Understanding Your Underbite
Not all underbites are the same. The treatment that will work for you depends on what is causing the lower jaw to sit too far forward. A dental underbite means the jaw bones are reasonably well-aligned, but the teeth are tilted in a way that creates the underbite appearance. A skeletal underbite means the lower jawbone itself is too large, the upper jawbone is too small, or both.
An orthodontist determines which type you have using clinical examination, dental X-rays, and a cephalometric analysis, which measures the relationships between your skull, jaw bones, and teeth. This assessment is essential because it determines whether braces alone can fix the problem or whether surgery will be part of the treatment plan.
When Braces Alone Can Fix an Underbite
Braces can correct an underbite when the problem is primarily dental rather than skeletal. In these cases, the jaw bones are close to the right size and position, but the teeth need to be moved.
Mild Dental Underbite Correction
For a mild underbite where only one or two lower teeth sit in front of the upper teeth, braces can tip the upper teeth forward and the lower teeth back into correct alignment. Elastics (rubber bands) worn between the upper and lower arches help guide the bite into position. Treatment time for a mild dental underbite with braces 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, so they are not appropriate for most underbite cases.
Growth Modification in Children
Children and young teens whose jaws are still growing have an option that adults do not: growth modification appliances. A reverse-pull headgear (also called a facemask) applies forward force to the upper jaw, encouraging it to grow forward and catch up with the lower jaw. Palatal expanders can widen the upper jaw to create a better fit.
These appliances work best when started between ages 7 and 10, before the growth plates in the jaw close. Early intervention during this window can reduce the severity of the underbite significantly and, in some cases, eliminate the need for jaw 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. If the lower jaw is significantly oversized, the upper jaw is significantly undersized, or both, braces cannot compensate for the bone discrepancy. Attempting to fix a skeletal underbite with braces alone often produces an unstable result that relapses over time.
How Jaw Surgery Corrects an Underbite
Orthognathic surgery for an underbite typically involves repositioning the lower jaw, the upper jaw, or both. 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 at the same time.
The surgery is performed under general anesthesia by an oral and maxillofacial surgeon, usually in a hospital setting. 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 that remain permanently in place.
Combined Orthodontic and Surgical Treatment
Jaw surgery is almost never a standalone procedure. In the traditional approach, braces are placed first to align the teeth within each arch. This pre-surgical orthodontic phase typically 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 surgery, braces remain in place for another 6 to 12 months to fine-tune the bite and settle the teeth into their final positions. The total treatment timeline from start to finish is usually 18 to 30 months. Some orthodontists now use a surgery-first approach that skips the pre-surgical braces phase, shortening the overall timeline.
Recovery After Underbite Surgery
Recovery from jaw surgery follows a predictable timeline, though individual experiences vary. Understanding what to expect helps you plan for time off work and adjust your daily routine.
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 treatment and combined surgical treatment is significant. Braces for an underbite typically cost $4,000 to $8,000, depending on the complexity and length of treatment. Costs vary by location, provider, and case complexity.
Jaw surgery adds substantially to the total. The surgical component typically ranges from $20,000 to $40,000, which includes the surgeon's fee, anesthesia, and hospital facility charges. Medical insurance, not dental insurance, often covers a portion of orthognathic surgery when it is deemed medically necessary rather than purely cosmetic. Many patients with documented functional problems such as difficulty chewing, breathing issues, or TMJ pain qualify for medical coverage.
If your orthodontist recommends surgery and you have medical insurance, request a pre-authorization to understand your coverage before committing to treatment. Some oral surgeons have staff dedicated to navigating insurance approvals for jaw surgery.
How Age Affects Underbite Treatment
Age plays a critical role in determining which treatment approach is available to you. Children whose jaws are still growing, generally up to ages 14 to 16 for girls and 16 to 18 for boys, may respond to growth modification appliances that can change how the jaw develops. This is the only window when the skeletal structure can be influenced without surgery.
Once jaw growth is complete, the bones can only be repositioned surgically. Adults with skeletal underbites have two realistic options: jaw surgery combined with orthodontics, or orthodontic camouflage. Camouflage uses braces to move the teeth enough to disguise the skeletal discrepancy, but it does not change the jaw position. It works in mild to borderline cases but has limitations and may compromise long-term stability.
Your Treatment Team: Orthodontist and Oral Surgeon
Underbite treatment starts with an orthodontist. The orthodontist evaluates whether the underbite is dental, skeletal, or a combination, and determines whether braces alone can address it. If surgery is needed, the orthodontist works closely with an oral and maxillofacial surgeon to plan the case together.
Both specialists complete additional years of residency training after dental school. An orthodontist completes a 2- to 3-year residency focused on tooth movement and jaw alignment. An oral and maxillofacial surgeon completes a 4- to 6-year surgical residency. For surgical cases, both specialists are involved from the initial planning through the final result.
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