DESCRIPTION
A modified condylotomy is an open surgical procedure utilized for the treatment of temporomandibular joint (TMJ) disorders. It is classified as an extra-articular procedure because it is performed outside of the TMJ. The procedure is performed through the mouth, behind the molar teeth, so there are no incisions on the face. The condyle itself is not cut; thus the term condylotomy is a misnomer. The procedure creates a vertical cut in the mandible such that the region containing the mandibular condyle can be shifted downward and forward.
Because the extra-articular procedure is performed to alter the internal anatomy of the TMJ, not to change the condyle per se, a more accurate term for this repositioning osteotomy operation is indirect arthroplasty. The goals of the operation are to increase the joint space, to unload the joint while maintaining an unchanged occlusion and to decrease the pain and TMJ symptoms. In many cases a more normal disc/condyle relationship is achieved. Following the procedure, the individual must undergo maxillomandibular fixation wherein the jaw is wired in place for three to six weeks
POLICY
A modified condylotomy for the treatment of temporomandibular joint (TMJ) disorders is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
See also: Orthognathic Surgery
MEDICAL APPROPRIATENESS
A modified condylotomy for the treatment of temporomandibular joint (TMJ) disorders, as demonstrated by history and clinical examination, x-ray, or imaging is considered medically appropriate if ANY ONE of the following criteria are met:
Internal derangement (i.e., disc displacement) of the TMJ
Degenerative joint disease (e.g., osteoarthritis) of the TMJ
Recurrent luxation (re-seating of the ball in the socket when the TMJ pops out of place)
Pain that is refractive to nonsurgical therapy (e.g., non-chew diet, intra-oral prosthetic devices/appliances, pharmacologic therapy)
Is being performed to salvage a previously failed open intracapsular TMJ surgery
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
A modified condylotomy differs from orthognathic surgery, although both utilize mandibular ramus procedures. Orthognathic surgery is performed to correct malocclusion. A modified condylotomy procedure is a vertical osteotomy of the mandibular ramus designed to unload the TMJ and increase the TMJ space. Unlike orthognathic surgery, the goal of performing a modified condylotomy is neither to change the position of the mandible with respect to the maxilla nor to change the bite in any way.
SOURCES
American Association of Oral and Maxillofacial Surgeons. (2008). Guidelines to the evaluation of impairment of the oral and maxillofacial region. Retrieved February 17, 2011 from http://www.aaoms.org/docs/practice_mgmt/impairment_guidelines.pdf.
American Dental Association. (1997). Temporomandibular (craniomandibular) disorders. Retrieved February 17, 2011 from http://www.ada.org/1958.aspx.
American Society of Temporomandibular Joint Surgeons. (2001, April). Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Retrieved February 17, 2011 from http://astmjs.org/final%20guidelines-04-27-2005.pdf.
Bakke, M., Eriksson, L., Thorsen, N. M., Sewerin, I., Petersson, A., & Wagner, A. (2008). Modified condylotomy versus conventional conservative treatment in painful reciprocal clicking - a preliminary prospective study in eight patients. Clinical Oral Investigations, 12 (4), 353-359. (Level 4 Evidence - Independent study)
BlueCross BlueShield Association. Medical Policy Reference Manual. (6:2010). Temporomandibular joint dysfunction (2.01.21). Retrieved February 17, 2011 from BlueWeb. (10 articles and/or guidelines reviewed)
Complete Guide to Medicare Coverage Issues [Computer software]. (2010, April). Treatment of temporomandibular joint (TMJ) syndrome (Section 150.1, p. 4-232). Ingenix.
Schiffman, E. L., Look, J. O., Hodges, J. S., Swift, J. Q., Decker, K. L., Hathaway, K. M., et al. (2007). Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. Journal of Dental Research, 86 (1), 58-63.
ORIGINAL EFFECTIVE DATE: 10/1/2002
MOST RECENT REVIEW DATE: 3/10/2011
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.
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