutual learning between orthodontists and surgeons are essential to address evolving clinical expectations. Literature increasingly supports collaborative CAT planning, especially for protocols such as surgery-first, which require coordinated efforts in digital planning, appliance design, and clinical workflow.²⁹ A standardized protocol and education effort may help mitigate current clinical uncertainties and enhance patient’s outcomes. The establishment of a standardized clinical protocol and a consolidated training program may be an approach to overcome these inconsistencies and improve the prognosis of patients undergoing complex surgical procedures.