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.

NOTE: Pre and/or post-surgical orthognathic surgery related orthodontia (i.e., non-cosmetic orthodontic braces) are considered medically necessary for individuals who meet the Medical Appropriateness criteria, and should not be denied or referred to dental benefits.

REFER TO EVALUATION TOOL

POLICY

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

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 

Alsulaimani, F. F., Al-Sebaei, M. O., & Afify, A. R. (2013). Surgical orthodontic treatment of severs skeletal class II. Case Reports in Dentistry, 2013, 1-6. (Level 3 evidence)

American Academy of Pediatric Dentistry (AAPD). (1991, revised 2014). Guideline on management of the developing dentition and occlusion in pediatric dentistry. Retrieved October 26, 2016 from http://www.aapd.org.

American Academy of Pediatric Dentistry (AAPD). (2010, revised 2015). Guideline on management consideration for pediatric oral surgery and oral pathology. Retrieved October 26, 2016 from http://www.aapd.org.

American Association of Oral and Maxillofacial Surgeons (AAOMS). (2017). Criteria for orthognathic surgery. Retrieved July 19, 2017 from http://www.aaoms.org.

American Association of Oral and Maxillofacial Surgeons (AAOMS). (2015). Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region. Retrieved July 19, 2017 from http://www.aaoms.org.

American Cleft Palate-Craniofacial Association. (2009, November). Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Retrieved April 12, 2013 from http://www.acpa-cpf.org/uploads/site/Parameters_Rev_2009.pdf.

BlueCross BlueShield Association. Medical Policy Reference Manual. (12:2016). Surgical treatment of snoring and obstructive sleep apnea syndrome (7.01.101). Retrieved July 19, 2017 from BlueWeb. (31 articles and/or guidelines reviewed)

Cappellozza, J. A., Guedes, F. P., Filho, H. N., Filho, L. C., & Cardoso, M. (2015). Orthodontic decompensation in skeletal Class III malocclusion: redefining the amount of movement assessed by cone-beam computed tomography. Dental Press Journal of Orthodontics, 20 (5), 28-34. (Level 3 evidence)

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)

Rachmiel, A., Even-Almos, M., & Aizenbud, D. (2012). Treatment of maxillary cleft palate: Distraction osteogenesis vs. orthognathic surgery. Annals of Maxillofacial Surgery, 2 (2), 127-130. (Level 3 evidence)

Riley, R., Powell, N., and Guilleminault, C. (1987) Current surgical concepts for treating obstructive sleep apnea syndrome. Journal of Oral Maxillofacial Surgery 45:149-157. (Level 5 evidence)

Thaler, E. R., Rassekh, C. H., Lee, J. M., Weinstein, G. S., & O’Malley, Jr., B. W. (2016). Outcomes for multilevel surgery for sleep apnea: Obstructive sleep apnea, transoral robotic surgery, and uvulopalatopharyngoplasty. Laryngoscope, 126 (1), 266-269. Abstract retrieved January 20, 2016 from PubMed database.

Yu, H. B., Mao, L. X., Wang, X. D., Fang, B., & Shen, S. G. (2015). The surgery-first approach in orthognathic surgery: a retrospective study of 50 cases.  International Journal of Oral & Maxillofacial Surgery, 44 (2), 1463-1467. (Level 4 evidence)

ORIGINAL EFFECTIVE DATE:  1/11/1983

MOST RECENT REVIEW DATE:  9/20/2017

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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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