When the criteria for coverage is not met, BCBSMT encourages all participating providers to have a member complete and sign an Advanced Member Notification (AMN) form stating that BCBSMT will not cover this service, supply, device, or drug. If an AMN is signed prior to delivery of the service, participating providers can balance bill the patient. If an AMN is not signed, participating providers are financially liable and cannot balance bill the BCBSMT member for denied services. Services provided by an out-of-state provider that are denied as not medically necessary are the financial responsibility of the patient even if an AMN is signed.
Refer to the Advanced Member Notification medical policy for more information. The AMN form is available at https://www.bcbsmt.com (Click on Providers and then Forms).
This medical policy was developed through consideration of peer reviewed medical literature, FDA approval status, accepted standards of medical practice in Montana, Technology Evaluation Center evaluations, and the concept of medical necessity. BCBSMT reserves the right to make exceptions to policy that benefit the member when advances in technology or new medical information become available.
The purpose of medical policy is to guide coverage decisions and is not intended to influence treatment decisions. Providers are expected to make treatment decisions based on their medical judgment. BCBSMT recognizes the rapidly changing nature of technological development and welcomes provider feedback on all medical policies.
When using this policy to determine whether a service, supply or device will be covered, please note that member contract language will take precedence over medical policy when there is a conflict.
Universal Dental Notation is the most common system for numerically identifying permanent dentition. The maxillary dentition is numbered sequentially from 1-16 starting with the right maxillary third molar as 1. The numbering system continues from 17-32 beginning with the left mandibular third molar as 17.
Orientation with respect to intraoral anatomy is referenced to the following terms:
- Mesial - Toward the dental mid line
- Distal - Away from the dental mid line
- Labial - Toward the lips
- Buccal - Toward the cheek
- Apex - Toward the root tip
- Lingual - Toward the tongue
- Incisal - Toward the biting surface (anterior dentition)
- Occlusal - Toward the biting surface (posterior dentition)
- Angulation - Mesiodistal tipping of the long axis of the tooth
- Inclination - Labiolingual or buccolingual tipping of the long axis of the tooth
Dental anatomic terms
- Cusp - Pronounced elevation on the occlusal surface
- Groove - Depression on the occlusal surface
- Crown - Visible portion of the tooth covered by enamel
- Cingulum - Bulbous convexity of the cervical one third of the lingual surface of anterior dentition
- Cervix (neck) - Junction of the crown and root
- Root - Portion of the tooth covered by cementum within the alveolar bone
- Curvature of the dental arches - Normal reciprocal curvature in the dental arches with the maxilla convex and the mandible concave (allows the dentition maximal contact during function)
- Curve of Spee - Normal curvature of the dental arch in the sagittal plane
- Curve of Wilson - Normal curvature of the dental arch in the coronal plane
- Class I (neutro-occlusion): The mesiobuccal cusp of the maxillary first molar articulates within the mesiobuccal groove of the mandibular first molar.
- Class II (disto-occlusion): The mandibular first molar articulates distal to the mesiobuccal cusp of the maxillary first molar, i.e., the mandibular teeth are behind the normal relationship with the maxillary teeth. This can be due to a deficiency of the lower jaw or an excess of the upper jaw; may be referred to as a deep bite deformity.
- Class III (mesio-occlusion): The mesiobuccal groove of the mandibular first molar is mesial to the mesiobuccal cusp of the maxillary first molar, i.e., the lower dental arch is in front of the (mesial to) the upper dental arch. People with this type of malocclusion usually have a strong or protrusive chin commonly referred to as an underbite.
Upper and lower arch dentition
- Overjet - Horizontal distance between the incisal edges of the maxillary incisor to the mandibular incisor
- Overbite - Vertical distance between the incisal edge of the maxillary incisor and the mandibular incisor
- Crossbite - Lingual-buccal malposition of the normal relationship between the upper and lower dentition (negative overjet)
- Deep bite - Condition of excessive overbite
- Open bite - Condition of negative overbite (teeth do not meet)
- Ortho-Panorex x-rays provide an overview of the stage of dental development, the mandibular anatomy, and gross pathology. Specific films such as occlusal and periapical views can be obtained to further assess the dentition, supporting bone, and interdental spaces.
- Cephalometric x-rays are standardized skull and/or facial views that allow for comparison over time to assess growth in an individual and for comparison of that individual against standardized population norms.
- Periapical films are obtained to determine if sufficient space exists for interdental osteotomies.
- On occasion, hand wrist films are useful to help determine skeletal age based on the known timing of sequential closure of the epiphyseal growth plates. However, typically facial skeletal maturity is determined by comparison of serial lateral cephalometric films obtained at 6-month intervals.
- Three-dimensional computerized tomography is being increasingly used for surgical evaluation and planning in academic university settings. In the future, such three-dimensional visualization of the patient's anatomic deformity is likely to replace today's conventional two-dimensional cephalometric analysis.
The elements of the facial skeleton can be repositioned, redefining the face through a variety of well-established osteotomies, including LeFort (I, II, and III) osteotomies, maxillary segmental osteotomies, sagittal split osteotomy of the mandibular ramus, vertical ramal osteotomy, inverted L- and C-osteotomies, mandibular body segmental osteotomies, and mandibular symphysis osteotomies. Most maxillofacial deformities can be managed with three basic osteotomies: the midface with the LeFort I osteotomy, the lower face with the sagittal split ramal osteotomy of the mandible, and the horizontal osteotomy of the symphysis of the chin.
The LeFort osteotomies are named after the three classic lines of weakness of the facial skeleton described by Rene LeFort in 1901. The LeFort I osteotomy allows for correction primarily at the occlusal level affecting the upper lip position, nasal tip and alar base region, and the columella labial angle without altering the orbitozygomatic region. The LeFort II osteotomy allows the surgeon to alter the nasomaxillary projection without altering the orbital volume and zygomatic projection. Complete craniofacial dysjunction by the LeFort III osteotomy allows the surgeon to alter the orbital position and volume, zygomatic projection, position of the nasal root, frontonasal angle, and position of the maxilla and to lengthen the nose. These standard LeFort osteotomies may be modified for a specific clinical situation. For most midfacial maxillofacial deformities, the LeFort I osteotomy and its variations are adequate.
Currently, the sagittal split ramal osteotomy is the primary choice for correcting most cases of mandibular retrognathism and prognathism. In extreme cases of mandibular prognathism, some surgeons prefer the intraoral vertical osteotomy or the inverted L-osteotomy. In situations of mandibular advancement in which the mandibular rami are hypoplastic and cannot be sagittally split, the inverted L- and the C-osteotomy with bone grafts are preferred.
- Alveolar or Alveolus – that portion of the upper and lower jaws that contain the teeth and form the dental arches
- Apertognathia – a type of malocclusion characterized by the premature occlusion of posterior teeth and the absence of anterior occlusion; sometimes referred to as open bite
- Dentition - The natural teeth, as considered collectively, in the dental arch; may be deciduous, permanent, or mixed
- Dysplasia - Abnormal tissue development
- Genial – pertaining to the chin
- Genioplasty – surgical alteration of the chin; also called mentoplasty
- Hyperplasia – an abnormal increase in cells in an organ or a tissue with consequent enlargement
- LeFort - an operation for reconstruction of the midface in which the teeth-bearing part of the maxilla is separated from its bony attachments and repositioned
- Mandible – lower jaw
- Maxilla – upper jaw
- Mentoplasty – surgical alteration of the chin; also called genioplasty
- Masticatory – refers to masticatory muscles or chewing
- Maxillary hyperplasia – Overgrowth of the maxilla, or upper jaw, often presenting as excess vertical height of the maxilla
- Maxillary hypoplasia – an abnormally small or posteriorly positioned maxilla, or upper jaw, often accompanying cleft palate or other craniofacial syndromes
- Micrognathia – an abnormally small mandible or lower jaw
- Occlusal - In dentistry, pertaining to the contacting surfaces of opposing occlusal units (teeth or occlusion rims) or the masticating surfaces of the posterior teeth
- Occlusion – the way the teeth bite or come together. Occlusions may be normal or abnormal (malocclusion) and are classified as Class I, Class II, or Class III
- Malocclusion – any deviation from a physiologically acceptable relationship of the upper and lower teeth with each other
- Orthodontics – The dental specialty and practice of preventing and correcting irregularities of the teeth, as by the use of braces
- Osteotomy – The incision, sectioning, or cutting of a bone, without removing any of its parts, for the purpose of repositioning it into a structurally correct location with itself and adjacent structures (bone cut)
- Ostectomy – The excision, sectioning, or cutting of a bone for the purpose of removing a portion of the bone and repositioning it into a more structurally balanced relationship with itself and adjacent structures (bone removal)
- Osteoplasty – A surgical procedure that is designed to change or modify the shape or configuration of a bone (bone graft)
- Prognathia – an abnormally large mandible or lower jaw
- Prosthodontics – the dental specialty concerned with the making of artificial replacements for missing parts of the mouth and jaw -- called also prosthetic dentistry, prosthodontia
- Retrognathia – a posteriorly positioned mandible, or lower jaw; most common problem for which orthognathic surgery is performed (sometimes referred to over bite)
- Sibilant sound distortions - children with repaired clefts that involve the gum ridge (alveolar ridge) will distort the sounds "s z ch j (as in “judge”) sh zh." These sounds are called "sibilants."
- Velopharyngeal distortion - pertaining to the soft palate (velum palatinum) and the pharyngeal walls