## 4 Discussion  
In accordance with previous publications [16], this case report highlights the possibility of treating a gummy smile Class II patient with a combined surgery-first approach using skeletal anchorage and aligners. The use of 3D individualised surgical plates instead of the common splint was essential to obtain the asymmetric maxillary impaction as planned before the treatment. Furthermore, the use of digitally-made osteosynthesis plates ensured that the pre-planned surgical movements were achieved and stabilised with the optimum fit. As previously suggested, splintless maxillary repositioning and patient-specific osteosynthesis plates could allow positioning of the maxilla independent of the amount of condylar sag and posterior pressure from the condyle [17]. The application of customised osteosynthesis plates without the need for occlusal splints permitted rapid and reliable positioning of the maxilla and can also be applied in cases of stable maximal intercuspation without asymmetric transposition of the mandibular-maxillary complex. Hence, we can  
Figure 6: Post Treatment Records. Patient after 15 months of treatment. confirm that the introduction of virtual treatment simulation and planning software utilising 3D imaging techniques and virtual models has greatly improved orthodontic diagnoses and the predictability of expected outcomes [18; 19; 20]. The use of the custom plates in combination with clear aligners allowed us to respond to the patient's complaints of a gummy smile and mandibular deficiency without the use of visible orthodontic appliances or pre-surgical facial aesthetic worsening. The patient had specifically requested 'invisible' orthodontic treatment and was well suited to this approach due to her good initial alignment and lack of major transverse discrepancies or occlusal interference simulating advancement to Class I relationships. Moreover, our patient presented minimal crowding in the anterior teeth, normal angle range between the basal bone and the upper and lower incisors, and no deep Spee curve, all features previously described as favourable factors for the surgery-first approach [21]. Finally, the use of Invisalign's ClinCheck system facilitated the precise development of virtual treatment goals by showing the intended final occlusion with a valid prediction of the final orthodontic outcome [16; 22; 23]. The combination of orthodontic treatment with aligners and initial surgery can be an extremely effective combination for patients who specifically require scarcely visible treatments and are not disposed to the 'aesthetic deterioration' classically characteristic of the conventional orthodontic-surgical protocol. Indeed, often patients who need orthographic surgery are held back or even refuse to undertake the therapeutic path, deeming the initial phase of aesthetic deterioration incompatible with their daily life or rejecting the notion of wearing brackets. The possibility of not wearing the classic braces combined with the possibility of seeing aesthetic improvement from the beginning can be instrumental in convincing patients to undergo necessary orthognathic surgery. However, it is important to underline that, as previously mentioned, the case described here presented ideal characteristics for this therapeutic approach, and this approach should not be considered an option in every surgical orthodontic case. Indeed, the presence of considerable dental crowding, the need to perform dental extractions or open or close already existing spaces in the arch, extremely accentuated arch curves, and the presence of severe occlusal instability after the simulation of surgical movements represent some of the factors which limit the applicability of the described protocol. In these cases, a conventional protocol should be prioritised, and the aid of orthodontic aligners employed depending on the specific case. During the post-surgical phase, the use of TADs was essential to solve the dental canting.