Orthognathic surgery: when the jaws, not the teeth, are the problem

Some bites cannot be corrected by moving teeth alone, because the problem is not where the teeth sit in the jaws but where the jaws sit in the face. When the upper and lower jaws are far enough out of proportion, and growth has finished, the options narrow to accepting the bite, camouflaging it with orthodontics, or repositioning the jaws surgically. That last option is orthognathic surgery.

What "orthognathic" actually means

Orthognathic surgery repositions one or both jaws. The bone is cut in a planned, predictable place, moved to a new position, and fixed there with small titanium plates and screws while it heals. The teeth are not the target; the bones that carry them are.

The common operations have names you will meet quickly once you start reading:

• Le Fort I osteotomy — the upper jaw. Moved forward, back, up, down, or widened.
• BSSO — bilateral sagittal split osteotomy, the lower jaw. Advanced or set back.
• Bimaxillary surgery — both jaws in one operation. More common than either alone in adult cases.
• Genioplasty — the chin point, moved independently of the jaw. Often added to one of the above.
• SARPE — surgically assisted expansion of a narrow upper jaw in an adult.

When it is genuinely indicated

Surgery becomes the honest recommendation when the skeletal discrepancy is large, growth is complete, and orthodontics alone would either fail to correct the bite or would do so by tipping teeth into positions that will not last. Typical situations:

• A lower jaw significantly behind the upper, where the chin sits far back and the overjet is severe.
• A lower jaw ahead of the upper — a true skeletal underbite that did not respond to, or was never treated with, growth modification.
• An open bite where the back teeth meet and the front teeth do not, and the cause is the shape of the jaws rather than a habit.
• Marked facial asymmetry, where one side of the jaw has grown differently from the other.
• A narrow upper jaw in an adult, where the palate will not split with an ordinary expander.
• Obstructive sleep apnea driven by jaw position. See jaw surgery, orthodontics and sleep apnea.

When it is not

Plenty of bites look severe and are not surgical. Crowding, even a lot of it, is an orthodontic problem. Moderate overjet in a growing child is often a growth problem, and that is a different conversation — see two-phase treatment. Many adults with mild to moderate skeletal discrepancies are treated successfully with orthodontics alone, accepting that the jaws stay where they are and the teeth compensate. That approach is called camouflage, and for the right person it is a good answer, not a compromise.

Our position on this is not neutral, and it is worth saying plainly. A great deal of adult jaw surgery traces back to a skeletal problem that was visible in childhood. Guiding jaw width and proportion while a child is still growing does not eliminate every future operation, but it changes the odds, and it is one of the reasons we look hard at seven-year-olds. It is also why we will not pretend surgery is avoidable when it is not.

The sequence, and how long it takes

1. Assessment and joint planning. Records, x-rays, a 3D scan, photographs. The orthodontist and surgeon agree on what moves and how far. Expect to meet both.
2. Pre-surgical orthodontics. Typically 12 to 18 months. This is the part patients find counterintuitive: the bite often looks worse during this phase, because the teeth are being straightened over their own jaw bases rather than compensating for the discrepancy. That is deliberate.
3. Surgery. A general anaesthetic, one to several hours depending on what is being moved, usually one to two nights in hospital.
4. Healing. Two to six weeks off work or school for most people. A soft or liquid diet for several weeks. Swelling peaks in the first few days and resolves over months.
5. Post-surgical orthodontics. Usually 6 to 12 months to settle the bite precisely into its new position.
6. Retention. Retainers, as with any orthodontic treatment. See retainers.

Start to finish, combined treatment commonly runs two to three years. Anyone quoting substantially less is describing a simpler case than most.

Risks worth understanding before you agree

This is real surgery on the facial skeleton and it deserves a frank list. Altered sensation in the lower lip and chin is common after lower jaw surgery and usually temporary, though a small proportion of patients have some permanent numbness. Relapse — the jaw drifting partway back — is possible, particularly in large movements and open bite cases. Other risks include infection, plate problems requiring removal, changes to the bite that need further orthodontics, and effects on the jaw joints. Your surgeon will discuss the specifics for your case; this page is orientation, not consent.

Cost and coverage in British Columbia

The surgical and hospital portion of orthognathic surgery is handled differently from the orthodontic portion, and eligibility depends on the specifics of the case and the assessment of the surgeon. Because the criteria change and are case-dependent, we do not publish coverage claims here. Ask the surgical office directly, and ask us separately about the orthodontic fee, which is quoted at your evaluation and is billed on an interest-free monthly plan through the clinic. See cost and insurance.

Getting a straight answer about your own bite

The only way to know whether a case is surgical is a proper assessment with records. A complimentary evaluation at myORTHODONTIST Maple Ridge will tell you which of the three paths — accept, camouflage, or surgery — actually applies to you, and we will say so even when the answer is that nothing needs doing.