Orthognathic Surgery Before Braces? When a Surgery-First Approach Is an Option

Surgery-first or orthodontics-first: which sequence is right for you?

 

Hello, I'm Dr. Chaeyeon Lee of EU Oral and Maxillofacial Surgery.

 

One of the questions I hear most often from people considering double jaw surgery is about the order of treatment.

 

"Am I a candidate for surgery-first?"

"I've heard my face can look worse if I start with braces. Can't I just have the surgery first?"

"Is it true that surgery-first makes treatment much shorter?"

 

Traditionally, the standard approach has been to complete orthodontic treatment first and then proceed to surgery. Recently, however, there has been growing interest in the surgery-first approach, in which jaw surgery is performed first and orthodontic treatment follows.

That said, surgery-first is not suitable for everyone. Whether it is appropriate depends on your tooth alignment, jaw structure, and how predictably the final bite can be planned. In today's column, I'll explain how this decision is made and what the process actually looks like.

✔ What is surgery-first? Jaw surgery is performed first with no (or minimal) pre-surgical orthodontics, and orthodontic treatment is carried out after surgery.

✔ Advantages: tends to shorten treatment time, skips the phase where appearance temporarily worsens, and reduces psychological burden.

✔ Good candidates: mild dental misalignment, near-normal incisor inclination, and a shallow curve of Spee.

✔ When orthodontics-first is needed: severe crowding (requiring extractions), abnormal incisor inclination, or cases where the post-surgical bite is difficult to predict.

1.    What Is Surgery-First, and Why Do Patients Prefer It?

The conventional approach proceeds in three stages: pre-surgical orthodontics → surgery → post-    surgical orthodontics.

Of these, pre-surgical orthodontics typically takes about 9 to 18 months. During this period, the teeth go through a process called decompensation, in which they are repositioned to match the underlying jaw. The catch is that as the teeth move into positions that fully reveal the original skeletal discrepancy, the face can temporarily look more pronounced before surgery. Some patients also experience discomfort with chewing or speech, or find this period psychologically difficult.

The surgery-first approach skips or minimizes this pre-surgical orthodontic stage: jaw surgery is performed first, and the teeth are aligned after surgery.

Ø  Why can treatment time be shorter?

After surgery, there is a period during which bone metabolism temporarily becomes more active in the area as the bone remodels. This is called the Regional Acceleratory Phenomenon (RAP). While RAP is active, bone turnover increases, and tooth movement may proceed relatively more easily. This is why post-surgical orthodontics is often timed to begin during this window. However, RAP does not occur at the same rate in every patient.

In addition, 3D virtual surgical planning (simulation) based on CT data now allows us to predict and verify the amount of jaw movement and the final bite relationship before surgery. Advances in this simulation technology play an important role in improving the predictability of surgery-first treatment, which proceeds without pre-surgical orthodontics.

Ø  Key features of the surgery-first approach

-     Treatment time tends to be shorter. Some studies have reported that surgery-first treatment was on average about 3 to 4 months shorter than the conventional approach.

-     The phase in which appearance worsens due to pre-surgical orthodontics is shortened or skipped. During the decompensation period described above, people with a protruding lower jaw may find their jaw looks even more prominent, and people with a recessed chin may find it looks even more retruded. With surgery-first, this period becomes very short.

-     When functional improvement is urgent, as in obstructive sleep apnea, surgery-first may be considered as a priority rather than waiting through a long course of pre-surgical orthodontics.

However, these advantages do not apply equally to every patient. Whether surgery-first is appropriate, and the results, can vary depending on each person's teeth and jaw structure.

2.    When Surgery-First Is Possible, and When Orthodont

ics-First Is Needed

Because surgery-first moves the jaws directly without first aligning the teeth through pre-surgical orthodontics, the key question is whether the dental alignment issues remaining after surgery can be resolved comfortably with orthodontics alone.

 

Ø  Cases relatively well suited to surgery-first

-     The front teeth are well aligned, or crowding (overlapping teeth) is mild: alignment should be achievable with post-surgical orthodontics alone, without extractions.

-     The curve of Spee (the front-to-back curve of the dental arch) is flat or shallow: a deep curve can make it harder to predict how the bite will settle after surgery.

-     The inclination of the upper and lower front teeth is close to the normal range: if the front teeth are excessively tipped back or upright, it is difficult to establish the bite with surgery alone.

-     There is no significant width discrepancy between the upper and lower arches (transverse discrepancy).

-     Cases with a protruding lower jaw (Class III malocclusion) and a tendency toward open bite are often cited as relatively good indications.

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Ø  Cases where orthodontics-first is needed, or surgery-first requires a cautious approach

-     Severe crowding requiring extractions: space for tooth movement must be created first, so this is considered a typical case in which surgery-first is difficult to apply.

-     The front teeth are severely flared forward (labial inclination) or tipped inward (lingual inclination).

-     A deep curve of Spee, or pronounced vertical problems such as facial asymmetry or open bite: these were once considered absolute contraindications, but with adjustments to surgical planning and advances in 3D simulation, cases where surgery-first has been applied have been reported. Even so, careful case-by-case judgment is still required.

-     Analysis of dental models (impressions) shows that the post-surgical bite relationship is difficult to predict.

 

Ø  Even surgery-first requires a minimal preparation period

Surgery-first does not mean there is no preparation at all. When there is significant occlusal interference, a short course of pre-surgical orthodontics of about 1 to 2 months may be added. In other words, it is more accurate to think of it not as "no orthodontics at all" but as "minimal preparation without a full decompensation phase."

 

Ø  Surgical planning may include the concept of "overcorrection"

Because surgery-first is performed without precisely aligning the teeth beforehand, rather than setting the bite exactly at surgery, the jaw is sometimes moved slightly further in the planned direction.

This accounts for the small positional changes (a tendency toward relapse) that naturally occur over time after surgery, and the bite is then refined to its final position during post-surgical orthodontics.

 

Ø  When caution is needed

The presence of temporomandibular joint disorder (TMD) is consistently cited across multiple studies as a factor calling for caution with surgery-first.

3.    The Surgery-First Treatment Process

Stage	Description	What We Check
Stage 1	Initial consultation and comprehensive examination	Cephalometric X-ray, CT, dental models, facial analysis
Stage 2	Bite analysis	Simulation of the expected bite relationship using dental models, Assessment of suitability for surgery-first
Stage 3	Surgery	Repositioning of the jaws
Stage 4	Start of post-surgical orthodontics	Usually begins 4 to 5 weeks after surgery
Stage 5	Bite refinement and finishing orthodontics	Continues for several months or longer depending on the individual; final bite stabilization

4.    Surgery-First vs. Orthodontics-First at a Glance

Category	Surgery-First	Orthodontics-First, Then Surgery (Conventional)
Sequence	Minimal preparation (days to weeks) → surgery → post-surgical orthodontics	Pre-surgical orthodontics (9–18 months) → surgery → post-surgical orthodontics
Suitable for	Mild crowding, near-normal incisor inclination, shallow curve of Spee	Severe crowding, cases requiring extractions, abnormal incisor inclination
Characteristics	Shorter phase of worsened appearance; tends to shorten treatment time	Bite prediction is relatively stable at the pre-surgical stage
Considerations	Precision of bite prediction is especially critical	Longer treatment time; temporary changes in facial appearance may occur

※ The treatment approach depends on each individual's skeletal and dental condition and is determined through a thorough examination and consultation with a specialist.

5. A Note from the Surgeon

Surgery-first is not "an option anyone can choose" but one that may be considered when the teeth and jaws meet certain conditions. Whether it is possible is determined by comprehensively evaluating tooth alignment, jaw structure, TMJ condition, and the predictability of the surgical plan, and both results and recovery vary from person to person.

 

Even with the same type of malocclusion, whether surgery-first can be applied depends on tooth alignment, the curve of Spee, and incisor inclination, so a precise diagnosis using cephalometric X-rays, CT, and model analysis must come first. In particular, because surgery-first proceeds without refining the bite beforehand, the accuracy of predictions at the planning stage has a major impact on the outcome. To determine whether surgery-first is feasible, our clinic uses a collaborative care system in which orthodontics and oral and maxillofacial surgery review each case together from the model surgery stage, allowing us to examine the expected post-surgical bite in greater detail. Through this process, we determine whether surgery-first or orthodontics-first is more likely to lead to a stable result.

6. Frequently Asked Questions

Q. Does surgery-first always shorten treatment time?

Several studies have reported a tendency toward shorter treatment time with surgery-first, but this is an average trend and varies depending on each person's teeth and jaw structure. It does not apply equally in every case.

Q. I have crowding (overlapping, crooked teeth). Can I still have surgery-first?

If the crowding is mild, surgery-first may be considered. However, if it is severe enough to require extractions, orthodontics-first may be necessary. This needs to be confirmed through a thorough examination.

Q. Is surgery-first carried out jointly by orthodontics and oral and maxillofacial surgery?

Yes. Surgery-first is a collaborative treatment: the orthodontist and surgeon plan the bite together from the pre-surgical model surgery stage and continue to coordinate throughout post-surgical orthodontics.

Q. How long does orthodontic treatment take after surgery-first?

It varies depending on the extent of surgery and your dental condition. You can get an estimated timeline through a thorough examination and consultation.

 

References

Falbo Martins et al. Evidence-Based Patient Selection for Surgery-First Orthognathic Treatment: Clinical Indicators and Contraindications. The Journal of Craniofacial Surgery. 2026;37(1/2):e57-e60.

Ahmadvand A et al. An overview of surgery-first orthognathic approach: History, indications and limitations, protocols, and dentoskeletal stability. Dental Research Journal. 2021;18:47.

Uribe FA, Farrell B. Surgery-First Approach in the Orthognathic Patient. Oral and Maxillofacial Surgery Clinics of North America. 2020;32(1):89-103.

Hoang TA et al. The Surgery-first Approach to Orthognathic Surgery. The Journal of Craniofacial Surgery. 2021;32(2):e153-e155.