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

Orthognathic surgery for the treatment of facial skeletal deformities that result in significant malocclusion is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

Orthognathic surgery for the treatment for obstructive sleep apnea (OSA) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

Orthognathic surgery for the improvement of an individual's facial structure in the absence of significant malocclusion is considered cosmetic.

Orthognathic surgery for the treatment of temporomandibular joint (TMJ) disorder is considered investigational.

See also:

• Modified Condylotomy for Treatment of Temporomandibular Joint (TMJ) Disorders

• Uvulopalatopharyngoplasty (UPPP)/Palatopharyngoplasty (PPP)

MEDICAL APPROPRIATENESS

Medical indications relate verifiable clinical measurements to significant facial skeletal deformities. Orthognathic surgery is considered medically appropriate for any of the following conditions:

• Maxillary and/or mandibular facial skeletal deformities associated with significant malocclusion as evidenced by any one of the following:

1. Anterior discrepancies

• Maxillary / Mandibular incisor relationship: overjet of 5mm or more, or a 0 to a negative value (norm 2mm) (Note: Overjet up to 5mm may be treatable with routine orthodontic therapy); or

• Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4mm or more (norm 0 to 1mm). (These values represent two or more standard deviation from published norms).

2. Vertical discrepancies

• Presence of a vertical facial skeletal deformity, which is two or more standard deviations from published norms for accepted skeletal landmarks; or

• Open Bite

• No vertical overlap of anterior teeth; or

• Unilateral or bilateral posterior open bite greater than 2mm.

• Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch; or

• Supra-eruption of a dentoalveolar segment due to lack of occlusion.

3. Transverse discrepancies

• Presence of a transverse skeletal discrepancy, which is two or more standard deviations from published norms; or

• Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4mm or greater, or a unilateral discrepancy of 3mm or greater, given normal axial inclination of the posterior teeth.

4. Asymmetries

• Anteroposterior, transverse or lateral asymmetries greater than 3mm with concomitant occlusal asymmetry.

• Clinically significant obstructive sleep apnea (OSA) due to type I obstruction (oropharynx) and the obstruction has been treated unsuccessfully by uvulopalatopharyngoplasty (UPPP).

• Clinically significant obstructive sleep apnea (OSA) due to type II obstruction (oropharynx/hypopharynx) or type III obstruction (hypopharynx) if all of the following criteria are met:

• A full polysomnogram has been performed and documented results confirm a diagnosis of OSA and support the need for treatment; and

• The individual has not responded to or not tolerated nasal continuous positive airway pressure (nCPAP); and

• A presurgical physical evaluation is performed and supports the need for orthognathic surgery; and

• The site of obstruction (oropharynx [palate] and/or hypopharynx [base of tongue]) is confirmed by fiberoptic pharyngoscopy and cephalometric radiographs with tracing.

ADDITIONAL INFORMATION  

Published literature supports the following:

• In phase 1 surgery:

• Individuals with type I obstruction (soft palate) should receive uvulopalatopharyngoplasty (UPPP).

• Individuals with type II obstruction (palate and base of tongue) should receive UPPP and mandibular osteotomy/genioglossus advancement with hyoid myotomy/suspension (GAHM) at the same setting.

• Individuals with type III obstruction (base of tongue) should receive GAHM.

• Follow-up polysomnograms should be obtained at 6 months and unsuccessful phase 1 surgeries are offered phase 2 reconstruction, maxillary and mandibular advancement osteotomy (MMO).

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

Alanen, P., & Varrela, J. (1997). The occlusal theory further complicated. Medical Hypotheses, 49 (5), 397-403. Abstract retrieved February 19, 2001 from PubMed database.

American Association of Oral and Maxillofacial Surgeons. (1999, November). Criteria for orthognathic surgery, 1-9.

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.

Bettega, G., Pepin, J. L., Veale, D., Deschaux, D., Raphael, B., & Levy, P. (2000). Obstructive sleep apnea syndrome. Fifty-one consecutive patients treated by maxillofacial surgery. American Journal of Respiratory and Critical Care Medicine, 162 (2 Pt 1), 641-649. Abstract retrieved February 22, 2001 from PubMed database.

BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2005). Surgical management of obstructive sleep apnea syndrome/upper airway resistance syndrome. (7.01.51). Retrieved September 21, 2007 from BlueWeb. (4 articles and/or guidelines reviewed)

BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Temporomandibular Joint Dysfunction. (2.01.21). Retrieved September 21, 2007 from BlueWeb. (no articles and/or guidelines reviewed)

Bodner, L., & Miller, V. J. (1998). Temporomandibular joint dysfunction in children: Evaluation of treatment. International Journal of Pediatric Otorhinolaryngology, 44 (2), 133-137. Abstract retrieved February 20, 2001 from PubMed database.

Clark, G. T., Tsukiyama, Y., Baba, K., & Simmons, M. (1997). The validity and utility of disease detection methods and of occlusal therapy for temporomandibular disorders. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics, 83 (1), 101-106. Abstract retrieved February 21, 2001 from PubMed database.

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]. (2007, July). Treatment of temporomandibular joint (Section 150.1, p. 4-215). St. Anthony Publishing.

Dawson, P. E. (1997). Why NIH is wrong about 'TMD'. The Journal of Craniomandibular Practice, 5 (1), 1-3.

De Boever, J. A., Carlsson, G. E., & Klineberg, I. J. (2000). Need for occlusal therapy and prosthodontic treatment in the management of temporomandibular disorders. Part I. Occlusal interferences and occlusal adjustment. Journal of Oral Rehabilitation, 27 (5), 367-379. Abstract retrieved February 19, 2001 from PubMed database.

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.

ECRI Institute. Health Technology Information Service. Executive Briefings. (1994, April). Orthognathic Surgery. Retrieved January 7, 2003 from ECRI Institute. (43 articles and/or guidelines reviewed)

Edgermark, I., Blomqvist, J. E., Cromvik, U., & Isaksson, S. (2000). Temporomandibular dysfunction in patients treated with orthodontics in combination with orthognathic surgery. European Journal of Orthodontics, 22 (5), 537-544. Abstract retrieved February 20, 2001 from PubMed database.

Guichet, N., Landesman, H. M. (1996). Understanding occlusion as it relates to the temporomandibular joint - The fourth molar paradigm. The Compendium of Continuing Education in Dentistry, 17 (3), 236-238. Abstract retrieved February 20, 2001 from PubMed database.

Hayes. Medical Technology Directory. (1999, April).Orthognathic Surgical. Retrieved January 8, 2003 from www.Hayesinc.com/subscribers. (48 articles and/or guidelines reviewed)

Ishii, K., Kaloust, S., Ousterhout, D. K., & Vargervik, K. (1996). Airway changes after Le Fort III osteotomy in craniosynostosis syndromes. Journal of Craniofacial Surgery, 7 (5), 363-370. Abstract retrieved February 22, 2001 from PubMed database.

Li, K. K., Riley, R. W., Powell, N. B., Troell, R., & Guillemkinault, C. (1999). Overview of phase II surgery for obstructive sleep apnea syndrome. Ear Nose and Throat Journal, 78 (11), 851, 854-857. Abstract retrieved February 22, 2001 from PubMed database.

Lipp, M. J. (1991). Temporomandibular symptoms and occlusion: A review of the literature & the concept. Journal of the Colorado Dental Association, 69 (3), 18-22. Abstract retrieved February 19, 2001 from PubMed database.

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.

Magnusson, T., Ahlborg, G., Finne, K., Nethander, G., & Svartz, K. (1986). Changes in temporomandibular joint pain-dysfunction after surgical correction of dentofacial anomalies. International Journal of Oral and Maxillofacial Surgery, 15 (6), 707-714. Abstract retrieved February 20, 2001 from PubMed database.

McNeil, C. (1997). Management of temporomandibular disorders: Concepts and controversies. The Journal of Prosthetic Dentistry, 77 (5), 510-522. Abstract retrieved February 19, 2001 from PubMed database.

National Institutes of Health Technology Assessment Conference Statement. (1996, November). Management of temporomandibular disorders. Retrieved February 20, 2001 from http://consensus.nih.gov/ta/018/018_statement.htm.

Onizawa, K., Schmelzeisen, R., & Vogt, S. (1995). Alteration of temporomandibular joint symptoms after orthognathic surgery: Comparison with healthy volunteers. Journal of Oral and Maxillofacial Surgery, 53 (2), 117-121. Abstract retrieved February 16, 2001 from PubMed database.

Orbach, S. (1998). TMD issues in patient with skeletal deformity of jaws. The New York State Dental Journal, 64 (3), 48-54. Abstract retrieved February 21, 2001 from PubMed database.

Panula, K., Somppi, M., Finne, K., & Oikarinen, K. (2000). Effects of orthognathic surgery on temporomandibular joint dysfunction. A controlled prospective 4-year follow-up study. International Journal of Oral and Maxillofacial Surgery, 29 (3), 183-187. Abstract retrieved February 20, 2001 from PubMed database.

Riley, R. W., Powell, N. B., & Guilleminault, C. (1990). Maxillofacial surgery and nasal CPAP. A comparison of treatment for obstructive sleep apnea syndrome, Chest, 98 (6), 1421-1425. Abstract retrieved February 22, 2001 from PubMed database.

Riley, R. W., Powell, N., & Guilleminault, C. (1987). Current surgical concepts for treating obstructive sleep apnea syndrome. Journal of Oral and Maxillofacial Surgery, 45 (2), 149-157.

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.

Rodrigues-Garcia, R. C., Sakai, S., & Rugh, J. D. (1998). Effects of major Class II occlusal corrections on temporomandibular signs and symptoms. Journal of Orofacial Pain, 12 (3), 185-192. Abstract retrieved February 16, 2001 from PubMed database.

The Technology Evaluation Center. (1996, April). Surgical Procedures for the Treatment of Obstructive Sleep Apnea Syndrome. (Vol. 10, No. 51). Chicago: BlueCross BlueShield Association. (39 articles and/or guidelines reviewed)

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

Throckmorton, G. S., Buschang, P. H., & Ellis, E. (1999). Morphologic and biomechanical determinants in the selection of orthognathic surgery procedures. Journal of Oral and Maxillofacial Surgery, 57 (9), 1044-1056. Abstract retrieved January 7, 2003 from PubMed database.

U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. Medicare Part B - Tennessee Local Medicare Review Policy. (1997, November). Surgical treatment of obstructive sleep apnea (97-13). Retrieved January 8, 2003 from http://www.cignagovernmentservices.com/partb/pubs/mb/1997/gr97_5/tn/surgical_treatment_of_obstructive_sleep_apnea_lmrp_97-09.html.

U. S. Food and Drug Administration. Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K021618. Retrieved January 8, 2003 from http://www.fda.gov/cdrh/pdf2/k021618.pdf.

U. S. Food and Drug Administration. Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K030448. Retrieved September 24, 2007 from http://www.fda.gov/cdrh/pdf3/k030448.pdf.

White, C. S., & Dolwick, M. F. (1992). Prevalence and variance of temporomandibular dysfunction in orthognathic surgery patients. International Journal of Adult Orthodontics and Orthognathic Surgery, 7 (1), 7-14. Abstract retrieved February 21, 2001 from PubMed database.

ID_BT

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.

This document has been classified as public information.