Surgery Section - Orthognathic Surgery

IMPORTANT REMINDER

This Medical Policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of medical policy is to provide a guide to coverage. Medical Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care.

Description

Orthognathic surgery involves the surgical manipulation of the facial skeleton, particularly the maxilla and mandible, to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies, which may be caused by congenital or developmental anomalies or by traumatic injury. (1)

Note: This policy does not address surgical management of sleep apnea; discussion of these conditions may be found in Medical Policy, Surgery No. 166.

Policy/Criteria

1. Orthognathic surgery for the treatment of obstructive sleep apnea may be considered medically necessary when the criteria in Surgery, Policy No. 49 are met.
2. Orthognathic surgery may be considered medically necessary to correct jaw and craniofacial deformities in the absence of obstructive sleep apnea when all of the following criteria (A-C) are met:
   1. Significant functional impairment is documented as a result of illness, injury, congenital anomaly, or developmental anomaly. Significant functional impairment must be directly attributable to jaw and craniofacial deformities and must include one or more of the following:
      1. Chewing-induced trauma secondary to malocclusion
      2. Significantly impaired swallowing and/or choking due to inadequate mastication secondary to malocclusion
      3. Significant speech abnormalities (e.g., sibilant distortions or velopharyngeal distortion) which have not responded to speech therapy and are secondary to malocclusion
      4. Loss of masticatory or incisive function due to malocclusion or skeletal abnormality
      5. Airway restriction
         
   2. Significant over- or underjet as documented by one of the following:
      1. In mandibular excess or maxillary deficiency, a reverse overjet of 3mm or greater
      2. In mandibular deficiency, an overjet of 5mm or greater
      3. Open bite of 4mm or greater
      4. Deep bite of 7mm or greater
      5. Less than six posterior teeth in functional opposition to other teeth secondary to a developmental or congenital growth abnormality (as opposed to a consequence of the loss of teeth)
   3. The functional impairment and over- or underjet are not correctable with non-surgical treatment modalities.
3. Orthognathic surgery in the absence of significant physical functional impairment is considered cosmetic, including but not limited to when used for altering or improving bite or for improvement of appearance.
4. The following documentation is required to determine medical necessity for orthognathic surgery:
   • Intra-oral and extra-oral photographs
   • Cephalometric x-rays
   • Diagnostic report
   • Panorex x-ray

References

1. Patel PK.  Craniofacial, Orthognathic Surgery.  www.emedicine.com/plastic/topic177.htm  (Verified 10/22/08)
2. American Association of Oral and Maxillofacial Surgeons. Reconstructive Oral and Maxillofacial Surgery www.aaoms.org/docs/practice_mgmt/condition_statements/reconstructive_surgery.pdf  (Verified 10/22/08)
3. Ahn SJ, Kim JT, Nahm DS. Cephalometric markers to consider in the treatment of Class II Division 1 malocclusion with the bionator. Am J Orthod Dentofacial Orthop 2001;119(6):578-86
4. Cain KK, Rugh JD, Hatch JP, Hurst CL. Readiness for orthognathic surgery: a survey of practitioner opinion. Int J Adult Orthodon Orthognath Surg 2002;17(1):7-11
5. Kim JC, Mascarenhas AK, Joo BH et al. Cephalometric variables as predictors of Class II treatment outcome. Am J Orthod Dentofacial Orthop 2000;118(6):636-40
6. Mogavero FJ, Buschang PH, Wolford LM. Orthognathic surgery effects on maxillary growth in patients with vertical maxillary excess. Am J Orthod Dentofacial Orthop 1997;111(3):288-96
7. Park JU, Baik SH. Classification of Angle Class III malocclusion and its treatment modalities. Int J Adult Orthodon Orthognath Surg 2001;16(1):19-29
8. Proffit WR, White RP Jr. Who needs surgical-orthodontic treatment? Int J Adult Orthodon Orthognath Surg 1990;5(2):81-9
9. Proffit WR, Phillips C, Tulloch JF et al. Surgical versus orthodontic correction of skeletal Class II malocclusion in adolescents: effects and indications. Int J Adult Orthodon Orthognath Surg 1992;7(4):209-20
10. Throckmorton GS, Buschang PH, Ellis E 3rd. Morphologic and biomechanical determinants in the selection of orthognathic surgery procedures. J Oral Maxillofac Surg 1999;57(9):1044-56
11. Thomas PM. Orthodontic camouflage versus orthognathic surgery in the treatment of mandibular deficiency. J Oral Maxillofac Surg 1995;53(5):579-87
12. Throckmorton GS, Ellis E 3rd, Sinn DP. Functional characteristics of retrognathic patients before and after mandibular advancement surgery. J Oral Maxillofac Surg 1995;53(8):898-908
13. Tucker MR. Orthognathic surgery versus orthodontic camouflage in the treatment of mandibular deficiency. J Oral Maxillofac Surg 1995;53(5):572-8
14. Vallino LD. Speech, velopharyngeal function, and hearing before and after orthognathic surgery. J Oral Maxillofac Surg 1990;48(12):1274-81
15. Wilmot JJ, Barber HD, Chou DG et al. Associations between severity of dentofacial deformity and motivation for orthodontic-orthognathic surgery treatment. Angle Orthod 1993;63(4):283-8
16. Wolford LM, Karras SC, Mehra P. Considerations for orthognathic surgery during growth, part 1: mandibular deformities. Am J Orthod Dentofacial Orthop 2001;119(2):95-101
17. Wolford LM, Karras SC, Mehra P. Considerations for orthognathic surgery during growth, part 2: maxillary deformities. Am J Orthod Dentofacial Orthop 2001;119(2):102-5
18. Wolford LM, Mehra P, Reiche-Fischel O et al. Efficacy of high condylectomy for management of condylar hyperplasia. Am J Orthod Dentofacial Orthop 2002;121(2):136-50
19. Zarrinkelk HM, Throckmorton GS, Ellis E 3rd et al. Functional and morphologic changes after combined maxillary intrusion and mandibular advancement surgery. J Oral Maxillofac Surg 1996;54(7):828-37

Cross References

Cosmetic and Reconstructive Surgery, Regence Medical Policy Manual, Surgery, Policy No. 12

Surgeries for Snoring, Obstructive Sleep Apnea Syndrome and Upper Airway Resistance Syndrome In Adults, Regence Medical Policy Manual, Surgyer, Policy No. 166

Regence Clinical Position Statement: Temporomandibular Joint Dysfunction

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