Understanding Your Underbite
Not all underbites are the same, and the right treatment options depend on what is causing the jaw misalignment. A dental underbite means the upper jaw and lower jaw are reasonably well-aligned, but the lower teeth are tilted in a way that creates the underbite appearance. A skeletal underbite means the lower jaw itself is too large, the upper jaw is too small, or both.
An orthodontist determines which type you have using clinical examination, dental X-rays, and a cephalometric analysis. This assessment shapes the treatment plan and tells the orthodontist whether braces fix the tooth alignment issue or whether orthognathic surgery is needed to correct the jaw position.
When Braces Alone Can Fix an Underbite
When the problem is primarily dental rather than skeletal, braces fix an underbite by moving the teeth. In these cases, the upper jaw and lower jaw are close to the correct position, but orthodontic treatment is needed to shift the teeth into proper alignment.
Mild Dental Underbite Correction
For a mild underbite where only one or two lower teeth sit in front of the upper teeth, braces fix the tooth alignment by tipping the upper teeth forward and the lower teeth back. Elastics worn between arches help guide the bite. Orthodontic appliances like brackets and archwires create balanced alignment. Treatment plan length is typically 12 to 24 months.
Clear aligners may also work for very mild dental underbites in compliant adult patients. However, aligners have limited ability to correct bite relationships compared to traditional braces and other orthodontic appliances, so they are not appropriate for most underbite cases.
Growth Modification in Children
Children and young teens whose jaws are still growing have treatment options that adults do not. Growth modification with orthodontic appliances can influence jaw growth in the upper jaw and lower jaw. A reverse-pull headgear applies forward force to the upper jaw, encouraging it to grow forward. Palatal expanders can widen the upper jaw to create a better fit with the lower teeth.
These orthodontic appliances work best when started between ages 7 and 10, before jaw growth stops. Early intervention can reduce the severity of the jaw misalignment and, in some cases, eliminate the need for orthognathic surgery later. The American Association of Orthodontists recommends an orthodontic evaluation by age 7 for this reason.[1]
When Surgery Is Needed for an Underbite
Jaw surgery, formally called orthognathic surgery, is indicated when the underbite is skeletal. In severe cases where the lower jaw is significantly oversized or the upper jaw is significantly undersized, braces cannot compensate. Surgery may be the only way to achieve a stable correction and restore facial balance. Attempting to correct a skeletal jaw misalignment with braces alone often produces a result that relapses.
How Jaw Surgery Corrects an Underbite
Orthognathic surgery for an underbite typically involves repositioning the lower jaw, the upper jaw, or both to correct jaw position and restore facial balance. The most common procedures are a bilateral sagittal split osteotomy (BSSO), which moves the lower jaw backward, and a Le Fort I osteotomy, which moves the upper jaw forward. In severe cases, both procedures are performed together.
The surgery is performed under general anesthesia by an oral and maxillofacial surgeon. All incisions are made inside the mouth, so there are no visible scars. The jaw bones are repositioned and secured with titanium plates and screws. Surgery may also include chin reshaping when needed for proper facial balance.
Combined Orthodontic and Surgical Treatment
Orthognathic surgery is almost never a standalone procedure. Braces are placed first to align the teeth within each arch before the operation. This pre-surgical phase lasts 12 to 18 months. The teeth may look worse before they look better, because the orthodontist is positioning them to fit correctly after the jaw is repositioned.
After orthognathic surgery, braces remain in place for another 6 to 12 months to fine-tune the bite. The total timeline is usually 18 to 30 months. Surgery may shorten this when orthodontists use a surgery-first approach that skips the pre-surgical braces phase.
Recovery After Underbite Surgery
Recovery from orthognathic surgery follows a predictable timeline, though individual experiences vary. Surgery may require several weeks of modified activity, but most patients find the recovery manageable.
During the first 1 to 2 weeks, swelling peaks around day 3 to 4 and then gradually improves. Most patients are on a liquid diet for the first 2 weeks, then transition to soft foods. Numbness in the lower lip and chin is common due to nerve stretching during surgery. For most patients, sensation returns over 3 to 6 months, though some may experience lasting numbness in small areas.
Most patients return to work or school within 2 to 4 weeks. Strenuous physical activity is typically restricted for 6 to 8 weeks. Full bony healing takes about 6 to 8 weeks, though continued remodeling occurs over several months. Your oral surgeon will monitor healing with regular follow-up appointments.
Cost: Braces Alone vs. Braces with Surgery
The cost difference between braces-only care and combined orthognathic surgery is significant. Braces for an underbite typically cost $4,000 to $8,000 depending on complexity.
Orthognathic surgery adds substantially to the total. The surgical component typically ranges from $20,000 to $40,000. Medical insurance often covers a portion when the procedure is deemed medically necessary. Patients with difficulty chewing, breathing issues, or TMJ pain are more likely to qualify for coverage.
If your orthodontist recommends orthognathic surgery, request a pre-authorization before committing. Surgery may be partially or fully covered depending on the severity of your jaw misalignment. Some oral surgeons have staff dedicated to navigating insurance approvals.
How Age Affects Underbite Treatment
Age plays a critical role in determining which treatment options are available. Children whose jaws are still growing may respond to orthodontic appliances that influence jaw growth and change how the upper jaw and lower jaw develop. This is the only window when jaw position can be modified without orthognathic surgery.
Once jaw growth is complete, the bones can only be repositioned through orthognathic surgery. Adults with skeletal underbites have two paths: surgery combined with orthodontic treatment, or orthodontic camouflage. Camouflage uses braces to move the lower teeth enough to disguise the discrepancy, but it does not change the underlying structure. It works in mild cases but may compromise facial balance and long-term stability.
Your Treatment Team: Orthodontist and Oral Surgeon
Underbite treatment starts with an orthodontist. They determine whether braces can fix the tooth alignment or whether orthognathic surgery is needed. If surgery may be part of the solution, the orthodontist coordinates with an oral and maxillofacial surgeon to develop a treatment plan together.
Both specialists complete additional years of residency training after dental school. An orthodontist completes a 2- to 3-year residency focused on orthodontic appliances and guiding jaw growth. An oral surgeon completes a 4- to 6-year surgical residency. For combined cases, both are involved from start to finish.
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