Analysis of reliability, accuracy, sensitivity and predictive value of a subjective method to classify facial pattern in adults

Factors associated with quality of life before and after orthognathic surgery

PURPOSE

Evaluate which factors compromise patients' quality of life who have undergone orthognathic surgery in the pre and postoperative period of 2 years.

STUDY DESIGN

In this longitudinal prospective study, 46 adult patients undergoing orthognathic surgery were evaluated. The primary outcome variable was quality of life, assessed using the overall score of the orthognathic quality of life questionnaire (OQLQ) in the pre and 2-year postoperative periods. The predictor variables were axis I (temporomandibular dysfunction) and axis II (psychosocial) RDC/TMD diagnoses, assessed preoperatively and 2 years postoperatively; profile, asymmetry, and open bite preoperatively; and orthodontic treatment active 2 years postoperatively. The covariables were age and sex. The OQLQ score was compared preoperatively and postoperatively using the Wilcoxon test and with the other variables using the Mann-Whitney and Kruskall-Wallis tests.

RESULTS

Preoperatively, higher OQLQ scores were associated with myofascial pain (P = .012) and severe depression (P = .030). Two years after surgery, there was an improvement in overall OQLQ (P < .001), myofascial pain (P = .012) and chronic pain (P = .001). However, higher OQLQ scores were associated with individuals who had myofascial pain (P = .012), active orthodontic treatment (P = .007), and other nonspecific physical symptoms including pain (NSPSIP) (P = .049).

CONCLUSION

Quality of life was affected preoperatively by myofascial pain and depression, and although it improved significantly 2 years after surgery, it continued to be affected by myofascial pain, NSPSIP, and active orthodontic treatment.

Temporomandibular Disorders at the Preoperative Time of Orthognathic Surgery

Individuals seeking orthodontic treatment combined with orthognathic surgery (OS) have a high prevalence of temporomandibular disorders (TMDs), but the relationship between TMD diagnoses and dentofacial deformities (DFDs) is still controversial. Therefore, this cross-sectional study with a comparison group aimed to analyze the association between dentofacial deformities and TMDs.

METHODOLOGY

Eighty patients undergoing OS were consecutively selected from the stomatology department of the Federal University of Paraná between July 2021 and July 2022. Forty patients who would undergo OS composed the group of participants with DFD, and forty who received other types of attention and did not present changes in the dental bone bases formed the group without DFDs (DFDs and no DFDs groups). The groups were matched for sex, age, and self-reported ethnicity. The diagnostic criteria for TMDs (DC/TMDs) were used to diagnose TMD based on the Axis I criteria. The psychosocial aspects, oral behaviors in wakefulness, and sleep bruxism were evaluated through the Axis II criteria. The data were analyzed with a 5% significance level.

RESULTS

The presence of DFDs was significantly associated with arthralgia (p = 0.01). The other types of TMDs were not associated with DFDs. Comorbidities, habits, and psychosocial variables were not associated with DFDs at a level of 0.05. (p > 0.05). In analyzing the participants with arthralgia, the ones with this condition presented higher frequencies of sleep bruxism (p = 0.046).

CONCLUSIONS

Participants with DFDs presented a significantly higher frequency of arthralgia when compared to no DFDs ones. Sleep bruxism was associated with the occurrence of joint TMDs in these participants.

Evaluation of palatal dimensions in different facial patterns by using digital dental casts

OBJECTIVE

To analyze the variations of hard palate volume in adults with normal occlusion and different facial types and patterns, by using a three-dimensional analysis on digital casts.

METHODS

The dental casts of 70 Caucasian adults (28 men, 42 women), mean age of 16.4 years (SD 1.3 years), were scanned by using a tridimensional scanner (Delcam PowerSHAPE™, 2010, Birmingham, UK). Close points were selected in the gingival and cervical regions on the lingual surface of the maxillary teeth, to analyze palatal morphology. The facial patterns and types, and the measurements (width, length, height, volume) of the space on the hard palate were compared using analysis of covariance (ANCOVA), with age as the covariate, and sex as the independent variable. The significance level of 5% (p < 0.05) was adopted.

RESULTS

This study showed that the measurements of the width and length were similar among the mesofacial, dolichofacial and brachyfacial facial types, although the height and volume of the space on the hard palate were slightly smaller in dolichofacial individuals, and both Pattern I and Pattern II individuals showed no significant changes for the four measurements. The mean values among facial patterns were: Pattern I - width 38.31±2.59 mm; length 37.44±2.42 mm; height 17.03±2.42 mm and volume 10.52±1.72 mm3; Pattern II - width 37.48±2.44 mm; length 37.48±2.44 mm; height 16.79±2.42 mm and volume 10.41±1.65 mm3 (p>0.05 for all variables).

CONCLUSION

There were no significant differences for the facial patterns and facial types of the individuals compared in the analyzed sample.

Validity of Medical Insurance Guidelines for Orthognathic Surgery

PURPOSE

The purpose of this study was to assess the validity of the medical insurance guidelines for orthognathic surgery used by the major American medical insurance companies.

MATERIALS AND METHODS

This study assessed the validity of the medical insurance guidelines for orthognathic surgery used by Aetna, Anthem Blue Cross Blue Shield (BCBS), Cigna, Humana, and UnitedHealthcare (UHC). To evaluate the validity, we calculated the approval and denial rates of the 5 guidelines when we used them to assess the medical necessity for a control group of carefully selected patients. Patients were included in the control group if they met the criteria of a "prudent provider," crafted for this study. All rejected cases were analyzed to determine the root cause of the denials. The validity of the guidelines was also ascertained by determining their completeness and correctness.

RESULTS

The current study proves that no insurance guideline is in agreement with the criteria of a "prudent provider." When applied to carefully chosen patients, the requirements of BCBS, Aetna, Humana, and Cigna produce modest rejection rates of 6 to 12%. UHC is an outlier. Its guideline rejects 86% of patients, a rate about 7 times higher than its peers. Insurance guidelines disqualified patients for 3 different reasons: 1) no significant jaw deformity, 2) no demonstrable health impairment, and 3) the etiology of the condition is not a covered benefit. Additional evaluations demonstrate that the private insurance guidelines are incomplete, and at times, incorrect.

CONCLUSIONS

This study shows that the medical insurance guidelines for orthognathic surgery used by the major American medical insurance plans need revision. The most consequential flaw was considering etiology in judging medical necessity. Fortunately, only one company adopted this policy. Moreover, all guidelines have omissions and errors in the way jaw deformity is determined and how health impairment is determined.