# Wafers Orthopathic Surgery with Customized Osteosynthesis and Surgical Guides: A Prospective Study
## 4 Discussion  
Securing accurate and predictable results with validated treatment protocols should be the goal in OS. In this regard, CAD/CAM technology and digital protocol workflows contribute to improve the surgical treatment plan and reduce the preoperative steps--leading to increased accuracy and efficiency in affording improved patient outcomes. The incorporation of 3D printing to OS has paved the way for the development and production of customized surgical guides and customized titanium plates. Such guides not only enhance surgical accuracy but also contribute to reduce surgery times and possible postoperative complications [13, 14, 16, 20, 21]. CAD/CAM technology also allows us to design and fabricate CMTPs that seamlessly fit the anatomy of the patient, facilitating optimal outcomes and reducing the complications associated with ill-fitting titanium plates. Traditionally, occlusal wafers (also known as splints) were used to guide repositioning of the jaws during OS. These wafers were created based on dental impressions and plaster models, which could prove time consuming and sometimes led to inaccuracies due to the manual fabrication process involved [22]. Additionally, patients were required to wear the wafers for an extended period of time, which could cause some discomfort. Novel approaches in orthognathic guided osteotomies seek to eliminate the wafer entirely, using CMSGs and CMTPs to reposition the maxilla independently from the mandible. Several authors have assessed the accuracy of splint-guided orthognathic surgery, reporting that the greatest deviations between virtual planning and the final outcome were found in the vertical dimension [23, 24]. In 2020, [PERSON] et al. conducted a randomized controlled trial in which 31 patients underwent conventional model surgery (control group) and 27 underwent orthognathic surgery without a surgical wafer. The results showed  
Figure 6: Box plots depicting signed linear deviations between the preoperative plan and the final result, categorized by axis (X/Y/Z). * Statistically significant (Bonferroni test, \(p\) < 0.001). the control group to have a mean deviation of 1.74 mm versus 1.05 mm in the waferless group [25]. With the use of CMSGs and CMTPs there is no need for an occlusal splint to achieve the planned bone movements, as described in the present study. Our protocol converts a bimaxillary technique into a procedure where the maxilla is positioned and fixed independently from the mandible as in a monomaxillary procedure, and the mandibular osteotomy is then performed. An additional advantage of using CMSGs in combination with CMTPs is preoperative planning of the screw position with regard to bone thickness and dental roots. This is especially important when segmenting the maxilla, choosing the best plate and screw position, and avoiding the risk of damaging the dental roots. The main disadvantage is a current turnaround time of approximately 2-4 weeks from approval of the virtual plan to delivery of the procedure kit to the hospital. Therefore, planning of the entire procedure has to be made weeks in advance and must be adapted into the clinical process. In our protocol, the minimum time was 5 working days to print and send the guides and plates to the hospital. This is because the manufacturing plant of the osteosynthesis company is located less than 50 km from our hospital. In any case, this timeframe for planning and fabrication in elective OS should be a minor problem. All cases included in our study were completed without unexpected incidents. Due to the lack of published randomized controlled trials, the current evidence is not strong enough to recommend the use of CMSGs and CMTPs for OS. In this regard, more well designed randomized controlled trials are needed to confirm significantly superior efficacy of waferless surgery. The main objective of our study was to assess the accuracy of waferless OS using CMSGs and CMTPs after virtually planned surgery.