## 4 Discussion  
The present study aimed to describe combined surgical and orthodontic treatments and compare fixed appliances versus clear aligners used in pre- and postoperative orthodontic phases. Orthopathic surgery associated with pre- and postoperative orthodontics represents the gold standard for treating skeletal malocclusions in adult patients. Previous studies also reported the long-term skeletal stability of the results, especially after bimaxillary correction [35; 36]. Orthopathic surgery positively affects the patient's psychology and self-esteem, improving psychosocial relationships and quality of life, especially in subjects with skeletal Class III malocclusion [37; 38]. In our study, the skeletal and aesthetic modifications following orthognathic surgery were analyzed by the comparison of lateral teleraliographies between T0 and T1. Indeed, lateral teleraliography allows us to evaluate hard and soft tissue measurements, as well as the anatomical characteristics of upper airways [39]. In the present study, we focused on aesthetic and skeletal changes following orthognathic surgery. Regarding the possible surgical consequences on airways, [PERSON] et al. described a reduced volume in posterior airway space in some subjects after bimaxillary surgery [40]. However, the onset of sleep-disordered breathing or obstructive sleep apnea after orthognathic surgery still remains unclear. The skeletal measurements detected at T0 were compatible with skeletal Class III malocclusion that qualifies patients to receive surgical treatment, whereas the relative T1 variations were related to the type of maxillofacial surgery performed [41]. In line with previous papers, we described the post-surgical changes a year after the orthognathic surgery, when the soft tissues had completed the healing process without any postoperative solid edema [42; 43]. Our results showed an essential modification of the face's middle and lower third, as confirmed in previous papers [44]. The increase in the convexity of the profile and the decreases in the lower and anterosuperior facial heights demonstrated how the surgery led to the achievement of a more orthognathic profile. We noted heterogeneous measurements regarding Pogonion that were probably due to possible mandibular rotation during surgery. The angular and linear cephalometric measurements evaluated in our study were consistent and reliable for performing pre- and post-surgical comparisons of hard and soft tissues in patients with skeletal Class III malocclusion who underwent an orthognathic surgery. As described in previous papers, our study further confirmed that a modification in the bone bases was associated with a variation in the soft tissues, leading to facial harmonization [45; 46]. Regarding the orthodontic phase, most previous papers dealt with conventional fixed brackets. On the contrary, few works examined clear aligners, despite their widespread use in orthodontics in recent years. The aligners associated with surgery show some undeniable advantages, such better aesthetics and home oral hygiene and less pain intensity [47]. On the other hand, the aligners are removable and, thus, require good patient compliance. We noticed analogous outcomes between fixed brackets and clear aligners, similar to previous papers [48]. In clear aligner cases, differently from other studies, we bonded metal fixed appliances before orthognathic surgery in order to facilitate intermaximillary fixation. For instance, CAD/CAM-designed acrylic splints or temporary anchorage devices (TADs) could be used for maxillomandibular fixation; however, conventional orthodontic brackets still represent a valid and simple approach for intermaximillary fixation, especially in multisegmental Le Fort osteotomies [49]. Therefore, the aligners were equally effective and, simultaneously, allowed us to satisfy the patients' aesthetic demands [50]. Similarly, [PERSON] et al.