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:
MEDICAL APPROPRIATENESS
Orthognathic surgery is considered medically appropriate for ANY ONE of the following conditions:
Maxillary and/or mandibular facial skeletal deformities associated with significant malocclusion as evidenced by ANY ONE of the following: [Note: Medical indications relate verifiable clinical measurements to significant facial skeletal deformities.]
Anterior discrepancies with ANY ONE of the following:
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)
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)
Vertical discrepancies with ANY ONE of the following:
Presence of a vertical facial skeletal deformity, which is two or more standard deviations from published norms for accepted skeletal landmarks
Open bite with ANY ONE of the following
No vertical overlap of anterior teeth
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
Supra-eruption of a dentoalveolar segment due to lack of occlusion
Transverse discrepancies with ANY ONE of the following:
Presence of a transverse skeletal discrepancy, which is two or more standard deviations from published norms
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
Asymmetries with 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
The individual has not responded to or not tolerated nasal continuous positive airway pressure (nCPAP)
A presurgical physical evaluation is performed and supports the need for orthognathic surgery
The site of obstruction (oropharynx [palate] and/or hypopharynx [base of tongue]) is confirmed by fiberoptic pharyngoscopy and cephalometric radiographs with tracing
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
Published literature supports the following:
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
American Academy of Pediatric Dentistry. (2009). Guideline on management of the developing dentition and occlusion in pediatric dentistry. Retrieved October 24, 2011 from http://www.aapd.org/media/Policies_Guidelines/G_DevelopDentition.pdf.
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. (2009, November). Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Retrieved October 24, 2011 from http://www.acpa-cpf.org/teamcare/Parameters%20Rev.2009.pdf.
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2011). Surgical treatment of snoring and obstructive sleep apnea syndrome (7.01.101). Retrieved October 24, 2011 from BlueWeb. (30 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Medical Policy Reference Manual. (7:2011). Temporomandibular joint dysfunction (2.01.21). Retrieved October 24, 2011 from BlueWeb. (13 articles and/or guidelines reviewed)
Complete Guide to Medicare Coverage Issues [Computer software]. (2011, November). Treatment of temporomandibular joint (Section 150.1, p. 4-246). The Ingenix Complete Guide to Medicare Coverage Issues.
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)
Mueller, D. T., & Callanan, V. P. (2007). Congenital malformations of the oral cavity. Otolaryngologic Clinics of North America, 40 (1), 141-160.
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)
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.
MOST RECENT REVIEW DATE: 12/8/2011
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