Orthognathic surgery in outpatient and inpatient care : risk factors and health economic aspects

For correction of large dentofacial deformities orthognathic surgery is performed. Treatment in the maxilla, mandible or as bimaxillary surgery, and by tradition in inpatient care (IPC). Mandibular fractures, unlike mandibular orthognathic surgical procedures, are mainly treated in outpatient care (OPC). There are studies showing that good patient satisfaction and few unexpected complications were achieved with orthognathic surgery in OPC. In times of strained healthcare finances as a result of, e.g., a growing elderly population with increased need for healthcare, with rising costs for medical technology innovations and drugs, and with long care queues for specialist care and operation, it is of utmost importance that healthcare resources are organised and prioritised responsibly and as cost-efficiently as possible. Complications connected with surgical procedures not only cause suffering for the patient with a risk of affecting the outcome but also are resource-intensive and burdensome for both the health economy and society. This thesis compares OPC and IPC single-jaw orthognathic surgery with respect to patient safety and cost, and identifies factors that may predict postoperative complications of orthognathic surgery.

Study I and II (n = 165) included patients operated with single-jaw orthognathic surgery (i.e., SARME, LF1, and BSSO) in OPC and IPC. Outcome in Study I was patient safety (i.e., complications, emergency visits, emergency phone calls, admission of patients operated in OPC, and re-admission of already discharged patients) after orthognathic surgery in OPC and IPC the first 12 months postoperatively. The outcomes in Study II were calculated costs (including orthognathic surgery, return visits, emergency visits, emergency phone calls, removal of osteosynthesis material, and re-operations) in OPC and IPC within 12 months after surgery.

Study III (n = 428) included patients registered in the National Registry of Orthognathic Surgery (NROK). Patient-specific and surgery-specific factors were analysed to identify risk factors for postoperative complications after orthognathic surgery.

Study I found that 101 of 107 patients (94.4%) operated in OPC were discharged day of surgery. There were no significant differences between treatment in OPC and IPC regarding number of emergency visits and emergency phone calls per patients, postoperative bleeding, postoperative pain, plate removal, and re- operations, but an increased risk of POI, about 2.5 times, was detected in the OPC group.

Study II found that the total mean cost (e.g., revisits, emergency visits, and emergency phone calls) over 12 months were 34.2% lower for SARME, 48.8% lower for LF1, and 38.3% lower for BSSO in OPC than in IPC. 130 days were used at the inpatient ward for the IPC group.

Study III showed that surgical site was the factor most clearly associated with postoperative complications after orthognathic surgery. Compared to maxillary surgery, single-jaw mandible surgery (e.g., BSSO) and bimaxillary surgery increased the risk of POI, removal of osteosynthesis material, and neurosensory deficit (NSD) by more than three times. For re-operations, there were no significant differences in risk between surgery in the maxilla, mandible, or bimaxillary surgery. Overweight (BMI>25.5 - 30.0), age over 40, smoking and no postoperative antibiotics were other factors increasing the risk for postoperative complications.

In conclusion, the results in this thesis show that operation of selected single-jaw orthognathic surgery can be performed with maintained patient safety in OPC, but the high rate of POI in the OPC group needs further study. The costs of performing SARME, LF1, and BSSO are associated with significantly lower healthcare costs in OPC than in IPC. Moreover, the transition to OPC will release resources for patients in more urgent need. Complications after orthognathic surgery are mainly associated with interventions in the lower jaw and with bimaxillary surgery, which should be considered before surgery.

List of scientific papers

I. Pekkari C, Weiner CK, Marcusson A, Davidson T, Naimi-Akbar A and Lund B. Patient safety with orthognathic surgery in an outpatient setting. Int J Oral Maxillofac Surg. 2023; 52: 806-12. https://doi.org/10.1016/j.ijom.2022.12.001

II. Pekkari C, Lund B, Davidson T, Naimi-Akbar A, Marcusson A and Weiner CK. Cost analysis of orthognathic surgery: outpatient care versus inpatient care. Int J Oral Maxillofac Surg. 2024; 53: 829-35. https://doi.org/10.1016/j.ijom.2024.02.005

III. Pekkari C, Weiner CK, Salinas Fredricson A, Lund B, Marcusson A and Naimi-Akbar A. Risk factors for postoperative complications in a cohort of Swedish orthognathic patients - The National Registry of Orthognathic Surgery (NROK). [Submitted]