Orthognathic treatment: how much does it cost?

Starting a Swedish national quality registry for orthognathic surgery: a tool for auditing fundamentals of care

BACKGROUND

National quality registries (NQRs) provide open data for user-directed acquisition. National Quality Registry (NQR) data are often used to analyze the rates of treatment success and adverse events for studies that aim to improve treatment quality and patient satisfaction. Thus, NQRs promote the goal of achieving evidence-based therapies. However, the scientific literature seldom focuses on the complex process of initiating, designing, and implementing an NQR. Starting an NQR may be particularly challenging in a setting where specialized care is decentralized, such as orthognathic surgery in Sweden. The present study describes the initiation and early phases of a new NQR for orthognathic surgery in Sweden.

METHODS

The initial inventory phase included gaining knowledge on regulations, creating economic plans, and identifying pitfalls in existing NQRs. Next, a crude framework for the registry was achieved. Outcome measures were selected with a nation-wide questionnaire, followed by a Delphi-like process for selecting parameters to include in the NQR. Our inclusive process comprised a stepwise introduction, feedback-based modifications, and preparatory educational efforts. Descriptive data were collected, based on the first 2 years (2018-2019) of registry operation.

RESULTS

Two years after implementation, 862 patients that underwent 1320 procedures were registered. This number corresponded to a 91% coverage rate. Bimaxillary treatments predominated, and the most common were a Le Fort I osteotomy combined with a bilateral sagittal split osteotomy (n = 275). Reoperations were conducted in 32 patients (3.6%), and the rate of patient satisfaction was 95%.

CONCLUSIONS

A National Quality Registry should preferentially be started and maintained by an appointed task force of active clinicians. A collaborative, transparent, inclusive process may be an important factor for achieving credibility and high coverage, particularly in a decentralized setting.

A Meta-Analysis of Palatal Repair Timing

ABSTRACT

Developing midface hypoplasia is common after palatoplasty and has been hypothesized to be influenced by the timing of hard palate repair. This meta-analysis assesses the risk of developing midface hypoplasia based on age at hard palate repair. A Pubmed PRISMA systematic review and meta-analysis was completed for literature focused on palatoplasty and midface hypoplasia published between 1970 and 2019. Cephalometric data were extracted and categorized by age at hard palate repair: <6, 7 to 12, 13 to 18, 19 to 24, and 25 to 83 months. Analysis of these groups and a control were compared using independent T-tests and Spearman correlation coefficients. SNA angles for each group were 77.9 ± 3.1° (<6 months), 77.7 ± 4.2° (7-12 months), 78.7 ± 4.2° (13-18 months), 75.1 ± 4.2° (19-24 months), 75.5 ± 4.8° (25-83 months), and were statistically different than the control group 82.4 ± 3.5° (P < 0.0001). Hard palate repair at 13 to 18 months had a statistically significant greater SNA angle than all other groups except for the repair at <6 months group (P = 0.074). As age at hard palate closure increased beyond 18 months, the SNA decreased, corresponding to a more hypoplastic maxilla (Spearman's correlation coefficient -0.381, P = 0.015). Analysis suggests that younger age at the time of repair is less likely to create in midface hypoplasia in adulthood. Minimizing midface hypoplasia in cleft palate patients by optimizing algorithms of care is a practical way to decrease the burden of disease on patients, families and medical systems. Further studies are needed to evaluate the role of technique on outcomes.Level of Evidence: IV.

Adequacy of the Italian National Tariff for Orthognathic Surgery: A Cost Analysis Using the Activity Based Costing (ABC) Method

ABSTRACT

The reduced economic resources in health care and the consequent spending review have brought great interest in surgical costs. The aim of the study is to determine direct hospital costs for Orthognathic procedures using the Activity based costing method and evaluate the adequacy of the refund provided by the Italian National Health Service. From January 2017 to December 2017 9 consecutive patients underwent the following Orthognathic procedures at IRCCS Casa Sollievo della Sofferenza (San Giovanni Rotondo, Italy): bimaxillary osteotomy (n = 7), Le Fort I osteotomy (n = 1) and Bilateral Sagittal Split Osteotomy (BSSO) (n = 1). Activity based costing was used to obtain costs of each single hospitalization split into surgery, instay, and services. The mean total cost for a bimaxillary osteotomy was 7596.40€. We observed a total cost of 3925.00€ for Le Fort I osteotomy and of 4334.50€ for BSSO. The refund of 4378.00€ provided by the Italian National Health Service system for Orthognathic surgery seems insufficient to cover costs of bimaxillary osteotomy but consistent for single osteotomy (Le Fort I or BSSO).

Retrospective study of eligibility for orthognathic surgery using the Index of Orthognathic Functional Treatment Need (IOFTN)

To assess the functional needs of orthognathic patients who had been accepted for treatment by Christchurch Hospital, New Zealand, we made a retrospective assessment of 80 consecutive patients using the Index of Orthognathic Functional Treatment Need (IOFTN). Eligibility was based on the Severity and Outcome Index (SOI) score of ≤3 derived from seven lateral cephalometric measurements (three skeletal, three dental, and one soft tissue), which made allowances for asymmetrical or reported important functional issues. The IOFTN grades 4 or 5 indicated "great" or "very great" need for treatment, and we also used a self-reported oral health-related quality of life (QoL) questionnaire (OHIP-14). Sixty-eight patients were considered eligible using the SOI, and 71 when the IOFTN was used. Eight who were eligible using the SOI would not have been eligible using the IOFTN while 11 who were not considered eligible using the SOI scored ≥4 using the IOFTN. However, when it was compared with the SOI, the IOFTN tended to underscore those patients who were Class III/skeletal 3 with reverse overjets of <3mm and with no reported functional difficulties, while it tended to overscore Class II/skeletal 2 patients with overjets ≥6mm. We found no association found between the OHIP-14 and the SOI or the IOFTN. Further investigations are required to clarify functional difficulties that are applicable to the IOFTN grading, and to find out the most appropriate self-reported, oral-health-related QoL measure(s) to complement the use of the IOFTN.

Length of Stay and Cost in Patients Undergoing Orthognathic Surgery: Does Surgeon Volume Matter?

PURPOSE

The relations among procedure-specific annual surgeon volume, hospital length of stay (LOS), and hospital costs for patients undergoing the 2 most common orthognathic surgical (OGS) procedures, segmental osteoplasty or osteotomy of the maxilla (SOM) or open osteoplasty or osteotomy of the mandibular ramus (SOMR), are not known. The authors hypothesized that treatment by high-volume surgeons would be associated with decreased LOS and costs.

MATERIALS AND METHODS

All patients 8 to 64 years old who underwent elective SOM or SOMR were selected from the 2001 to 2009 Nationwide Inpatient Sample. Patients with missing vital status or payment mode status or who underwent more than 1 OGS procedure during the index hospitalization were excluded. Based on year- and procedure-specific annual surgeon volumes, the highest (highest quartile) and lowest (lowest quartile) procedure volume surgeon groups were compared. Multivariable logistic regression was used to study the relation between surgeon volume and extended patient LOS (defined as LOS ≥ 75th percentile). Generalized linear models with a log-link and gamma distribution were used to examine the association between surgeon volume and hospital costs. Models were adjusted for patient- and hospital-level factors and type of procedure (SOM or SOMR). Analysis was weighted to represent national-level estimates and an α value of 0.05 was used for all comparisons.

RESULTS

After weighting to the population level, 8,062 patients were included for study. Most were white (80.6%), female (61.4%), and privately insured (84.6%). Mean age was 26 years (standard deviation, 0.38 yr). After adjusting for potential confounders, patients treated by high-volume surgeons showed 40% lower odds of extended LOS (odds ratio = 0.60; 95% confidence interval [CI], 0.38-0.95; P = .032) and incurred substantially lower costs (-$1,484.74; 95% CI, -2,782.76 to -185.58; P = .025) compared with patients treated by low-volume surgeons.

CONCLUSION

These findings suggest that regionalization of patients to high-volume surgeons for OGS procedures could decrease LOS and incurred costs.

Adhesives for bonded molar tubes during fixed brace treatment

BACKGROUND

Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. The success of a fixed appliance depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a fixed appliance. It can also be costly in terms of clinical time, materials and time lost from education/work for the patient. This is an update of the Cochrane review first published in 2011. A new full search was conducted on 15 February 2017 but no new studies were identified. We have only updated the search methods section in this new version. The conclusions of this Cochrane review remain the same.

OBJECTIVES

To evaluate the effectiveness of the adhesives used to attach bonded molar tubes, and the relative effectiveness of the adhesives used to attach bonded molar tubes versus adhesives used to attach bands, during fixed appliance treatment, in terms of: (1) how often the tubes (or bands) come off during treatment; and (2) whether they protect the bonded (or banded) teeth against decay.

SEARCH METHODS

The following electronic databases were searched: Cochrane Oral Health's Trials Register (to 15 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library (searched 15 February 2017), MEDLINE Ovid (1946 to 15 February 2017), and Embase Ovid (1980 to 15 February 2017). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials of participants with full arch fixed orthodontic appliance(s) with molar tubes, bonded to first or second permanent molars. Trials which compared any type of adhesive used to bond molar tubes (stainless steel or titanium) with any other adhesive, were included.Trials were also included where:(1) a tube was bonded to a molar tooth on one side of an arch and a band cemented to the same tooth type on the opposite side of the same arch;(2) molar tubes had been allocated to one tooth type in one patient group and molar bands to the same tooth type in another patient group.

DATA COLLECTION AND ANALYSIS

The selection of papers, decision about eligibility and data extraction were carried out independently and in duplicate without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion.

MAIN RESULTS

Two trials (n = 190), at low risk of bias, were included in the review and both presented data on first time failure at the tooth level. Pooling of the data showed a statistically significant difference in favour of molar bands, with a hazard ratio of 2.92 (95% confidence intervals (CI) 1.80 to 4.72). No statistically significant heterogeneity was shown between the two studies. Data on first time failure at the patient level were also available and showed statistically different difference in favour of molar bands (risk ratio 2.30; 95% CI 1.56 to 3.41) (risk of event for molar tubes = 57%; risk of event for molar bands 25%).One trial presented data on decalcification again showing a statistically significant difference in favour of molar bands. No other adverse events identified.

AUTHORS' CONCLUSIONS

From the two well-designed and low risk of bias trials included in this review it was shown that the failure of molar tubes bonded with either a chemically-cured or light-cured adhesive was considerably higher than that of molar bands cemented with glass ionomer cement. One trial indicated that there was less decalcification with molar bands cemented with glass ionomer cement than with bonded molar tubes cemented with a light-cured adhesive. However, given there are limited data for this outcome, further evidence is required to draw more robust conclusions.

The index of orthognathic functional treatment need accurately prioritises those patients already selected for orthognathic surgery within the NHS

The index of orthognathic functional treatment need (IOFTN) is a newly-proposed system to help to prioritise patients for orthognathic treatment. The five categories are similar to those used in orthodontics, but include additional parameters such as sleep apnoea and facial asymmetry. The aim of this audit was to validate the index and find out the potential future implications, should such a system ever be adopted by commissioners. We calculated the IOFTN category of 100 consecutive patients who had orthognathic surgery between 2010-14 using clinical notes, photographs, study models, and radiographs, and determined the number in categories 4 or 5, analogous to the current indications for orthodontic treatment within the NHS. Sufficient clinical information was available to categorise 59/100 patients, and 56 of the 59 (95%) were in either category 4 or 5. All three of the remaining patients (in categories 1-3) who were operated on were treated because of the anticipated favourable impact on their quality of life. The IOFTN has been proposed for use in future commissioning of orthognathic services within the NHS, and this study has confirmed its efficacy in prioritising treatment accurately, with 95% of patients being in categories 4 or 5. We recommend that the orthognathic treatment index be adapted to include additional psychosocial assessment so that patients who fall into the lower functional categories are not automatically excluded from this potentially life-changing treatment.

Health economic evaluations in orthodontics: a systematic review

BACKGROUND

Economic evaluation is assuming increasing importance as an integral component of health services research.

AIM

To conduct a systematic review of the literature and assess the evidence from studies presenting orthodontic treatment outcomes and the related costs.

MATERIALS/METHODS

The literature review was conducted in four steps, according to Goodman's model, in order to identify all studies evaluating economic aspects of orthodontic interventions. The search covered the databases Medline, Cinahl, Cochrane, Embase, Google Scholar, National Health Service Economic Evaluation Database, and SCOPUS, for the period from 1966 to September 2014. The inclusion criteria were as follows: randomized controlled trials or controlled clinical trials comparing at least two different orthodontic interventions, evaluation of both economic and orthodontic outcomes, and study populations of all ages. The quality of each included study was assessed as limited, moderate, or high. The overall evidence was assessed according to the GRADE system (The Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

The applied terms for searches yielded 1838 studies, of which 989 were excluded as duplicates. Application of the inclusion and exclusion criteria identified 26 eligible studies for which the full-text versions were retrieved and scrutinized. At the final analysis, eight studies remained. Three studies were based on cost-effectiveness analyses and the other five on cost-minimization analysis. Two of the cost-minimization studies included a societal perspective, i.e. the sum of direct and indirect costs. The aims of most of the studies varied widely and of studies comparing equivalent treatment methods, few were of sufficiently high study quality. Thus, the literature to date provides an inadequate evidence base for economic aspects of orthodontic treatment.

CONCLUSION

This systematic review disclosed that few orthodontic studies have presented both economic and clinical outcomes. There is currently insufficient evidence available about the health economics of orthodontic interventions. Further investigation is warranted.

Long-term surgical versus functional Class II correction: a comparison of identical twins

The purpose of this twin case comparison was to assess the short- and long-term effects of nonsurgical treatment vs orthognathic surgical treatment for Class II correction. Two identical twins (age 13 years 3 months) were treated for Class II correction where one patient was treated nonsurgically using a fixed functional appliance, while the other was treated using orthognathic mandibular advancement surgery. The patients were recalled and evaluated 5 years in retention. Comparing changes in the short and long term, surgical treatment led to superior skeletal results compared to the nonsurgical twin. However, the soft tissue profile was remarkably similar for both patients suggesting that soft tissue profile changes may not necessarily follow similar changes in the bony skeletal structures.

A Scottish cost analysis of interceptive orthodontics for thumb sucking habits

OBJECTIVE

There is a potential cost saving to be made within the NHS by providing simple interceptive treatment rather than comprehensive treatment at a later date. The focus of this study is to determine the size of this potential cost by looking at the cost to NHS Tayside for the provision of interceptive treatment for cessation of thumb sucking and where this has been unsuccessful (or not provided) the costs of correction of the associated malocclusion.

DESIGN

A cost analysis is described, investigating the costs of treatment solely to the NHS, both in the primary and secondary setting.

METHODS

Three potential treatment pathways are identified with the costs calculated for each pathway. The actual cost of providing this treatment in NHS Tayside, and the potential cost saving in Tayside if there was a change in clinical practice are calculated. Both discounting of costs and a sensitivity analysis are performed.

RESULTS

The cost to NHS Tayside of current practice was calculated to be between £123,710 and £124,930 per annum. Change in practice to replace use of a removable with a fixed habit breaker for the interceptive treatment of thumb sucking reduced the calculated cost to between £99,581 and £105,017.

CONCLUSION

A saving could be made to the NHS, both locally and nationally, if the provision of a removable habit breaker was changed to a fixed habit breaker. In addition, increasing the proportion receiving active treatment, in the form of a fixed habit breaker, rather than monitoring, would appear to further reduce the cost to the NHS considerably.

Comparison of treatment costs and outcome in public orthodontic services in Finland

The objectives of the study were to compare the costs and outcome of orthodontic treatment in eight municipal health centres in Finland. A random sample of the age groups of 16- and 18-year-olds (n = 1109) living in these municipalities was clinically examined by two calibrated orthodontists. The acceptability of the morphology and function of the occlusion were assessed with the Occlusal Morphology and Function Index (OMFI). The data concerning previous orthodontic treatment were collected from the patient records of all subjects (n = 608) who reported previous or ongoing orthodontic treatment or who could not recall if they had received orthodontic treatment. The health centres were grouped into an early and a late timing group according to the mean age of starting the treatment. The mean age for starting orthodontic treatment was 8.0 years (SD 1.9) in the early group and 10.7 years (SD 2.3) in the late group. The visit costs and the costs of orthodontic appliances without overheads comprised the operating costs. The cost-effectiveness of orthodontic services was measured by estimating how much each health centre had to have paid for one per cent unit of acceptable morphology and acceptable function of occlusion. The mean appliance costs were higher in the late timing group and the mean visit costs higher in the early timing group. The mean operating costs per case were €720 in the early and €649 in the late timing group. However, there was a great variation within both groups. The cost of one per cent unit of acceptable morphology was the same in the two timing groups, while the cost of one per cent unit of acceptable function was lower in the early timing group. The low operating costs as such did not totally explain the better cost-effectiveness of orthodontic care. Furthermore, the cost-effectiveness was not directly connected with the timing of treatment.

Adhesives for bonded molar tubes during fixed brace treatment

BACKGROUND

Orthodontic treatment involves using fixed or removable appliances (dental braces) to correct the positions of teeth. The success of a fixed appliance depends partly on the metal attachments (brackets and bands) being glued to the teeth so that they do not become detached during treatment. Brackets (metal squares) are usually attached to teeth other than molars, where bands (metal rings that go round each tooth) are more commonly used. Orthodontic tubes (stainless steel tubes that allow wires to pass through them), are typically welded to bands but they may also be glued directly (bonded) to molars. Failure of brackets, bands and bonded molar tubes slows down the progress of treatment with a fixed appliance. It can also be costly in terms of clinical time, materials and time lost from education/work for the patient.

OBJECTIVES

To evaluate the effectiveness of the adhesives used to attach bonded molar tubes, and the relative effectiveness of the adhesives used to attach bonded molar tubes versus adhesives used to attach bands, during fixed appliance treatment, in terms of: (1) how often the tubes (or bands) come off during treatment; and (2) whether they protect the bonded (or banded) teeth against decay.

SEARCH STRATEGY

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 16 December 2010), the Cochrane Central Register of Controlled Clinical Trials (CENTRAL) (The Cochrane Library 2010, Issue 3), MEDLINE via OVID (1950 to 16 December 2010) and EMBASE via OVID (1980 to 16 December 2010). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

Randomised controlled trials of participants with full arch fixed orthodontic appliance(s) with molar tubes, bonded to first or second permanent molars. Trials which compared any type of adhesive used to bond molar tubes (stainless steel or titanium) with any other adhesive, are included.Trials are also included where:(1) a tube is bonded to a molar tooth on one side of an arch and a band cemented to the same tooth type on the opposite side of the same arch; (2) molar tubes have been allocated to one tooth type in one patient group and molar bands to the same tooth type in another patient group.

DATA COLLECTION AND ANALYSIS

The selection of papers, decision about eligibility and data extraction were carried out independently and in duplicate without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion.

MAIN RESULTS

Two trials (n = 190), at low risk of bias, were included in the review and both presented data on first time failure at the tooth level. Pooling of the data showed a statistically significant difference in favour of molar bands, with a hazard ratio of 2.92 (95% confidence intervals (CI) 1.80 to 4.72). No statistically significant heterogeneity was shown between the two studies. Data on first time failure at the patient level were also available and showed statistically different difference in favour of molar bands (risk ratio 2.30; 95% CI 1.56 to 3.41) (risk of event for molar tubes = 57%; risk of event for molar bands 25%).One trial presented data on decalcification again showing a statistically significant difference in favour of molar bands. No other adverse events identified.

AUTHORS' CONCLUSIONS

From the two well-designed and low risk of bias trials included in this review it was shown that the failure of molar tubes bonded with either a chemically-cured or light-cured adhesive was considerably higher than that of molar bands cemented with glass ionomer cement. One trial indicated that there was less decalcification with molar bands cemented with glass ionomer cement than with bonded molar tubes cemented with a light-cured adhesive. However, given there are limited data for this outcome, further evidence is required to draw more robust conclusions.

Orthodontic therapists--the first Bristol cohort

This paper outlines the development of the training of orthodontic therapists in the UK, the experiences of the first cohort to pass through the Bristol course, the roles and responsibilities of the therapist and possible issues with future orthodontic manpower planning.

An exploratory study of the cost-effectiveness of orthodontic care in seven European countries

This study investigated the orthodontic treatment of 429 consecutive patients [172 male (40.1 per cent) and 257 female (59.9 per cent)] carried out by 10 orthodontic specialist practitioners in seven European countries [two in the Czech Republic (A and B), two in Germany (A and B), Italy, Latvia, Lithuania, and Netherlands, and two in Slovenia (A and B)]. The median age of the patients at the start of treatment was 13.0 years (minimum 7.3 years maximum 50.3 years). The patients had a range of malocclusions and the majority (97 per cent) were treated with upper and lower fixed appliances. Real exchange rates were calculated using purchasing power parity (PPP) indicators to allow cross-border comparisons of costs. The Index of Complexity, Outcome and Need (ICON) was used to measure the effectiveness of treatment and cost per ICON point reduction to compare cost-effectiveness of orthodontic treatment between practitioners in different European countries. The median cost per ICON point reduction for all the cases treated was 57.69 euro. The median cost per ICON point reduction varied greatly between practitioners from 21.70 euro (Lithuania) to 116.62 euro (Slovenia A). Analysis of variance and Tukey post hoc tests showed the differences in cost-effectiveness between the practitioners to be statistically significant (P<0.001). The cost per ICON point reduction is a simple and effective method of comparing cost-effectiveness between orthodontic practitioners in different countries.