Orthognathic Surgery Dublin: The Orthodontist’s Role in Severe Malocclusion

Last reviewed: September 2026

Some bite problems are not problems with the teeth at all. They are problems with the size, shape or position of the jaws themselves, and no appliance — metal, ceramic, lingual or clear — can move a jaw. Those cases are corrected by an oral and maxillofacial surgeon repositioning the bone, with a specialist orthodontist preparing the arches beforehand and finishing the bite afterwards. At the Institute of Specialist and Cosmetic Dentistry (ISCD) in Dublin’s IFSC, we co-ordinate the orthodontic phases of these combined cases; the jaw surgery itself is carried out by a maxillofacial surgical team in a hospital setting. This guide explains what that pathway involves, for patients weighing up a surgical plan and for referring dentists deciding when a case has moved beyond what braces alone can achieve.

What is orthognathic surgery, and when is it needed?

Orthognathic surgery is the surgical repositioning of the upper jaw, the lower jaw or both to correct a skeletal discrepancy. It is indicated when the jaws themselves, rather than the position of the teeth within them, are the cause of the malocclusion.

The distinction matters more than any other point in this article. Orthodontics moves teeth through bone. It cannot lengthen a deficient mandible, reduce an excessive one, or change the vertical height of the middle third of the face. Where the underlying skeletal pattern is the problem, orthodontics on its own can only disguise it — and there is a limit to how far a tooth can be tipped before the disguise costs more than it gains.

In practice, the patients who end up on a surgical pathway usually present with one of a small number of patterns: a markedly prominent or deficient lower jaw, an open bite where the front teeth never meet however well aligned they are, a facial asymmetry, or a severe discrepancy that has already defeated a course of conventional braces. Ireland’s Dental Council recognises only two dental specialties — orthodontics and oral surgery — and complex cases of this kind sit at the junction of orthodontics and maxillofacial surgery, which is why they are planned jointly from the outset rather than handed on at the halfway point.

Which bite problems cannot be corrected by braces alone?

Skeletal Class II and Class III discrepancies, anterior open bites of skeletal origin, significant transverse deficiencies and facial asymmetries are the patterns most often beyond the reach of orthodontic treatment on its own in an adult.

Growth is the deciding variable. In a growing child or adolescent, some skeletal discrepancies can be modified with functional appliances or expansion while the sutures and condyles are still responsive — one of several reasons the timing of a teenager’s orthodontic assessment matters. Once growth is complete, that option closes. An adult with the same pattern has two honest choices: accept a compromise in which the teeth are aligned and the skeletal relationship is masked, or correct the skeleton surgically.

What does not belong in this category is ordinary crowding, mild spacing, or a moderate overjet in a patient with an acceptable facial profile. Those cases are treated routinely with fixed appliances, customised lingual braces or clear aligners, and a patient who has been told they need jaw surgery for crowding alone is entitled to a second specialist opinion. Our guide to treating dental crowding covers what is achievable without surgery.

How does a specialist orthodontist decide between camouflage and surgery?

The decision rests on where the correction is made. Camouflage moves teeth within the existing jaws to mask a discrepancy; combined orthodontic-surgical treatment repositions the jaws and changes the underlying skeletal relationship.

A systematic review by Alhammadi and colleagues, published in Clinical Oral Investigations in 2022, examined precisely this question in borderline Class III cases. From 2,089 retrieved articles only six met the inclusion criteria, with an overall risk of bias judged moderate, and the authors state plainly that a meta-analysis was not possible because of the variation between studies. That is worth reporting honestly: this is a decision made every week in specialist practice, and the published comparative evidence for it is thinner than most patients would assume.

What the included studies did show is a consistent difference in mechanism. Surgical treatment produced a protrusive effect on the maxillary base and a retrusive effect on the mandibular base, improving the sagittal relationship, together with a clockwise rotational effect on the mandibular plane. Camouflage produced more proclination of the upper incisors and more retroclination of the lower incisors — in other words, it achieved the bite by tipping teeth to compensate for a jaw relationship that had not changed.

For a referring dentist, that is the useful framing. Both approaches can close an overjet. Only one of them alters the skeletal pattern, and the price of the other is paid in incisor inclination, which has consequences for periodontal support and long-term stability in the lower labial segment.

What does the orthodontist actually do before the surgery?

The pre-surgical orthodontic phase aligns and levels each arch independently and removes the dental compensations the patient has developed, so that the jaws can be moved into a planned position that the teeth will then fit.

This phase is called decompensation, and it is counter-intuitive. Over years of growth, teeth drift to compensate for a skeletal discrepancy: in a Class III patient the upper incisors procline and the lower incisors retrocline, partially camouflaging the underlying pattern. If a surgeon repositions the jaws while those compensations are still in place, the bones can only move as far as the interfering teeth allow, and the skeletal correction is limited.

So the orthodontist deliberately undoes the body’s own camouflage — proclining what has been retroclined, and vice versa — to place each arch where it would have been had the skeletal relationship been normal. Arch widths are co-ordinated so that the two arches will meet after the jaws move. Records are taken throughout, and the final surgical plan is built on them.

Much of this work uses conventional fixed appliances, because they give the three-dimensional control the surgical plan depends on. That is a clinical decision rather than an aesthetic one, and it is discussed openly at the planning stage; our comparison of aligners and fixed appliances sets out where each has the advantage.

Why does the bite look worse before it looks better?

Because decompensation deliberately reverses the dental camouflage that has been masking the skeletal discrepancy, a patient’s overjet or open bite frequently increases during the pre-surgical phase, and this is a planned intermediate stage rather than a setback.

It is the single most common source of anxiety in these cases, and it is entirely predictable. A Class III patient whose upper teeth have been tipped forward for years to reach the lower ones will see the reverse overjet become more obvious as those teeth are uprighted. A Class II patient may see the overjet increase.

We say this before treatment starts rather than when it happens, and we say it in the same terms to the referring practice, because a general dentist reviewing the patient at a routine appointment mid-treatment will otherwise be looking at what appears to be a deteriorating bite. This phase typically runs for a number of months and ends when the arches are in the position the surgical plan requires.

Is the “surgery-first” approach a better option?

Current pooled evidence indicates that a surgery-first or early-surgery approach yields poorer postoperative skeletal stability than the conventional orthodontics-first sequence, and this is the most important finding for any patient attracted by a shorter overall treatment time.

The surgery-first approach reverses the order: the jaws are repositioned at the start, and the orthodontics is done afterwards. Its appeal is obvious — the facial change happens early rather than after a year or more in braces, and total treatment time can be shorter. It is actively marketed on that basis.

Wei and colleagues addressed it in a systematic review and meta-analysis published in Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology in 2018, pooling 12 studies covering 498 participants, with horizontal relapse at the pogonion as the primary outcome. The pooled estimate showed less postoperative stability in the surgery-first group, with a weighted mean difference of 1.50 and a P value below .00001, and moderate heterogeneity (I² = 53%). Subgroup analysis produced no subgroup difference, and a sensitivity analysis omitting one study at a time supported the robustness of the result. The authors conclude that the mandible tends to rotate counterclockwise more after a surgery-first approach, and that patient screening and treatment planning should be reviewed carefully to compensate for possible relapse where it is adopted.

This is not a reason to say the technique is never appropriate; the authors do not say that, and neither do we. It is a reason to be sceptical of it being offered as a general convenience. The pre-surgical orthodontic phase is not padding in the timeline — it is the part of the treatment that gives the surgeon a predictable target, and the evidence suggests something is given up when it is removed. A patient told that jaw surgery can be done first and sorted out afterwards should ask what the stability data says, and should expect a specific answer.

Who performs the jaw surgery, and where does it happen?

Orthognathic surgery is performed by an oral and maxillofacial surgeon under general anaesthetic in a hospital setting. ISCD co-ordinates the orthodontic phases of these cases and works alongside the surgical team; we do not carry out jaw surgery ourselves.

We are explicit about this because it is a reasonable thing for a patient to be confused about. Our oral surgery service, led by Dr Marie O’Neill, covers surgical extractions, wisdom teeth, implants and the exposure of impacted teeth under local anaesthetic or conscious sedation — procedures carried out in the practice. Orthognathic surgery is a different undertaking, requiring a general anaesthetic, an inpatient stay and a hospital theatre, and it belongs with a maxillofacial surgical team.

What we provide is the orthodontic half of a joint plan: the diagnostic records, the decompensation, the co-ordination with the surgeon during planning, and the post-surgical finishing and retention. Dr Erfan Salloum, who leads these cases here, is one of a small number of orthodontists in Ireland to hold European distinctions across the three major fields of contemporary orthodontics — comprehensive, clear aligner and lingual — and works with ENT surgeons, oral and maxillofacial surgeons, restorative dentists and sleep physicians where a case calls for it. A related example of the same joint working, on a smaller scale, is our guide to impacted canines, where the orthodontist and oral surgeon plan one tooth together.

How long does combined orthodontic and surgical treatment take?

Combined orthodontic-surgical treatment is measured in years rather than months, comprising a pre-surgical orthodontic phase, the surgery and its recovery, and a post-surgical phase to detail the bite, followed by long-term retention.

We do not publish a single figure, because the honest answer depends on the severity of the discrepancy, the amount of decompensation required, whether one jaw or both are being moved, and the patient’s own response. What we do commit to is giving an estimate specific to the case once the diagnostic records and the joint plan are complete, and revising it openly if the case changes.

The stage that patients most often underestimate is the post-surgical one. The surgery corrects the skeletal relationship; it does not, on its own, produce a finished bite. The detailing that follows — settling the occlusion, closing residual spaces, refining the intercuspation — is orthodontic work, and it is what determines how well the result functions rather than merely how it looks.

What are the risks, and what should the consent conversation cover?

Altered sensation in the distribution of the inferior alveolar nerve is the complication most associated with lower jaw surgery, and the published literature does not support quoting a single reliable incidence figure for it.

That last point deserves stating plainly, because it is unusual for us to decline to give a number. Agbaje and colleagues, writing in the International Journal of Oral and Maxillofacial Surgery in 2015, reviewed 61 reports on inferior alveolar nerve injury after bilateral sagittal split osteotomy and found the methodology behind the published incidence figures to be highly inconsistent: 16 reports (26%) did not indicate the incidence of injury at all, preoperative nerve status was not assessed in 22 reports (36%), the assessor was described in detail in only 21 reports (34%), and information on the assessors’ training appeared in just two reports (3%). Subjective evaluation was the commonest assessment method. The authors conclude that the wide variation in reported incidence reflects the absence of standardised assessment and reporting, and call for an international consensus to establish a standard-of-care method.

The practical consequence for a patient is this: a percentage quoted from a website — including ours — is not a sound basis for consenting to jaw surgery. The figure that matters is the one the operating surgeon can give for their own practice, for the specific osteotomy planned, in the context of that patient’s own anatomy on three-dimensional imaging. Our role is to make sure that conversation happens with the surgeon before a decision is made, not to substitute a number for it.

Does orthognathic treatment actually improve quality of life?

Pooled data from observational studies indicate a positive impact of orthognathic surgery on quality of life in patients with dentofacial deformity, with the effect larger on condition-specific measures than on general oral-health measures.

Meger and colleagues, in a systematic review and meta-analysis published in the British Journal of Oral and Maxillofacial Surgery in 2021, identified 2,263 articles, retained twelve in qualitative synthesis and seven in the meta-analysis, assessing risk of bias with the Newcastle-Ottawa Scale. Comparing before and after treatment, the impact on quality of life measured with the OHIP-14 questionnaire was 7.63 (95% CI 1.62 to 13.65; p = 0.01) and with the condition-specific Orthognathic Quality of Life Questionnaire 20.53 (95% CI 14.27 to 26.79; p < 0.0001), with an overall impact of 16.01 (95% CI 10.50 to 21.52; p < 0.0001).

Two caveats belong with those figures. The review pooled observational studies rather than randomised trials, so it describes change over time in patients who chose surgery rather than proving surgery caused the change. And the larger effect on the condition-specific questionnaire is consistent with what we see clinically — the things these patients report improving are the things a general oral-health questionnaire is not designed to detect.

How stable is the result five to fifteen years later?

Long-term dental stability after combined orthodontic-surgical treatment is variable rather than uniform, differing between skeletal Class II and Class III patients, with dentolabial changes at long follow-up consistent with normal ageing.

Mulier and colleagues, in a systematic review in the European Journal of Orthodontics in 2021, screened 3,178 articles and included 11 studies — two randomised controlled trials and nine retrospective — with postoperative follow-up ranging from 5 to 15 years. Overjet decreased over the long term in skeletal Class III patients and increased in Class II patients; overbite increased in Class II, while Class III showed variable results. The lower incisor position proved more stable vertically than horizontally, with the horizontal dimension showing more variability in outcome. Dentolabial changes corresponded to the normal ageing process and were not clinically significant at long-term follow-up.

The authors’ own conclusion is that current evidence suggests variability in both Class II and Class III patients and that further prospective studies are needed before firm guidelines can be drawn. For a patient, the message is not that the result is fragile; it is that retention is part of the treatment rather than an optional extra afterwards, and that the direction of any long-term drift is somewhat predictable from the skeletal pattern that was corrected.

What does treatment cost at ISCD, and how do dentists refer?

A specialist orthodontic assessment at ISCD is €150. The orthodontic phases of a combined surgical case are quoted individually once the diagnostic records and the joint plan are complete, and the surgical fee is set separately by the hospital and surgical team.

Our published orthodontic fees are a specialist assessment at €150, fixed metal or ceramic braces at €1,250 to €3,500 per arch, Invisalign at €2,500 to €3,500 per case, and interceptive treatment for children from €600. Where a case also involves our oral surgery service, an oral surgery consultation including a panoramic radiograph where required is €150, a CT scan is €150, and intravenous sedation is €395. We do not publish a fee for orthognathic surgery, because we do not perform it — that fee comes from the surgical team and the hospital, and it should be confirmed with them in writing.

We quote the orthodontic component in writing after assessment rather than over the phone, because the length of the pre-surgical phase is the main cost variable and it is not knowable until the records are read. Our guide to orthodontic costs explains how we approach fees generally, and our adult treatment options page covers the non-surgical alternatives where a case is genuinely borderline.

For referring dentists: ISCD accepts direct orthodontic referrals, and the referring practice keeps the patient for routine and restorative care throughout. Cases suspected of needing a surgical opinion are welcome as an assessment referral rather than a treatment referral — an early joint look at the records is more useful than a late one, particularly where a course of conventional treatment is being considered first. Our referral process for Dublin dentists sets out what to send.

Related reading

You can read more about our specialist orthodontic service, our oral surgery service, and Dr Salloum’s full specialist profile. For related reading, see our guides to impacted canines, braces for teenagers, adult brace options, lingual braces and Invisalign compared with fixed braces. You can also read about the practice.

Frequently asked questions about orthognathic surgery in Dublin

Does ISCD perform jaw surgery?
No. Orthognathic surgery is carried out by an oral and maxillofacial surgeon under general anaesthetic in a hospital. ISCD provides the orthodontic phases of these cases — the pre-surgical decompensation, co-ordination with the surgical team during planning, and the post-surgical finishing and retention.

Can braces fix a severe underbite without surgery?
Sometimes, by camouflage rather than correction. Orthodontic camouflage tips the teeth to mask the skeletal discrepancy — proclining the upper incisors and retroclining the lower ones — while surgery changes the position of the jaws themselves. Which is appropriate depends on the severity of the skeletal pattern, the facial profile and how much incisor movement the periodontal support will tolerate.

Is it better to have the surgery first and the braces afterwards?
The pooled evidence does not support it on stability grounds. Wei and colleagues (2018) pooled 12 studies covering 498 participants and found less postoperative stability with a surgery-first or early-surgery approach than with the conventional orthodontics-first sequence, with a weighted mean difference of 1.50 in horizontal relapse at the pogonion.

Will my bite look worse during treatment?
Very often, yes, and it is planned. Removing the dental compensations that have been masking the skeletal discrepancy usually makes the overjet or open bite more obvious before surgery corrects it. This is an intermediate stage, and we explain it before treatment begins.

What is the risk of permanent numbness after jaw surgery?
Altered sensation in the inferior alveolar nerve is the complication most associated with lower jaw surgery, but the published figures vary widely because assessment methods are not standardised. Agbaje and colleagues (2015) reviewed 61 reports and found that 26 percent did not state an incidence at all and 36 percent did not assess nerve status before surgery. The figure that matters is the one your operating surgeon can give for their own practice and your own anatomy.

How much does a specialist orthodontic assessment cost?
A specialist orthodontic assessment at ISCD is €150. The orthodontic phases of a combined surgical case are quoted in writing after that assessment; the surgical fee is set separately by the hospital and surgical team.

Arranging an assessment

If you have been told that your bite cannot be corrected with braces alone, or you are a dentist with a patient whose skeletal pattern looks beyond conventional treatment, a specialist orthodontic assessment is the place to start. Where a case does turn out to need a surgical opinion, we plan the orthodontics around it and co-ordinate with the surgical team from the outset.

Institute of Specialist and Cosmetic Dentistry (ISCD)
4 NCI, Lower Mayor Street, IFSC, Dublin, D01 R7W7
Telephone: +353 1 504 2065
Email: info@iscd.ie

Written by Dr. Erfan Salloum, BDS, PGCert(Orth), DClinDent(Orth), MsLing(Orth), MFD RCSI, MFDS RCPSG, MOrth RCSEd, FFD(Orth) RCSI, MOrth RCSEng, FDS RCSEng, FDS RCPSG — Specialist Orthodontist at the Institute of Specialist and Cosmetic Dentistry, Dublin.

References

1. Alhammadi MS, Almashraqi AA, Khadhi AH, Arishi KA, Alamir AA, Beleges EM, Halboub E. Orthodontic camouflage versus orthodontic-orthognathic surgical treatment in borderline class III malocclusion: a systematic review. Clinical Oral Investigations. 2022;26(11):6443–6455. doi:10.1007/s00784-022-04685-6
2. Wei H, Liu Z, Zang J, Wang X. Surgery-first/early-orthognathic approach may yield poorer postoperative stability than conventional orthodontics-first approach: a systematic review and meta-analysis. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2018;126(2):107–116. doi:10.1016/j.oooo.2018.02.018
3. Agbaje JO, Salem AS, Lambrichts I, Jacobs R, Politis C. Systematic review of the incidence of inferior alveolar nerve injury in bilateral sagittal split osteotomy and the assessment of neurosensory disturbances. International Journal of Oral and Maxillofacial Surgery. 2015;44(4):447–451. doi:10.1016/j.ijom.2014.11.010
4. Meger MN, Fatturi AL, Gerber JT, Weiss SG, Rocha JS, Scariot R, Wambier LM. Impact of orthognathic surgery on quality of life of patients with dentofacial deformity: a systematic review and meta-analysis. British Journal of Oral and Maxillofacial Surgery. 2021;59(3):265–271. doi:10.1016/j.bjoms.2020.08.014
5. Mulier D, Gaitán Romero L, Führer A, Martin C, Shujaat S, Shaheen E, Politis C, Jacobs R. Long-term dental stability after orthognathic surgery: a systematic review. European Journal of Orthodontics. 2021;43(1):104–112. doi:10.1093/ejo/cjaa022