Intraoperative Challenges of Patient-Specific Osteotomy Guides in Anterior Maxillary Osteotomy: A Case Report

Orthognathic surgery has increasingly incorporated digital workflows and patient-specific surgical guides to enhance accuracy and predictability. While these technologies offer improved planning and execution, their intraoperative application in segmented maxillary osteotomies remains technically demanding. Limited literature exists describing the practical challenges encountered during guide-assisted osteotomy, particularly in anatomically constrained regions. This case report describes the use of a patient-specific cutting guide in a 24-year-old male patient undergoing anterior two-piece maxillary osteotomy for correction of skeletal Class II malocclusion with gummy smile. Virtual surgical planning was performed using cone-beam computed tomography and digital dental models to simulate a 7 mm maxillary setback and 4 mm superior impaction. A custom osteotomy guide and surgical splint were fabricated using computer-aided design (CAD)/computer-aided manufacturing (CAM) technology. Intraoperatively, the guide was positioned following mucoperiosteal flap elevation and used to perform vertical and horizontal osteotomy cuts. The maxillary segment was mobilized, repositioned using a prefabricated occlusal splint, and stabilized with titanium miniplates. The use of the osteotomy guide facilitated accurate transfer of the planned osteotomy lines and segment repositioning. However, intraoperative challenges were encountered, including increased operative time due to guide positioning and verification, limited access during osteotomy cuts, and difficulty in executing palatal osteotomy. Initial instability of the guide due to soft tissue interference required intraoperative adjustment. A minor palatal mucosal tear occurred, which was managed conservatively. Despite these challenges, satisfactory occlusal alignment and postoperative stability were achieved.