Complex case treatment: Is there a limit for surgery-first approach?

Are there any limits for Surgery-first approach? the article strives to identify the tenets of effective management of complex cases, such as facial asymmetry, with surgery-first approach. The main purpose of the article is in attempting to itemize prerequisites or determining factors, through various degrees of facial asymmetry severity, for the successful management of facial asymmetry cases. The key factors such as (1) assessment of chin deviation, (2) quantification or discernment of transverse occlusal plane canting, (3) spatial orientation evaluation of differential anterior and posterior region transverse occlusal canting, and (4) contemplations of six degrees of freedom (6DoF) (translation movements combined with rotation axis - pitch, roll and yaw) are evaluated. Furthermore, dental alignment, severity of mandibular and maxillary occlusal (anterior and posterior) plane canting, critical cephalometric parameters, such as, incisor mandibular plane angle, and other vital sub- components of facial asymmetry are analysed, in detail. Subsequently, these are coherently synchronized with the maxillomandibular complex (MMC) rotation surgery during planning for the successful execution of facial asymmetry correction. Additionally, the article describes the (1) usage of orthodontic arch wires, (2) selection criteria of specific surgical osteotomies, and (3) coordination of maxillary and mandibular dentition to establish a transitional or treatable malocclusion. In conclusion, a thorough evaluation of the determining factors, as described in the article, for the correction of facial asymmetry with surgery-first, aid in categorising facial asymmetry cases that require minimal pre-surgical orthodontics or without pre-surgical orthodontic treatment, thereby defining the limits of surgery-first.