Orthognathic Surgery in Patients Over Age 40: Incidence, Indications, Outcomes

Orthognathic surgery is the treatment of choice to improve facial aesthetics and to correct malocclusion in patients with dentofacial deformities. Traditionally, patients are in the second or third decade of life and motivated to seek treatment by a combination of functional and aesthetic complaints. Recently, there has been a perceived increase in older patients (≥40 years) seeking orthognathic surgery. Although it has been reported that patients over 30 years of age have increased rates of neurosensory disturbance and hardware removal, most studies include few patients over 40 years of age [1, 2]. As such, little is known about this older demographic with regard to motivation to seek treatment and surgical outcomes.

The purpose of this study was to assess indications, incidence, and outcomes of orthognathic surgery in patients over 40 years of age. This was a retrospective cohort study of all patients who underwent orthognathic surgical procedures at Massachusetts General Hospital from 1995-2012. Demographic variables including age, gender, presence of co-morbidities, date of procedure, and type of operation were documented. Subjects were divided into two groups by date of operation: 1) 1995-2002 and 2) 2003-2012. The predictor variable was age over or under 40 years. Outcome variables included indications for treatment (functional or aesthetic), date of operation, length of hospital stay, removal of hardware, and skeletal stability. Statistical comparisons were performed using Student’s t-test and One-Way ANOVA. Kaplan-Meier survival analysis was used to assess time to event of hardware removal.

During the study period 1420 patients underwent 2170 procedures; 911 subjects (1343 procedures) met the inclusion criteria. Group 1 consisted of 260 subjects (346 procedures, 35 subjects ≥40, 13.5%) and Group 2, 651 subjects (997 procedures, 89 subjects ≥40, 13.8%). Subjects over 40 had longer hospital stays measured in hours (p ≤ 0.0001) and days (p ≤ 0.0001) than those under 40. Indications for men were more frequently functional problems, while women sought aesthetic improvements (p = 0.0001). Indications for subjects over 40 were more likely to be functional compared to those under 40 (p = 0.0010). Subjects over 40 were 2.48, 2.41, and 2.70 times more likely to require hardware removal 6 months (p = 0.0267), 12 months (p = 0.0081), and 24 months (p= 0.0003) after operative correction. Subjects over and under 40 years of age had very similar skeletal stability at 1 year postoperatively.

The results of this study confirm that patients over 40 represent a significant subset of orthognathic surgery patients and that motivating factors vary by age and gender. Patients over 40 had longer hospital stays and an increased risk of requiring hardware removal compared to younger patients. Overall, this study provides insight into how surgical outcomes may change with increasing age. Understanding these changes can help surgeons educate patients to improve accuracy of expectations and ultimately to improve patient experience.

References

1. Baas EM, Horsthuis RB, de Lange J: Subjective alveolar nerve function after bilateral sagittal split osteotomy or distraction osteogenesis of mandible. J Oral Maxillofac Surg 70:910, 2012

2. Kuhlefelt M, Laine P, Suominen-Taipale L, et al: Risk factors contributing to symptomatic miniplate removal: a retrospective study of 153 bilateral sagittal split osteotomy patients. Int J Oral Maxillofac Surg 39:430, 2010