When Is Orthognathic Surgery Needed? Braces or Jaw Surgery?

Bite problems have two main sources:

• Dental problem: The jawbones match each other, but the teeth are out of line or tilted. Crowding, gaps and teeth tipped forward or back fall into this group. These problems can usually be corrected with orthodontics (braces or clear aligners).
• Skeletal problem: The problem lies in the size or position of the jawbones. For example, the lower jaw is too long or too far back relative to the upper jaw. Even if the teeth are straightened, the bite and facial balance stay out of line because the jaws do not match. With a marked skeletal problem, braces alone are not enough; the jawbones are moved into the right position with orthognathic surgery.

Many patients have both. This is why orthognathic surgery is almost always planned together with orthodontics.

None of the following is a diagnosis on its own, but each is a good reason to have an assessment:

• A clear difference in profile: The chin sitting noticeably forward or back
• The lower teeth closing in front of the upper teeth
• Open bite: The front teeth not touching when the teeth are closed, making it hard to bite into food
• Facial asymmetry: The chin shifted to one side
• A lot of gum showing when smiling, or a lower face that is noticeably short or long
• Not being able to bite through food with the front teeth, or difficulty chewing
• Not being able to close the lips without effort
• Snoring and pauses in breathing during sleep, especially when the lower jaw is set back
• Recurrent pain or clicking in the jaw joint (not a reason for surgery on its own, but taken into account in the assessment; see TMJ Disorders)

With mild skeletal problems, the bite can be corrected by changing the angles of the teeth without touching the jawbones. This is called camouflage orthodontics: the jaw mismatch that causes the problem stays, but the teeth are positioned to hide it.

Camouflage orthodontics gives good results in suitable patients, but it has limits:

• If the jaw mismatch is marked, there is a limit to how far the teeth can be tilted; too much tilting can strain the health of the teeth and gums.
• Even if the bite is corrected, the facial profile does not change; for patients concerned about their profile, it may not meet expectations.
• In some cases the result may be more likely to relapse over time.

Which route is right depends on the size of the mismatch, facial structure, and the patient's concerns and expectations, and is decided jointly by the orthodontist and the oral and maxillofacial surgeon.

In growing children, some skeletal problems can be reduced at an early age with orthodontic appliances that guide jaw growth. This is why early orthodontic assessment matters in children.

Orthognathic surgery, however, is usually done after jaw growth has finished. An operation done while the jaw is still growing can be undone by later growth. There is no upper age limit for adults; general health is what matters.

1. Listening to your concerns. Is it appearance, chewing and biting, snoring, or all of these that bothers you? Expectations are discussed from the start.
2. Examining the face and bite. The face is examined from the front and in profile, and the bite and jaw joints are assessed.
3. Records. Facial photographs, skull X-rays and, if needed, a 3D CT scan are taken. Measurements on these records show how much of the mismatch comes from the teeth and how much from the bone.
4. Planning with the orthodontist. Whether camouflage orthodontics or orthognathic surgery is suitable is explained, along with the advantages and limits of each option.
5. Deciding together. Surgery is not so much an obligation as an option offered when it is clearly indicated. The decision is made together after the process, timeline, risks and expected change have been discussed.

• Any previous X-rays or CT scans
• Information about any previous orthodontic treatment
• Any sleep tests, if you snore or have sleep problems
• A few profile and smile photographs showing what bothers you can be helpful