## 4 Discussion  
An SFOA is not recommended in more severe orthognathic surgical cases, due to the high demand of accuracy in a post-surgical occlusion that is not decompensated [13]; although, limits for planning an SFOA are under continuous expansion. As the understanding of an SFOA deepens, and new technological advancements emerge, the criteria for eligible cases are broadening, allowing more patients to benefit from this approach. Improvements in digital planning and 3D printing technology have made it possible to better predict post-surgical outcomes, even in moderately complex cases. The use of surgical guides and spacers can be used to overcome challenges in more complicated cases. The presented case fulfilled the guidelines for an SFOA, making her a good candidate for SFOA-CAT treatment. To date, there is no literature regarding case selections for SFOA-CAT, and our assessment is based upon our experience, where we look at the treatment modalities SFOA-CAT separately. In order to be a candidate, the patients' malocclusion must be possible to treat with CAT, as well as fulfill the guidelines for an SFOA. One of the limiting factors for SFOA-CAT are cases that require extensive root movements without the use of auxiliaries to aid with the movements. An alternative treatment approach involved bimaxillary surgery to correct the chin asymmetry through a bilateral sagittal split osteotomy. However, this option was not prioritized by the patient as it would entail additional surgical comorbidities. From an objective point of view, mandibular asymmetry was limited, and did not justify a bilateral sagittal split. Instead, the anterior open bite was successfully resolved by mandibular autorotation, as illustrated in Figures 7 and 8. Because of earlier orthodontic treatment with  
Figure 6: Final models. full fixed appliance, the patient expressed a preference for a less conspicuous appliance and sought to minimize the use of traditional braces, if feasible. Consequently, the patient favored the use of CAT. IMF in a clear aligner case differs from conventional treatment as there are no brackets when patients are treated with CAT. Clear aligner orthognathic splints [22; 29], TADs, brackets [22], and buttons, in combination with a splint [27], have been described. Our protocol regarding IMF included ligation to buttons in upper and lower jaw teeth together with a CAD/CAM designed and manufactured surgical wafer. To minimize the risk of displacement into the surgical site in case of debonding during the procedure, we employed a passive ligation technique for the buttons. Ceramic buttons were chosen for the incisors due to esthetic reasons, while metallic buttons were used on the sides due to their radiopaque properties, in case they needed to be located if displaced. It is important to note that using buttons carries a heightened risk of debonding incidents. Additionally, TADs were strategically placed to serve as both post-elastic guidance and a safety measure, in case the surgeon encountered difficulties with the buttons for IMF. The idea behind incorporating the surgical wafer and surgical spacers was to validate the precision of the in-house manufactured surgical guides and ensure a predictable surgical outcome. However, recent research has shown that wafer-less surgery with surgical guides offers improved accuracy in the maxilla [30]. It is worth noting that in-house resin-produced surgical guides have become a viable option and have the potential to replace traditional surgical wafers. Figure 7: Tracings before and after treatment. The additional corticotomies performed during the surgery were conducted with the sole purpose of increasing the RAP. However, future investigation into the effect of corticotomies in orthognathic surgery are needed. To our knowledge, while there are reports on the effects of corticotomies in general [31], none specifically address their impact within the context of orthognathic surgery.