Orthognathic and orthofacial surgery: jaw osteotomies

Orthognathic surgery corrects abnormalities in the position or size of the jaws and chin. It repositions the jaws to obtain functional and aesthetic benefits, such as a normal dental occlusion and better facial proportions. It is indicated when orthodontics alone is not enough: a mismatch between the jaws, a receding or prominent chin, asymmetry, open bite, gummy smile, or sleep apnoea linked to a short lower jaw.

Specialised, collegial care

Procedures are planned and performed jointly with Dr Christophe Politis, who is also an expert in orthofacial surgery.

Consultations take place at the Erasme Medical Center (EMC) – 900 route de Lennik, 1070 Anderlecht, Brussels.

Surgery is performed at Erasme Hospital – 808 route de Lennik, 1070 Anderlecht, Brussels.

Who is orthognathic surgery for?

You may be concerned if you have:

• A visible mismatch between the jaws: a receding lower jaw (class II) or a protruding lower jaw (class III, "prognathism")

• A chin that is too far back or too prominent

• Asymmetry of the face or chin

• An open bite: the front teeth do not touch

• Difficulty speaking or chewing, or difficulty closing the lips at rest

• Breathing difficulties, especially at night: snoring and sleep apnoea in a young patient with a receding jaw

• A gummy smile, teeth that show too much at rest, or a vertically long face

• A narrow upper jaw in adulthood (narrow palate, crossbite)

Orthodontists play an essential role in detecting jaw disharmonies, which are usually caused by an abnormality in the growth of the facial skeleton. When surgery is being considered, treatment generally starts with an orthodontic assessment completed by a surgical assessment, so that a coherent, personalised treatment plan can be established together.

The procedures

Mandibular osteotomy (bilateral sagittal split osteotomy)

Advancement or repositioning of the lower jaw. Incisions inside the mouth, no visible scar. Fixation with titanium mini-plates. Read more

Maxillary osteotomy (Le Fort I)

Advancement, impaction (raising), down-grafting (lowering) or recentring of the upper jaw. Corrects a gummy smile, open bite and asymmetry. Read more

Bimaxillary osteotomy

Both jaws in a single operation (a Le Fort I osteotomy combined with a sagittal split osteotomy of the mandible), the most frequent situation for large discrepancies, asymmetries, open bites with a receding mandible and vertically long faces. Bimaxillary advancement is also the reference surgical treatment for obstructive sleep apnoea, with a success rate above 85%. The maxilla is repositioned first using the first splint, then the mandible is brought into occlusion with it using the final splint; a genioplasty is often performed at the same time. The operation lasts about 3 hours, with 1 night in hospital (sometimes 2); swelling is more marked than after a single osteotomy, peaking on days 3–4, and work can be resumed after 2 to 3 weeks. Sharing the movement between the two jaws gives a more balanced profile and a more stable result; proportions are harmonised and the identity of the face is preserved.

Genioplasty

Advancement, setback, raising or recentring of the chin by osteotomy, alone or combined with a jaw osteotomy. Read more

Palatal distraction (SARPE)

Widening of the upper jaw in adolescents at the end of growth and in adults: a surgical osteotomy combined with an expander, activated progressively after the operation. Read more

Minimally invasive orthofacial surgery

In selected cases, jaw osteotomies can be performed with a minimally invasive approach: the same bone movements, with shorter incisions, tissue detachment limited to the strict minimum and adapted fixation. The aim is to reduce swelling, pain and recovery time without compromising the precision or the stability of the result.

What changes for the patient: markedly less swelling, often visible from day 3; faster recovery of sensation, because the nerves are less exposed; an earlier return to social life and work; a soft diet resumed sooner.

What does not change: 3D planning and printed surgical splints, bone movements planned to a tenth of a millimetre, fixation with titanium mini-plates. The minimally invasive approach applies to maxillary and mandibular osteotomies and to genioplasties when the anatomy and the extent of the movement allow it; large movements, some asymmetries and revision surgery require the conventional exposure. The indication is decided on the 3D plan and discussed case by case at the consultation. Published studies show stability equivalent to the conventional approach, with less swelling and pain; the operating time is comparable, sometimes slightly longer because of the precision required with reduced exposure.

The treatment pathway

1. Surgical consultation: clinical examination, explanation of the options and of the procedure. A report is sent to your orthodontist.

2. Orthodontic preparation (8 months on average, highly variable).

3. 3D planning appointment, about 2 weeks before surgery.

4. Anaesthesia consultation, scheduled a few weeks before surgery; additional tests such as a blood test or an electrocardiogram may be requested by the anaesthetist.

5. Surgery at Erasme Hospital under general anaesthesia, 1 to 4 hours depending on the number of osteotomies.

6. Hospital stay: 1 night; usually day surgery for palatal distraction.

7. Follow-up: once a week for 4 weeks, then at 6 months and 1 year.

8. Finishing orthodontics (6 months to 1 year), then retention.

Orthodontics before surgery: a key step

Orthodontic treatment beforehand is essential before any orthognathic surgery. It aligns the teeth on each arch so that the jaw can be repositioned under the best conditions.

It can be carried out with fixed braces (brackets) or clear aligners, depending on preferences and clinical indications. It lasts 8 months on average, with wide variations from one patient to another. In some cases, a "surgery first" protocol allows the operation to be done first.

This step optimises post-operative stability and reduces the risk of relapse.

Orthodontic treatment generally continues after surgery, to finalise the adjustments and stabilise the result in the long term.

3D surgical planning

Every operation is preceded by digital 3D surgical planning, at a dedicated appointment about 2 weeks before surgery, based on:

• A 3D bone CBCT of the whole face.

• An optical impression: 3D models of the teeth.

• Clinical photographs.

These data are merged in the IPS CaseDesigner® planning software, where the osteotomies and the movements are simulated to a tenth of a millimetre. Surgical splints (repositioning wafers) are then 3D-printed for each osteotomy: they make it possible to reproduce in the operating theatre exactly what was planned on the computer.

This precise planning simulates the bone movements and anticipates the final result, both functional and aesthetic.

What happens during the operation?

Duration: between 1 and 4 hours, under general anaesthesia, depending on the number of osteotomies.

• Approach: incisions inside the mouth (no visible scar)

• Technique: osteotomies performed with a piezotome (ultrasound), for greater precision and safety

• Fixation: titanium mini-plates

• Intra-operative checks: occlusion, symmetry, facial profile

Patients are usually admitted to hospital after the operation. In most cases a single night is enough; palatal distraction is most often done as day surgery.

Follow-up takes place once a week for 4 weeks, then at 6 months and 1 year. Daily activities can be resumed after about two weeks, depending on post-operative progress.

Orthognathic surgery is a safe procedure, performed at Erasme Hospital in a specialised and fully secure setting. Everything is done to ensure patients' comfort, with attentive support before, during and after the operation.

Risks

Any surgical procedure carries a risk of complications, even when performed under the best conditions. They are rare in orthognathic surgery and are explained at the consultation and in the consent form provided before the operation.

• Numbness (hypoaesthesia): frequent and expected. Lower lip, chin and lower incisors after a mandibular osteotomy (the inferior alveolar nerve runs through the operated area); upper lip, side of the nose, upper teeth and palate after a maxillary osteotomy. Recovery takes a few weeks to a few months; a persistent deficit is rare (less than 10%). More rarely, the lingual nerve may be affected (sensation of one half of the tongue), also temporary in the vast majority of cases.

• Bleeding: slight bleeding during the first 24 hours is normal. Significant haemorrhage during the operation is rare and exceptionally requires a transfusion.

• Infection: rare. A cheek abscess may require drainage; sinusitis after a maxillary osteotomy usually resolves with antibiotics. In some cases, infection requires removal of the plates.

• Bone healing: delayed healing (non-union) is exceptional; it is treated by temporary immobilisation, sometimes by a bone graft. Partial necrosis of the moved segment is extremely rare.

• Occlusion: after the operation, the relationship between the upper and lower teeth may differ slightly from the plan, because of swelling or muscle pull. Elastic traction, additional orthodontics or light grinding allow it to be adjusted. Progressive relapse over time is rare and is treated by orthodontics or, exceptionally, by a further operation.

• Teeth: a root may be damaged during the osteotomy and require treatment (root canal treatment, apicoectomy).

• Temporomandibular joint: onset or worsening of a pre-existing dysfunction (clicking, pain), usually temporary and treated with a splint or orthodontic adjustment.

• Facial nerve: cases of paralysis of one side of the face have been described during mandibular osteotomies; this complication is extremely rare.

In some cases, some time after the operation, surgery of the nose or chin may be proposed when the osteotomy alone does not bring the expected aesthetic improvement. Speech therapy is sometimes indicated to optimise the functional result.

Post-operative guide: the first 6 weeks

Day 0 – Day 1 (hospital)

• You wake up with a swollen face, a blocked nose and a dry mouth: this is normal. Continuous cold on the cheeks for the first 48 hours; swelling lasts about two weeks.

• Painkillers by drip, then by mouth. Antibiotics and corticosteroids to limit swelling.

• The jaws are not wired shut. Light elastics are often placed to guide the occlusion, but not systematically.

• Up and about the next day. Sleep in a semi-sitting position.

• The next morning, a surgeon from the team visits the room to check that everything is fine and to go over the instructions before you go home.

• Diet: liquid, cold to lukewarm, by spoon or glass. Water, broth, pulp-free juice, drinking yoghurt, liquid nutritional supplements (Fortimel, Fresubin), smooth smoothies. Target: 1.5 L of fluid and, on average, 1,500 to 2,000 kcal and 80 to 100 g of protein per day from day 1. Nothing that needs chewing.

Day 1 – Day 7 (back home)

• Swelling peaks on days 3–4, then decreases. Bruising may extend down to the neck.

• Cold until day 3.

• Hygiene: gentle brushing with a surgical toothbrush, prescribed mouthwash after each meal, saline nasal spray (maxillary osteotomy: do not blow your nose for 3 weeks).

• Numbness (hypoaesthesia) of the lower lip and chin (mandibular osteotomy) or of the upper lip and cheeks (maxillary): expected, recovers over weeks to months, sometimes up to a year; very rarely permanent.

• No smoking, no alcohol, no hot food or drinks.

• Walk every day. No sport, no carrying heavy loads, no driving while you are taking strong painkillers.

• Diet: thick liquid to semi-liquid, 5 to 6 small meals a day. Enriched blended soups (cream, cheese, olive oil), smooth purées (potato, sweet potato, carrot, avocado), fruit compote, custard, very soft scrambled eggs, fine porridge, Greek yoghurt, fromage frais, protein smoothies (milk, banana, peanut butter, protein powder). A loss of 3 to 5 kg is usual and is regained afterwards.

Weeks 2 – 3 (days 8 – 21)

• Swelling clearly decreasing; the face is still "round". Social activities, remote work or a desk job can be resumed from week 2.

• The elastics are adjusted at each weekly check-up.

• Mouth-opening exercises, 5 times a day: with the mouth slightly open, place two fingers between the incisors and open gently to the comfortable limit, hold for 5 seconds, release; 10 repetitions. Add sideways movements (right, left) and forward movements (jaw forward). Never force.

• Lip exercises, 5 times a day: alternate a wide smile and a "kiss" position, 10 times. They speed up the return of mobility and sensation.

• Tingling and small electric shocks in the numb area are good signs: the nerve is recovering.

• Maxillofacial physiotherapy sessions may be prescribed to rehabilitate mouth opening and help the swelling resolve.

• Finishing orthodontics resumes between week 3 and week 6.

• Diet: soft, with no real chewing. Well-cooked pasta, risotto, flaked steamed fish, minced meat in sauce, omelette, very soft mashed vegetables, crustless sandwich bread soaked, soft cakes. Small mouthfuls, at the front of the mouth.

Weeks 4 – 6 (days 22 – 42)

• Bone healing under way. Sensation gradually returning.

• Non-contact sport can be resumed at 6 weeks, or from 4–5 weeks only if the swelling has completely disappeared for at least a week. Contact and ball sports: not before 3 months.

• Diet: tender, gentle chewing. Tender chicken, fish, rice, cooked vegetables, ripe fruit, sandwich bread. Still avoid crusty bread, firm red meat, raw apples, nuts and chewing gum.

After 6 weeks

• Gradual return to a normal diet.

• Residual swelling for up to 3–6 months, especially in the morning. Final aesthetic result at 6–12 months.

• Removal of the titanium plates: not necessary unless they cause discomfort or infection, or at the patient's request; possible from 6 months.

When to ask for a check-up

A prompt check-up is possible in case of:

• fever above 38.5 °C, swelling that increases on one side after day 5;

• discharge, persistent bad taste, a plate that becomes palpable or tender;

• a change in the bite: teeth that no longer meet as they did when you woke up from surgery;

• significant pain not relieved by the treatment;

• heavy bleeding from the nose or mouth.

Reimbursement and cost

In Belgium, orthognathic surgery is reimbursed by the INAMI/RIZIV (national health insurance) when it meets functional criteria (measured skeletal discrepancy, occlusal disorder, sleep apnoea). The operation is performed at Erasme Hospital at the agreed (conventioned) rate in a shared or two-bed room; a single room entails supplements, covered by hospitalisation insurance.

Please note:

• the palatal expander is a device not reimbursed by the INAMI/RIZIV;

• 3D planning and the printing of surgical guides may generate additional costs, reimbursed by hospitalisation insurance;

• reimbursement of orthodontics depends on the type and duration of treatment: to be discussed with your orthodontist.

A detailed hospital estimate is provided before the operation.

FAQ — Orthognathic surgery

What is the ideal age?

From the end of growth: 16–17 for girls, 17–18 for boys, confirmed by X-ray. There is no upper limit; patients aged 40 to 50 are operated on regularly.

How long does the whole treatment take?

On average 8 months of orthodontics before surgery and 8 months after, but this varies enormously from one patient to another. The "surgery first" protocol shortens this time in selected indications.

Can the surgery be done with aligners (Invisalign) rather than braces?

Yes, in many cases, in agreement with the orthodontist. Temporary attachments are placed for the elastics used during and after the operation.

Is it painful?

Less than most patients imagine: bone is not very sensitive and the nerves are numb. The main discomfort comes from the swelling, the blocked nose and the liquid diet of the first few days.

Are the jaws wired shut after the operation?

No. The jaws are fixed with titanium mini-plates. Light elastics often guide the occlusion for a few weeks; they can be removed for eating and brushing.

How long is the hospital stay?

One night. Palatal distraction is most often done as day surgery.

How long off work?

Two weeks on average, longer for physical work.

Will I lose weight?

3 to 5 kg on average in the first month. A liquid diet enriched with protein and calories limits this loss.

Will the scars be visible?

No: all the incisions are inside the mouth. Genioplasty is also performed through the mouth.

What are the risks?

Complications are rare. The most frequent is numbness (hypoaesthesia) of the lip and chin after a mandibular osteotomy, temporary in the vast majority of cases and persistent in fewer than 10%. The others are infection around a plate, bleeding, partial relapse or the need for a minor revision. Everything is explained at the consultation and in the consent form.

Is the result permanent?

Yes for the position of the jaws, provided the orthodontic retainer is worn. The face continues to age normally.

Will my face change?

The surgery harmonises the proportions; you remain recognisable. It is important to discuss your aesthetic expectations at the consultation so that the treatment plan takes them into account.

Do the wisdom teeth need to be removed first?

The lower wisdom teeth are removed at least 6 months before a mandibular osteotomy. The upper ones can be removed during the maxillary osteotomy.

Does orthognathic surgery treat sleep apnoea?

Bimaxillary advancement is the most effective surgical treatment for obstructive sleep apnoea syndrome in young patients who cannot tolerate CPAP, with a success rate above 85%.

Can a genioplasty be done on its own?

Yes, when only the chin is involved, under general anaesthesia with one night in hospital.

How much does it cost?

Reimbursed by the INAMI/RIZIV on functional criteria. In a shared room at Erasme, the amount left to pay is limited to the patient contribution and to non-reimbursed material (palatal expander, 3D planning and guides depending on the case), detailed in the hospital estimate. A single room entails supplements covered by hospitalisation insurance.

Do the plates have to be removed?

No, unless they cause discomfort or infection, or at the patient's request; possible from 6 months. They are MRI-compatible and do not set off airport security gates.

Consultation

Erasme Medical Center, Route de Lennik 900, 1070 Anderlecht — 02 555 37 91 — cons.stomato.erasme@hubruxelles.be

Consultations at Erasme are exclusively dedicated to orthognathic surgery. Please bring your orthodontist's letter and your recent X-rays.