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
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.
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 (Note: These values represent two or more standard deviation from published norms):
Maxillary/Mandibular incisor relationship (norm 2mm): Overjet of 5mm or more, or 0 to a negative value (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)
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 REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
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 or government program (e.g., TennCare), the express terms of the health plan or government program 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
Al-Moraissi, E. A., Wolford, L. M., Perez, D., Laskin, D. M., & Ellis, E., 3rd (2017). Does orthognathic surgery cause or cure temporomandibular disorders? A systematic review and meta-analysis. Journal of Oral and Maxillofacial Surgery, 75 (9), 1835–1847. (Level 1 evidence)
American Academy of Pediatric Dentistry (AAPD). (1991, revised 2021). Guideline on management of the developing dentition and occlusion in pediatric dentistry. Retrieved March 14, 2022 from http://www.aapd.org.
American Academy of Pediatric Dentistry (AAPD). (2010, revised 2020). Guideline on management consideration for pediatric oral surgery and oral pathology. Retrieved April 5, 2021 from http://www.aapd.org.
American Academy of Pediatric Dentistry (AAPD). (2016, revised 2021). Policy on obstructive sleep apnea (OSA). Retrieved March 14, 2022 from http://www.aapd.org.
American Academy of Sleep Medicine (AASM). (2009). Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. May 27, 2020 from https://aasm.org.
American Academy of Sleep Medicine (AASM). (2021). Referral of adults with obstructive sleep apnea for surgical consultation: An American academy of sleep medicine clinical practice guideline. March 14, 2022 from https://aasm.org.
American Association of Oral and Maxillofacial Surgeons (AAOMS). (2023). Criteria for orthognathic surgery. Retrieved July 17, 2024 from http://www.aaoms.org.
American Association of Oral and Maxillofacial Surgeons (AAOMS). (2018). Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region. Retrieved June 10, 2019 from http://www.aaoms.org.
American Cleft Palate-Craniofacial Association. (2018, January). Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Retrieved June 10, 2019 from https://journals.sagepub.com/doi/pdf/10.1177/1055665617739564.
BlueCross BlueShield Association. Evidence Positioning System. (7:2023). Surgical treatment of snoring and obstructive sleep apnea syndrome (7.01.101). Retrieved July 17, 2024 from www.bcbsaoca.com/eps/. (40 articles and/or guidelines reviewed)
Pachnicz, D., & Ramos, A. (2021). Mandibular condyle displacements after orthognathic surgery-an overview of quantitative studies. Quantitative Imaging in Medicine and Surgery, 11 (4), 1628–1650. (Level 1 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)
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)
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)
Zhou, N., Ho, J., Huang, Z., Spijker, R., de Vries, N., Aarab, G., et al. (2021). Maxillomandibular advancement versus multilevel surgery for treatment of obstructive sleep apnea: A systematic review and meta-analysis. Sleep Medicine Reviews, 57, 101471. (Level 1 Evidence)
ORIGINAL EFFECTIVE DATE: 1/11/1983
MOST RECENT REVIEW DATE: 9/12/2024
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.