BlueCross BlueShield of Tennessee Medical Policy Manual

Orthognathic Surgery

DESCRIPTION

Orthognathic surgery is the surgical correction of abnormalities of the mandible, maxilla, or both. The underlying abnormality may be present at birth, may become evident as an individual grows and develops or may be the result of traumatic injuries. The severity of these deformities precludes adequate treatment through dental treatment alone. Orthodontic consultation may be needed to confirm that the surgery is necessary or that an individual can receive improved function with orthodontic therapy alone. Depending on the severity of the deformity, one of the following surgical methods is usually employed: linear osteotomy, sagittal osteotomy, or the complete division of the mandibular body. Teeth may also be moved in any direction, depending on each individual case.

Orthognathic surgery is performed to correct malocclusion, which cannot be improved with routine orthodontic therapy and where the functional impairments are directly caused by the malocclusion. Examples of conditions for which this surgery is used are mandibular prognathism, crossbite, open bite, overbite, underbite, mandibular deformity, and maxillary deformity.

The following surgical procedures would be considered orthognathic surgery: reconstruction of the mandibular ramus, mandibular osteotomy, maxilla osteotomy, and reconstruction of the mandible/maxilla, which are related to function. Osteotomy involves the surgical cutting of the bone to correct the deformity.

Two orthognathic procedures have been used to correct obstructive sleep apnea caused by hypopharyngeal obstruction: the conservative procedure of mandibular osteotomy/genioglossus advancement, in which a small portion of the lower jaw which attaches to the tongue is moved forward, to pull the tongue away from the back of the airway, with hyoid myotomy, movement of the hyoid bone in the neck/suspension (GAHM) and the more aggressive procedure maxillary and mandibular advancement osteotomy (MMO). The surgical concept is to advance the mandible and hyoid bone, which results in advancement of pharyngeal muscles and the base of tongue resulting in expansion of the airway.

Orthognathic surgery has been proposed as a treatment for temporomandibular joint (TMJ) disorder.

REFER TO EVALUATION TOOL

POLICY

See also:

MEDICAL APPROPRIATENESS

ADDITIONAL INFORMATION

Published literature supports the following:

Scientific literature does not support orthognathic surgery for temporomandibular joint dysfunction (TMJ), due to a lack of a cause-and-effect relationship between occlusion and TMJ dysfunction.

SOURCES

American Association of Oral and Maxillofacial Surgeons. (2008). Criteria for orthognathic surgery. Retrieved October 8, 2009 from http://www.aaoms.org/docs/practice_mgmt/ortho_criteria.pdf.

American Cleft Palate-Craniofacial Association. (2007, November). Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Retrieved October 8, 2009 from http://www.acpa-cpf.org/teamcare/Parameters07rev.pdf.

American Society of Plastic and Reconstructive Surgeons, Inc. (1994, September). Maxillary retrognathia (hypoplasia) and maxillary protrusion (hyperplasia) and vertical deficiency or excess. Clinical Practice Guidelines for Plastic and Maxillofacial Surgery, 1-6.

BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2005). Surgical management of obstructive sleep apnea syndrome/upper airway resistance syndrome. (7.01.51). Retrieved October 6, 2009 from BlueWeb. (4 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Temporomandibular Joint Dysfunction. (2.01.21). Retrieved October 6, 2009 from BlueWeb. (0 articles and/or guidelines reviewed)

Coleman, J. (1999). Oral and maxillofacial surgery for the management of obstructive sleep apnea syndrome. Otolaryngologic Clinics of North America, 32 (2), 235-241.

Complete Guide to Medicare Coverage Issues [Computer software]. (2009, July). Treatment of temporomandibular joint (Section 150.1, p. 4-228, 4-229). The Ingenix Complete Guide to Medicare Coverage Issues.

Dimitroulis, G., Gremillion, H. A., Dolwick, M. F., & Walter, J. H. (1995). Temporomandibular disorders. 2. Non-surgical treatment. Australian Dental Journal, 40 (6), 372-376.

Kasahara, K., Yajima, Y., Ikeda, C., Kamiyama, .I, Takaki, T., Kakizawa, T., et al. (2009). Systemic inflammatory response syndrome and postoperative complications after orthognathic surgery. The Bulletin of Tokyo Dental College, 50 (1), 41-50. (Level 4 Evidence - Independent study)

Lundstrom, A., Forsberg, C. M., Peck, S., & McWilliam, J. (1992). A proportional analysis of the soft tissue facial profile in young adults with normal occlusion. The Angle Orthodontist, 62 (2), 127-134.

Luther, F. (1998). Orthodontics and the temporomandibular joint: Where are we now? Part 2. Functional occlusion, malocclusion, and TMD. The Angle Orthodontist, 68 (4), 305-318.

Mehra, P. & Wolford, L. M. (2000). Surgical management of obstructive sleep apnea. Proceedings, 13 (4), 338-342.

Mueller, D. T., & Callanan, V. P. (2007). Congenital malformations of the oral cavity. Otolaryngologic Clinics of North America, 40 (1), 141-160.

National Guideline Clearinghouse. (2005). Clinical guideline on management of the developing dentition and occlusion in pediatric dentistry. Retrieved October 8, 2009 from http://www.guidelines.gov.

National Guideline Clearinghouse. (2008). Diagnosis and treatment of obstructive sleep apnea in adults. Retrieved October 8, 2009 from http://www.guidelines.gov.

Phillips, C., Blakey, G., & Jaskolka, M. (2008). Recovery after orthognathic surgery: Short-term health-related quality of life outcomes. Journal of Oral and Maxillofacial Surgery, 66 (10), 2110-2115. (Level 2 Evidence – Independent study)

Rabie, A. B., Wong, R. W., & Min, G. U. (2008). Treatment in borderline class III malocclusion: orthodontic camouflage (extraction) versus orthognathic surgery. The Open Dentistry Journal, 2, 38-48. (Level 2 Evidence - Independent study)

Riley, R. W., Powell, N.B., & Guilleminault, C. (1993). Obstructive sleep apnea syndrome: A review of 306 consecutively treated surgical patients. Otolaryngology and Head and Neck Surgery, 108 (2), 117-125.

Thomas, P. M., & Tucker, M. R. (1999). Complex orthodontic problems: The orthognathic patient with temporomandibular disorders. Seminars in Orthodontics, 5 (4), 244-256.

U. S. Department of Health and Human Services. National Institute of Health. National Institute of Dental and Cranofacial Research. (2006, June). TMJ disorders. Retrieved October 6, 2009 from http://www.nidcr.nih.gov/OralHealth/Topics/TMJ/TMJDisorders.htm.

U. S. Food and Drug Administration. (2002, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K021618. Retrieved October 8, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf2/K021618.pdf.

U. S. Food and Drug Administration. (2003, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K030448. Retrieved October 8, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf3/K030448.pdf.

U. S. Food and Drug Administration. (2009, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K083388. Retrieved October 8, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf8/K083388.pdf.

ORIGINAL EFFECTIVE DATE:  1/11/1983    

MOST RECENT REVIEW DATE:  11/12/2009  

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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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