Orthognathic surgery is a procedure that repositions the upper jaw, lower jaw, or both to correct skeletal misalignments that braces alone can’t fix. It’s performed by an oral and maxillofacial surgeon, typically in coordination with an orthodontist, and involves precisely cutting and moving bone segments into a new position where they’re secured with titanium plates and screws. The surgery is done entirely through incisions inside the mouth, so there are no visible scars on the face.
Why Jaw Surgery Is Needed
Braces and aligners work well when teeth are crooked but the underlying bone structure is reasonably aligned. When the problem is the jaw itself, meaning one jaw is too far forward, too far back, too narrow, or asymmetric relative to the other, no amount of tooth movement can compensate. This is the core distinction: orthognathic surgery corrects the skeleton, while orthodontics corrects the teeth.
The conditions that lead to surgery vary widely. Some people have a lower jaw that juts forward (skeletal Class III), making it difficult to bite into food. Others have a recessed lower jaw that creates a large gap between the upper and lower front teeth. Vertical problems are common too, such as an open bite where the front teeth don’t touch even when the back teeth are fully closed, or a face that appears excessively long or short. Facial asymmetry, where the chin deviates noticeably to one side, is another frequent indication. In adults who have stopped growing, surgery combined with orthodontics is the only reliable way to resolve these skeletal discrepancies.
Beyond appearance, jaw misalignment creates real functional problems. Chewing can be inefficient or painful, speech may be affected, and breathing can be compromised. Maxillomandibular advancement, a version of this surgery that moves both jaws forward, is one of the most effective treatments for obstructive sleep apnea. A meta-analysis of outcomes found that this procedure reduces the number of breathing interruptions per hour by roughly 30 events on average, a substantial improvement for people with moderate to severe sleep apnea.
The Three Core Procedures
Most jaw deformities can be addressed with three well-established operations, used individually or in combination.
Le Fort I osteotomy targets the upper jaw. The surgeon separates the entire upper jaw from the rest of the facial skeleton, then repositions it. It can be moved forward, upward, downward, or rotated to correct an open bite, a gummy smile, or a recessed midface. Once in the planned position, titanium plates and screws hold it in place.
Bilateral sagittal split osteotomy (BSSO) addresses the lower jaw. Precise cuts are made on both sides of the lower jaw behind the back teeth, allowing the tooth-bearing portion to slide forward or backward. This is the go-to procedure for correcting a protruding or recessed lower jaw. It’s also fixed with titanium hardware.
Genioplasty reshapes the chin independently of the teeth. The chin bone is separated and moved forward, backward, up, or down. This is sometimes performed alongside a Le Fort I or BSSO to fine-tune facial proportions, or on its own for isolated chin deficiency.
When both jaws need correction, the surgeon performs a Le Fort I and BSSO in the same operation. This “bimaxillary” approach is common because many skeletal problems involve both jaws contributing to the overall imbalance.
The Full Treatment Timeline
Orthognathic surgery isn’t a standalone event. It’s the middle phase of a longer process that typically spans one to three years from start to finish.
Pre-Surgical Orthodontics
Before surgery, you’ll wear braces or aligners for a period that varies depending on your case. The orthodontist’s goal during this phase is counterintuitive: they often make your bite look and feel worse before surgery. This is called “decompensation,” and it means moving your teeth into positions that will align properly only after the bone is repositioned. Your teeth may have naturally tilted over the years to compensate for the skeletal problem, and the orthodontist needs to undo that compensation so the surgical plan works. In a newer approach called “surgery first,” this pre-surgical phase is skipped or shortened to one or two months, with most orthodontic work happening after the operation.
The Surgery Itself
The procedure is performed under general anesthesia and takes anywhere from two to five hours depending on complexity. Modern techniques use 3D computer planning to map the exact millimeter movements before entering the operating room, and custom surgical guides to execute them precisely. You’ll typically spend one to two nights in the hospital afterward.
Post-Surgical Recovery
The first two weeks are the hardest. Your face will be significantly swollen, your jaws may be held together with elastic bands to guide healing, and you’ll be restricted to a liquid diet. The most common post-surgical diet protocol is liquids for two to four weeks, followed by soft foods for another two to six weeks. Weight loss during this period is nearly universal, and your surgeon will give you guidance on maintaining caloric intake through smoothies and protein shakes.
Most people return to work or school within two to three weeks, though swelling takes longer to fully resolve. You can expect the majority of visible swelling to subside within six to eight weeks, with residual subtle swelling continuing for up to a year. Post-surgical orthodontics then fine-tunes your bite over the following months.
Nerve Changes and Other Risks
The most talked-about risk of orthognathic surgery is altered sensation in the lower lip and chin. The inferior alveolar nerve, which provides feeling to this area, runs directly through the bone that’s cut during a BSSO. Temporary numbness or tingling after lower jaw surgery is extremely common, with studies reporting it in anywhere from 20% to 98% of patients in the early postoperative period. For most people, sensation gradually returns over weeks to months. Persistent changes in feeling, ranging from mild tingling to complete numbness, occur in a smaller but significant percentage of patients, with reported rates varying widely from near zero to as high as 82% depending on the study and how “persistent” is defined. This wide range reflects differences in surgical technique, how aggressively the nerve was handled, and how sensation was tested.
Other risks include infection, bleeding, unfavorable splits during surgery, and the possibility that the bone segments don’t heal properly. Titanium hardware occasionally becomes bothersome and needs removal months or years later. These complications are relatively uncommon in experienced surgical hands, but they’re worth understanding before committing to the procedure.
Long-Term Stability and Relapse
One concern patients often raise is whether the jaw will drift back toward its original position after surgery. Some degree of skeletal relapse does occur. Research on maxillary advancement found an average relapse of about 1.8 mm from an initial advancement of 6.3 mm, roughly a 29% partial return toward the starting position. Mandibular setback procedures show similar rates, around 25%. Most of this movement happens in the first year after surgery and then stabilizes.
This doesn’t mean you’ll lose the results. A 25% to 30% relapse from a large surgical movement still leaves a very significant correction in place, and surgeons typically account for some relapse in their planning. Rigid titanium fixation, which replaced older wire-based methods, has improved stability substantially. Post-surgical orthodontics also helps compensate for minor skeletal shifts by fine-tuning tooth positions.
Insurance Coverage and Cost
Orthognathic surgery is expensive, often ranging from $20,000 to $40,000 or more including hospital fees, anesthesia, and the surgeon’s fee. Whether insurance covers it depends on whether it’s deemed “medically necessary” rather than cosmetic.
Insurers use specific skeletal measurements to make this determination. Aetna’s criteria, which are representative of many major carriers, require documented evidence that the jaw deformity causes significant problems with chewing and that orthodontics alone can’t fix it. The thresholds include an overjet (horizontal gap between upper and lower front teeth) of 5 mm or more, or a reverse bite where the lower teeth sit ahead of the upper teeth. For open bites, a vertical gap greater than 2 mm with no overlap of the front teeth qualifies. Jaw asymmetries greater than 3 mm and certain crossbite measurements also meet the bar. These values represent skeletal discrepancies that fall well outside the normal range.
If your case meets these criteria and your surgeon documents the functional impairment, medical insurance (not dental) typically covers the surgical portion. Orthodontic costs are usually handled separately through dental insurance, and the out-of-pocket share for braces can still be significant. Getting pre-authorization before starting treatment is essential, as retroactive approval is far more difficult to obtain.