Maxillofacial deformities are skeletal discrepancies that may lead to occlusal, functional, and esthetic problems. Their management requires a multidisciplinary approach, including careful orthodontic, surgical, and periodontal evaluation. Furthermore, when periodontal disease has already caused extensive bone resorption, the clinician faces the dilemma of whether orthognathic surgery is still appropriate or whether tooth extraction and implant placement should be considered instead. This decision should be based on the periodontal prognosis of the remaining teeth, the feasibility of achieving a stable occlusal and skeletal outcome, and, importantly, the patient’s motivation and compliance. Surgically assisted rapid palatal expansion (SARPE) appears to be a potentially effective technique for achieving transverse maxillary expansion in adult patients. However, possible adverse effects on periodontal and alveolar bone tissues have been reported, including alveolar bone thinning, gingival recession, and gingival hypertrophy. Only careful periodontal examination, appropriate case selection, and close periodontal monitoring can reduce the risk of significant complications. Overall, the take-home message is that successful surgical treatment depends on four key factors: proper case selection, patient preparation, surgical management, and post-operative care.