We praise the authors of the article entitled “Surgery-first orthognathic approach vs traditional orthognathic approach: oral health-related quality of life assessed with 2 questionnaires” (Pelo S, Gasparini G, Garagiola U, Cordaro M, Di Nardo F, Staderini E, et al. Am J Orthod Dentofacial Orthop 2017;152:250-4) for their involvement in advancing the specialty of orthodontics and surgical disciplines. In recent years, we have come across a shift in the approach toward management of patients with dentofacial skeletal deformities. With the traditional orthognathic surgical approach, orthodontists and patients need tremendous patience to finally see the outcome of orthognathic surgery. However, recently, the structure and process of managing a skeletal adult patient has taken a new dimension with the introduction of the surgery-first approach to orthognathic surgical protocols. Although it is a promising venture, there are no strong conclusions regarding the outcome of the protocols or the associated oral health-related quality of life.

This study is a move forward with the cue to understand further the merits of the approaches. However, we have a few concerns that may need clarification.

• 1.

  What is the nature of a skeletal Class II malocclusion with a mild curve of Spee? All the subjects required bimaxillary surgeries. We wondered how the clinicians managed to selectively choose those with a mild curve of Spee in the skeletal Class II deformity who required bimaxillary surgeries. We would like to know the severity of a skeletal Class II or Class III deformity that can have profound implications on the differences in the outcome of both approaches and the associated oral health-related quality of life.

• 2.

  What is the distribution of Class II and Class III subjects in each group? We could not find the details in the article. The esthetic and functional concerns between these types of deformities could differ, and accordingly, quality of life could vary. Have the authors considered comparing the quality of life outcomes between the skeletal deformities across the groups?

• 3.

  It is not clear from the description in the “Material and methods” section what the timeline was for the administration of the questionnaires in both groups: “… the patients were given the following self-administered questionnaires before bracket placement, 1 month preoperatively and 1 month postoperatively for both groups: the OQLQ-22 and the OHIP-14.”

• 4.

  Quality of life was assessed 1 month postoperatively, which referred to the end of the protocol. However, we are concerned that assessment of the health-related quality of life cannot be limited to that time point (1 month postoperatively). The reason could be the difference in the quantum of postsurgical orthodontic treatment phase associated with both approaches. Quality of life assessment may need to be more elaborate during this phase of treatment (postsurgical orthodontics) to represent the true differences in the approaches. Although we understand that the investigators used exclusively the Orthognathic Quality of Life Questionnaire (OQLQ-22), it seems prudent to assess the quality of life comprehensively.

We would appreciate clarifications regarding these concerns.