Orthodontics/Jaw surgery


What are the long term ramifications of NOT doing orthognathic surgery to correct an underbite?

I'm a 35 year old female with a class 3 malocclusion, and an impacted incisor.  My teeth are fairly straight because I did Invisalign about a decade ago.  At the time I was told by one orthodontist I should get jaw surgery to fix my bite and bring my tooth down, which I rejected due to time and cost, and a desire for straight teeth without messing with my bite.

After the Invisalign my bite did get worse. I cannot cleanly bite through things, such pizza, but I didn't appear to have any other problems with not doing the surgery at that time.

The past month or so I've been having pain in my teeth while biting on chewy foods, and my dentist ruled out cracked teeth.  I've also been having pain under my jawline and accompanied by a painful swollen lymph node for about 6 months (which corresponds to a bad cold, and which my PCP has dismissed as nothing).  My dentist also ruled out an infection in the roots of any of my teeth on that side.

He referred me to another orthodontist who did xrays and impressions, and who is recommending I speak with an oral surgeon about orthognathic surgery to correct my bite and to deal with my impacted tooth.  

My bite issues are definitely skeletal in nature. I have a very small mouth; they use the child sized trays on me for things like fluoride treatments, and often have issues with placing xray "film" properly.  The orthodontist thinks the oral surgeon will actually recommend two jaw surgeries based on mouth size and the impacted tooth.  

I have not spoken to an oral surgeon yet, because I'm still hesitant about such major surgery and I feel that is the direction I'm being pushed.  

But what is my likely outcome if I don't do the surgery?  Am I dooming myself in someway that hasn't been explained to me?  Is there another medical professional I should seek out regarding my swollen lymph node to perhaps get a better or more accurate diagnosis around my jaw pain?

Dear Missy,

I apologize for the delay in answering your question. One of my colleagues was recently hospitalized.

First let me again say that what I write here are only my opinions based on very limited information. My comments should not be viewed as any form of diagnosis, definitive or otherwise,  or any form of  treatment recommendation.  Indeed, in the ultimate analysis all final decisions, particularly clinical ones, should  only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.

Okay… having said  that…  your  questions focused on surgical orthognathic intervention to address a Class III under bite.  You  wrote: But what is my likely outcome if I don't do the surgery?

My gut feeling, quite frankly, is that if you don't get surgery, life will go on for you, and nothing major will occur. When I did my dental training in the late 1970s and 80s, surgery was quite the rage. People with white coats and lofty titles expressed their learned opinions, and residents like me scribbled notes and further propagated these opinions, all with the best of intentions.

In the intervening years however, there have been some marked changes in the profession. Concepts like Evidence Based Medicine and Evidence Based Dentistry arose and rather than listening to experts in white coats, more evidence was demanded in terms of case control studies, cohort trials, and randomized control trials. In the late 90's dentistry was not faring well in the area of Evidence Based Dentistry.

Likewise changes in insurance coverage policies forced people to take a very careful look at the efficacy of surgical orthodontics in terms of resolving various problems. Esthetics aside, many problems pose unique challenges and no surgeon with integrity should guarantee absolute resolution.  Temporo Mandibular Dysfunction may or may not be related to the manner in which your teeth meet or "occlude". Surgery to make them simply "fit better" indeed may or MAY NOT resolve the problems, pain, function, or otherwise, which you may have.

You mention that your teeth are now fairly "straight" and that the teeth themselves within the upper and lower jaw have good dental alignment, albeit the "bite" when the upper and lower teeth meet is not idea ( Class III with a negative overjet or "underbite" ). You nte that your bite "got worse".  Well, that coul be due to possible residual continued growth forward of your  lower jaw or mandible. It might also be due to the act that your teeth, after clear aligner treatment, were made to mesh differently, and that in time the upper nad lower teeth 'settled" into a new bite relationship with one another, namely one with the lower jaw perhaps advanced a bit more forwards than before. These two processes may account for the "changes" which you describe post Invisalign.

Now for an important part of your question. You state: " pain under my jawline and accompanied by a painful swollen lymph node for about 6 months  ".  Before launching into even considering surgery, I would resolve what this swelling and pain is all about. My wife is a physician, board certified in Dermatology, as well as Clinical, Anatomical, and Dermato Pathology.Some medical conditions require a lot of detective work and crack clinicians to help diagnose.

Finally, as far as getting an opinion from a surgeon on whether you should get surgery, do understand that we all have a tendency to often see things through the rose colored glasses of our own training. An ethical and well intentioned surgeon may well recommend surgery because that is the mindset, and biases, however  unintentional, may exist nevertheless. Surgeries are NOT without their many drawbacks. Complications from anesthesia, permanent numbness, loss of muscle (motor) function, etc are just some of the issues which need to be exhaustively explained as part of an informed consent process.

So... what is the take home message Missy. I would get an opinion from an oral surgeon, but take it all in perspective. Ask him/her  just what would be the most severe problem if you decline surgery. I hope you will then return to your dentist and or orthodontist and get a follow up "balanced " perspective. I would, before doing any of this, get the lymph node and related pain issue resolved. Then see the oral surgeons and other dentists. Also, ask for a small might guard or clear retainer to help prop your teeth slightly apart. This may afford some relief from pain and discomfort, and is certainly an affordable and very non-invasive first step to consider.

Missy, I would encourage you to write back once to have completed these steps.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health


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Paul Supan, DDS, MA, MPH


First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.


Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

Available upon Request.

BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

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