orthognathic surgery in patients over 40 years of age: indications and special considerations

Accepted Manuscript

Orthognathic Surgery in Patients Over 40 Years of Age: Indications and SpecialConsiderations

Zachary S. Peacock, DMD, MD Cameron C.Y. Lee, BS Katherine P. Klein, DMD, MSLeonard B. Kaban, DMD, MD

PII: S0278-2391(14)00333-4

DOI: 10.1016/j.joms.2014.03.020

Reference: YJOMS 56267

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 23 February 2014

Revised Date: 25 March 2014

Accepted Date: 25 March 2014

Please cite this article as: Peacock ZS, Lee CCY, Klein KP, Kaban LB, Orthognathic Surgery in PatientsOver 40 Years of Age: Indications and Special Considerations, Journal of Oral and Maxillofacial Surgery(2014), doi: 10.1016/j.joms.2014.03.020.

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http://dx.doi.org/10.1016/j.joms.2014.03.020

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Orthognathic Surgery in Patients Over 40 Years of Age: Indications and Special Considerations

Zachary S. Peacock, DMD, MD1

Cameron C.Y. Lee, BS2

Katherine P. Klein, DMD, MS3

Leonard B. Kaban, DMD, MD4

From the Department of Oral & Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, Massachusetts 1) Assistant Professor of Oral and Maxillofacial Surgery 2) DMD candidate, Harvard School of Dental Medicine 3) Instructor in Orthodontics 4) Walter C. Guralnick Professor and Chairman, Department of Oral and Maxillofacial Surgery Address Correspondence to: Zachary S. Peacock, DMD, MD Massachusetts General Hospital Warren 1201 55 Fruit St. Boston, MA 02114 E-mail: [email protected]

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Abstract

Purpose: To assess indications, incidence, patient experience, and outcomes of orthognathic

surgery in patients over 40 years of age.

Patients and Methods: 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, indications, date, 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, date of operation, length of hospital stay, removal of hardware, and

complications.

Results: During the study period, 1420 patients underwent 2170 procedures; 911 subjects (1343

procedures) met 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 (p ≤ 0.0001) than those under 40. Indications for men

were more frequently functional problems, while women sought aesthetic improvements (p =

0.0001). Subjects over 40 were, respectively, 2.51, 2.44, and 2.72 times more likely to require

hardware removal 6 months (p = 0.0245), 12 months (p = 0.0073), and 24 months (p = 0.0003)

postoperatively than those less than 40.

Conclusion: Motivation to undergo orthognathic surgery varies with respect to age and gender.

Older patients, particularly men, tend to seek treatment for functional rather than aesthetic

reasons. Patients over 40 had longer hospital stays and an increased rate of postoperative

hardware removal.

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Introduction

Orthognathic surgery is the treatment of choice to improve facial aesthetics and to correct

malocclusion in patients with dentofacial deformities. Traditionally, the majority of patients were

in the second or third decade of life, and they were motivated to seek treatment by a combination

of functional and aesthetic complaints.

Recently, there has been an apparent increase in older patients seeking orthognathic

surgery [1, 2]. It has been hypothesized that much of this increase may be attributed to the

frequency of obstructive sleep apnea (OSA) and the success of maxillo-mandibular advancement

for its treatment [3, 4]. Apart from this, patients have become aware of improvements in

orthognathic surgical techniques and the favorable overall experience. Previously, they may have

delayed orthognathic surgery because of misunderstandings about the dangers of the operation or

the fear of having “my teeth wired shut.” Orthognathic surgery can also play a role in complex,

multidisciplinary treatment plans, especially for periodontal and restorative dental problems that

cannot be successfully managed in the presence of a jaw size discrepancy. Finally, there are

increasing numbers of men and woman over 40 years of age seeking orthognathic surgery

specifically to improve facial aesthetics.

Older patients undergoing orthognathic surgery may experience more difficulty during

the perioperative and postoperative periods. There have been multiple reports of increased rates

of neurosensory disturbance following mandibular and/ or maxillary surgery in patients over age

30 [5-13]. Others have suggested that patients over 30 may have increased rates of hardware

removal [14, 15].

The definition of “older patients” in relation to orthognathic surgery and their specific

characteristics are not well described in the literature. In most published studies, patients over 30

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years of age are included with only a few patients over 40 in the analyses [16-18]. Outcome

studies documenting recovery, complications and anatomic stability with most subjects less than

25 years of age may not be applicable to patients over 40. Therefore, a focused study of older

patients (> 40 years old) would provide useful information for clinicians and would improve the

surgeon’s ability to educate this cohort regarding expectations for recovery and outcomes. As a

result, patient experience and satisfaction may be improved.

This is the first in a series of studies our group is conducting on orthognathic surgery in

patients over 40 years of age to document demographics, indications for treatment, frequency of

various operations, length of stay (LOS), expected outcomes, complications and stability. We

have defined “older patients” for this project as being at least 40 years of age. This is somewhat

arbitrary, but in our clinical experience and from the literature, this age seems to be a threshold

or dividing point with regard to the above outcome measures[5-15]. It has been reported that

permanent paresthesia and hardware removal are more common in patients over 30 years of age,

but few patients over the age of 40 [5-15] are included in these studies. The next phase of this

research will be to collect data and report on duration of recovery, return to normal function,

anatomic stability, patient satisfaction and complications specifically related to diagnosis and

operative variables in this cohort of patients. The goals of the present study were to determine

the proportion of patients undergoing orthognathic surgery at MGH over the last two decades

who were at least 40 years of age and to define their motivation for seeking treatment. Secondary

goals were to determine length of hospital stay and the incidence of hardware removal in this

patient population compared to those under 40 years of age. We hypothesized that: 1) There has

been an increase in patients over 40 undergoing orthognathic surgery in the last 10 years

compared to the previous decade; 2) men over 40 most commonly seek functional improvements

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for conditions such as OSA; 3) women over 40, more commonly than men, seek aesthetic

improvements; and 4) the mean hospital stay and incidence of hardware removal are higher in

patients over 40 when compared to those under 40 years of age.

Materials and Methods

Study Design/Population:

This was a retrospective cohort study of all patients undergoing orthognathic surgery in the

Department of Oral and Maxillofacial Surgery at Massachusetts General Hospital (MGH)

between January 1995 and December 2012. Potential subjects were identified via search of the

hospital database using current procedural terminology (CPT) codes for orthognathic procedures

(21141, 21142, 21143, 21145, 21146, 21147, 21193, 21194, 21195, 21196, 21121, and 21122).

Patients were included as study subjects if they had accessible preoperative, intraoperative, and

postoperative records, and a clear indication of a chief complaint. Those who had non-

conventional orthognathic surgery procedures (e.g. osteotomies for distraction osteogenesis,

condylar reconstruction) or had a diagnosis of hemifacial microsomia, craniofacial microsomia,

or other craniofacial syndromes were excluded. Patients undergoing only surgically-assisted

maxillary expansion were also excluded from the outcomes analyses. The project was approved

by the MGH Institutional Review Board (Protocol #2010-P-002315).

Study Variables

Demographic variables collected included age at the time of operation, gender, race, and

procedure(s) performed. Patients were divided into two groups by date of operation: 1) 1995-

2002 and 2) 2003-2012. Comparing the last 2 complete decades was not possible as very few

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patients underwent orthognathic surgery prior to 1995 and the accompanying records were sparse

and not standardized. The predictor variable was age (over or under 40 years). Outcome

variables included indications for treatment (functional vs. aesthetic), date of operation, length of

hospital stay and incidence of hardware removal. Indications for treatment were classified as

functional or aesthetic based upon the patient’s chief complaint at the initial consultation. Chief

complaints classified as functional included problems with mastication, speech, breathing, OSA,

pain, or muscle fatigue. Patient motivation was classified as aesthetic if the chief complaint was

dissatisfaction with appearance of the face and/or the teeth. Length of stay was measured as time

(hours) from postoperative admission to discharge. Hardware removal was defined as any

unplanned post-operative removal of fixation hardware at our institution, regardless of the

indication for hardware removal (e.g. infection, temperature sensitivity, pain, etc). In the

analyses subjects were stratified by age over or under 40 as well as by decade (≤19, 20-29, 30-

39, 40-49, 50-59, and 60-69).

Statistical Analysis:

Statistical analysis was performed using GraphPad Prism 5.0 (GraphPad, La Jolla, CA). Data are

presented as mean ± standard deviation. Hazard ratios are presented with 95% confidence

intervals. Descriptive and bivariate statistics were computed to compare study variables between

Group 1, years 1995-2002 and Group 2, years 2003-2012, and the entire study period. Statistical

comparisons in One-Way ANOVA were performed using Bonferroni’s Multiple Comparisons

Test. Comparisons in Kaplan Meier survival analyses were performed using the Log-Rank Test

with Bonferroni correction. Subjects with less than 1 month of follow-up were excluded from

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hardware removal and survival analyses. For all analyses a p-value ≤ 0.05 was considered

statistically significant.

Results

Patient Demographics

Of the 1420 patients undergoing 2175 procedures enrolled in the study, 911 subjects

(1343 procedures) met the inclusion criteria. There were 260 subjects (146 women) included

who had orthognathic surgery between 1995 and 2002 and 651 subjects (330 women) between

2003 and 2012. There were 365 subjects 19 years of age or younger, 279 between 20 and 29, 143

between 30 and 39, 89 between 40 and 49, 29 between 50 and 59, and 6 between 60 and 69. The

study sample was 52.2% female with a mean age of 26.4 ± 11.1 years (Tables 1-2).

The total number of patients increased by 106% between Group 1 (1995-2002) and

Group 2 (2003-2012) when adjusted for the unequal duration of the time periods. Subjects over

40 years of age comprised 13.7% of the sample. Subjects over 40 made up 13.5% of the sample

of Group 1 and 13.8% of Group 2 (p = 0.93). The percentage of Asian and Hispanic patients

increased by 1.1% and 2.5%, respectively, in the current decade compared to the previous

decade.

Motivation to Seek Treatment

Motivation to seek treatment varied significantly with respect to subject age, gender, and

procedure, but not race (Tables 3 and 4). Overall, subjects were more likely to seek treatment for

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a functional rather than an aesthetic problem, with 67.1% citing a functional problem as their

chief complaint. Patients over 40 were 1.23 times more likely to have a functional chief

complaint (79.8%) compared to patients under 40 (65.1%) (p = 0.0010). The incidence of a

functional chief complaint increased for each increasing age group by decade of life (p ≤ 0.0001)

(Fig 1).

Men were 1.19 times more likely than women to have a functional chief complaint in all

age groups (73.6% vs. 61.8%, p = 0.0001) and 1.31 times more likely if over 40 (89.7% vs.

68.6%, p = 0.0049).

There were 56 subjects (13 women) who had a chief complaint of OSA with 89.3%

occurring between 2003 and 2012. 31 of these subjects were over 40 years of age. OSA was the

functional chief complaint for 47.1% of men over 40 years of age, but only 12.5% of women

over 40 years of age.

Length of Hospital Stay

The mean hospital stay for the entire cohort of 818 admitted subjects was 34.9 ± 16.5

hours. Those over 40 had significantly longer hospital stays than subjects under 40, with mean

hospital stays of 42.0 ± 17.9 hours compared to 33.9 ± 16.0 hours, respectively (p ≤ 0.0001) (Fig

2A). When stratified by decade of life length of hospital stay in hours varied significantly with

respect to age (p = 0.0002) (Fig 2B). Subjects who were 50-59 had longer hospital stays than

those ≤19 and 20-29, while subjects who were 40-49 had longer hospital stays than all the

younger age groups (p ≤ 0.05). Two outlier subjects with hospital stays of 15 days (38 years old)

and 19 days (16 years old) were excluded from analysis.

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Hardware Removal

There were 76 cases of unplanned hardware removal in the study sample resulting in an

overall incidence of 12.8% over 17 years (Table 4). The mean time to hardware removal was

21.0 ± 28.3 months. Subjects over 40 were 1.95 times more likely to have hardware removed

than subjects under 40, with removal occurring in 23.0% and 11.0% of cases in subjects over and

under 40, respectively (p = 0.0050). The mean time to removal for subjects over and under 40

was 14.4 ± 17.2 months and 23.4 ± 31.2 months, respectively (p = 0.2254). Kaplan Meier

analysis indicated that subjects over 40 were 2-3 times more likely to experience hardware

removal 6 months post-operatively (p = 0.0245, Hazard Ratio (HR) = 2.51 [1.18-10.1]) (Fig 3A),

12 months post-operatively (p = 0.0073, HR = 2.44 [1.38-7.87]) (Fig 3B), and 24 months post-

operatively (p = 0.0003, HR = 2.72 [1.88-8.22]) (Fig 3C) compared to subjects under 40.

Analysis of survival across the 17-year study period indicated that subjects over 40 were 1.94

times more likely to experience hardware removal than subjects under 40 (p = 0.0087, HR = 1.95

[1.24-4.30]) (Fig 3D). When stratified by decade of life incidence of hardware removal

significantly varied by age (p = 0.017). Subjects over 50 were significantly more likely to require

hardware removal compared to subjects 19 years or younger at all time points (p ≤ 0.05) (Fig 4).

Similarly, subjects over 40 were significantly more likely to require hardware removal compared

to subjects 19 years or younger 12 months post-operatively, 24 months post-operatively, and

over the entire study period (p ≤ 0.05). Subjects between the ages of 60-69 were included in

analyses, but a relatively small sample size (6 subjects without an incidence of hardware

removal) limited statistical comparisons.

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Discussion

The purpose of this study was to determine how the demographics and motivation of

patients undergoing orthognathic surgery have changed over the past 2 decades at a single

institution. Secondarily, we assessed how age affects hospital stay and the incidence of hardware

removal following orthognathic surgery. We hypothesized that the proportion of patients over 40

increased between the current decade and the previous decade, and that within this subset of

patients, men primarily sought treatment for functional problems while women sought treatment

for aesthetic problems. With regard to outcomes, we hypothesized that the mean length of

hospital stay as well as incidence of hardware removal would be increased in patients over 40.

Although orthognathic surgery is usually performed in the second or third decade,

patients over 40 years of age made up a significant proportion of this patient pool. In the present

study, 13.7% of orthognathic surgery patients were over 40 years of age. While this percentage

increased by only 0.30% over the past 2 decades, the total number of patients treated per year

more than doubled between the two time periods. Using the absolute data adjusted for years, the

number of patients undergoing orthognathic surgery increased by 106% between decades, with a

proportional increase in patients over 40.

While these data did not support our hypothesis that the percentage of patients over 40 is

increasing, the apparent increase can perhaps be explained as follows. Orthognathic surgery has

increasingly become a procedure performed in academic institutions[19]. In the first time period

of this study (1995-2002), a higher portion of orthognathic procedures were likely performed by

private practitioners [19]. It would be reasonable to think that atypical patients (i.e. older patients

or those with OSA) were still referred to teaching hospitals while younger ‘standard’ cases were

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more likely to be done privately. Thus, the patients over 40 undergoing treatment at our

institution between 1995 and 2002 may actually be a smaller percentage of the total number of

patients undergoing orthognathic surgery in the region. It can be assumed that the rate of

skeletal malocclusion has remained the same and the percentage of total orthognathic surgery

patients treated at academic institutions has increased; therefore, an unchanging percentage of

patients over 40 between the two time periods may actually represent an increase in this

demographic due to the increase in total patients being treated at our institution.

In this study, motivation to seek treatment varied significantly with age and gender. This

information could be helpful for optimizing treatment plans for each patient demographic.

Subjects who were older or male were more likely to seek treatment for functional reasons

whereas younger and female subjects sought aesthetic improvements. Patients with obstructive

sleep apnea represented 47.1% of males and 12.5% of females in the over 40 year cohort, a much

higher percentage than in those under 40 (p ≤ 0.0001). Subjects over 40 year of age had longer

hospital stays and increased likelihood of hardware removal. Specifically, subjects that were 40-

49 and 50-59 had a longer duration of hospital stay compared to each of the younger groups.

Similarly, subjects 40-49 and 50-59 also had an increased likelihood of hardware removal

compared to subjects 19 years or younger. No difference in hospital stay or risk of hardware

removal was detected between subjects 40-49 and 50-59, supporting our overall comparison of

subjects over and under 40 years of age.

The study sample and results of this study are similar to prior studies conducted on

motivation for treatment and outcomes following orthognathic surgery. Previously published

reports indicate similar gender percentages [2, 20-25] and that 60-80% of patients seek

functional improvements [20, 23, 26-28]. Most authors also report that women are more likely to

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seek cosmetic improvement in accordance with our results [13, 26, 29]. Results of the current

study also support the recent finding that Asian and Hispanic patients are beginning to comprise

a greater percentage of the patient population [2, 30]. As the population becomes more diverse,

racial and ethnic differences in anatomy may warrant further attention in research and treatment

planning.

The mean hospital stay (1.57 days, 34.9 hours) in this study was within range of previous

reports of hospital stays between 1-4 days [30-33]. The incidence of hardware removal (12.8%)

was also comparable to the rate of 9-15% found in the literature [14,15,18, 24, 32, 34-36]. This is

the first report of an increased risk of hardware removal specifically in patients over 40 years of

age compared to other age groups. While there have been reports of up to 3.67 times greater risk

of hardware removal in patients over 30, we did not detect a statistically significant difference in

risk between subjects 50-59, 40-49, and 30-39 [14, 15, 24, 37].

This study has several limitations. First, patients undergoing correction of OSA have

often been considered different from ‘standard’ orthognathic surgery patients. Excluding OSA

patients from this analysis, results in a loss of significance for length of stay and hardware

removal in the older age group. This could be explained by a loss of statistical power as subjects

over 40 are disproportionately impacted by this method of analysis. Conversely, the large

skeletal movements for correction of OSA could be a risk factor for hardware removal, and

would require further study.

The rate of functional deficit as motivation for seeking treatment could be falsely

elevated to improve the chances of obtaining insurance authorization. Patients and providers

alike understand that if an aesthetic motivation is stated, third party coverage may be denied.

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Surveys and/or patient interviews may be better for analyzing the real motivation for seeking

treatment, but would not be feasible in this 17 year study.

This study is one of the largest to assess outcomes following orthognathic surgery in

patients over 40. The results confirm that these patients represent a significant subset of

orthognathic surgery patients and that age and gender have an impact on motivation for seeking

treatment. Our data also suggest that patients over 40 have 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. The next phases of this project will include an analysis of

anatomic stability by diagnosis and procedures, patient satisfaction, quality of life measures and

complications related to age of orthognathic surgery patients.

Funding

This work was funded by the MGH Department of Oral and Maxillofacial Surgery Education

and Research Fund and the Harvard Medical School Scholars in Medicine Program

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Table 1: Summary of Study Variables.

Data are presented as n (%). A Chi-squared test was used for all statistical analyses.

Variable 1995-2002 2003-2012 Total P-value1 P-value2

Patient Population 501 (35.3) 919 (64.7) 1420 N/A N/A

Procedures 726 (33.4) 1449 (66.6) 2175 N/A N/A

Study Sample (n) 260 (28.5) 651 (71.5) 911 N/A N/A

Included Procedures (Categorical)

Total 346 (25.8) 997 (74.2) 1343 N/A N/A

Mandible 171 (49.4) 506 (50.8) 677 (50.4) 0.7082

Maxilla 175 (50.6) 491 (49.2) 666 (49.6) 0.7082

Sex (Binary)

Male 114 (43.8) 321 (49.3) 435 (47.8) 0.1424

Female 146 (56.2) 330 (50.6) 476 (52.2) 0.1424

Race (Categorical)3

White 206 (79.2) 534 (82.0) 740 (81.2) 0.6558

Asian 15 (5.8) 45 (6.9) 60 (6.6) 0.6558

Black 9 (3.5) 23 (3.5) 32 (3.5) 0.6558

Hispanic 7 (2.7) 34 (5.2) 41 (4.5) 0.6558

Other/Mixed 23 (8.8) 15 (2.3) 38 (4.2)

Age (Categorical)

≤19 99 (38.1) 266 (40.8) 365 (40.0) 0.4706

20-29 76 (29.2) 203 (31.1) 279 (30.6) 0.4706

30-39 50 (19.2) 93 (14.3) 142 (15.6) 0.4706

40-49 27 (10.4) 62 (9.5) 89 (9.8) 0.4706

50-59 6 (2.3) 23 (3.5) 29 (3.2) 0.4706

60-69 2 (0.77) 4 (0.61) 6 (0.70) 0.4706

Under 40 225 (86.5) 562 (86.2) 787 (86.3) 0.9336

Over 40 35 (13.5) 89 (13.8) 124 (13.7) 0.9336

1. P-values represent Chi-squared test with two demographic groups included in statistical analysis. 2. P-values represent Chi-squared test with greater than two demographic groups included in statistical analysis. 3. Other/Mixed group excluded from analysis

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Table 2: Comparison of Study Groups by Procedure.

Current Procedural Terminology codes present in the study sample are italicized. Fisher’s exact

test was used for all statistical analyses.

Procedure Type Over 40 Under 40 P-value

Mandibular

21193, 21194, 21195, 21196 89 455 0.1352

Maxillary

21141, 21142, 21143, 21145, 21146, 21147 93 484 0.2125

Genioplasty

21121, 21122 14 118 0.1950

Total Procedures 196 1147 N/A

Table 3: Motivation to Seek Treatment Sorted by Subject Demographics.


1995-2002 2003-2012 All Patients

Variable Functional Aesthetic Total Functional Aesthetic Total Functional Aesthetic P value

Race

White 140 (68.0) 66 (32.0) 206 358 (67.0) 176 (33.0) 534 498 (67.3) 242 (32.7) 0.4172

Asian 13 (86.7) 2 (13.3) 15 31 (68.9) 14 (31.1) 45 44 (73.3) 16 (26.7) 0.4172

Black 6 (66.7) 3 (33.3) 9 16 (69.6) 7 (30.4) 23 22 (68.8) 10 (31.3) 0.4172

Hispanic 6 (85.7) 1 (14.3) 7 19 (59.4) 13 (40.6) 32 25 (64.1) 14 (35.9) 0.4172

Other/Mixed 10 (43.5) 13 (56.5) 23 12 (70.6) 5 (29.4) 17 22 (55.0) 18 (45.0) 0.4172

Gender

Male 89 (78.1) 25 (21.9) 114 228 (71.0) 93 (29.0) 321 317 (72.9) 118 (27.1) 0.0004

Female 86 (58.9) 60 (41.1) 146 208 (63.0) 122 (37.0) 330 294 (61.8) 182 (38.2) 0.0004

Age

≤19 57 (57.6) 42 (42.4) 99 146 (54.9) 120 (45.1) 266 203 (55.6) 162 (44.4) ≤0.0001

20-29 58 (76.3) 18 (23.7) 76 140 (69.0) 63 (31.0) 203 198 (71.0) 81 (29.0) ≤0.0001

30-39 37 (74.0) 13 (26.0) 50 74 (79.6) 19 (20.4) 93 111 (77.6) 32 (22.4) ≤0.0001

40-49 19 (70.4) 8 (29.6) 27 51 (82.3) 11 (17.7) 62 70 (78.7) 19 (21.3) ≤0.0001

50-59 3 (50.0) 3 (50.0) 6 21 (91.3) 2 (8.70) 23 24 (87.8) 5 (12.2) ≤0.0001

60-69 1 (50.0) 1 (50.0) 2 4 (100.0) 0 (0.00) 4 5 (83.3) 1 (16.7) ≤0.0001

Under 40 152 (67.6) 73 (32.4) 225 360 (64.1) 202 (35.9) 562 512 (65.1) 275 (34.9) 0.0010

Over 40 23 (65.7) 12 (34.3) 35 76 (85.4) 13 (14.6) 89 100 (80.0) 25 (20.0) 0.0010

Procedure

Mandible 105 (61.4) 66 (38.6) 171 318 (62.8) 188 (37.2) 506 423 (62.5) 254 (37.5) 0.0068

Maxilla 121 (69.1) 54 (30.9) 175 342 (69.7) 149 (30.3) 491 463 (69.5) 203 (30.5) 0.0068

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Table 4. Motivation to Seek Treatment Sorted by Age and Gender.


1995-2002 2003-2012 All Patients

Demographic Functional Aesthetic Total Functional Aesthetic Total Functional Aesthetic P value

Men ≥40 12 (85.7) 2 (14.3) 14 39 (90.7) 4 (9.3) 43 51 (89.5) 6 (10.5) 0.0147

Women ≥40 11 (52.4) 10 (47.6) 21 37 (80.4) 9 (19.6) 46 48 (71.6) 19 (28.4) 0.0147

Men ≤40 77 (77.0) 23 (23.0) 100 189 (68.0) 89 (32.0) 278 266 (70.4) 112 (29.6) 0.0027

Women ≤40 75 (60.0) 50 (40.0) 125 171 (60.2) 113 (39.8) 284 246 (60.1) 163 (39.9) 0.0027

Table 5: Comparison of Outcomes by Age. Data are presented as n or mean ± standard

deviation.

Patient Age

Variable ≤19 20-29 30-39 40-49 50-59 60-69 ≤40 ≥40 P

value1 P

value2

OSA 4 9 12 20 10 1 25 31 ≤0.0001 ≤0.0001

Hospital Stay

Subjects 330 238 115 77 24 5 683 105 N/A N/A

Length of Stay 34.1± 16.6

33.3± 14.6

34.35 ±17.2

41.44 ± 16.1

44.29 ± 22.7

40.06 ± 21.5

33.85 ± 16.0

42.02 ± 17.9 0.0002 ≤0.0001

Hardware Removal

Subjects 234 182 81 62 21 4 497 87 N/A N/A

Total Removals

22 24 10 14 6 0 56 20 0.0041 0.0024

Months to Event

35.5 ±41.7

16.8 ±18.8

12.7 ±19.1

17.9 ± 19.4

6.33 ± 4.97 N/A

23.4 ± 31.2

14.4 ± 17.2 0.05783 0.2254

% Removal 6 mo.

1.64% 5.20% 6.17% 6.45% 19.0% 0.00% 3.55% 9.20% 0.0013 0.0245

% Removal 12 mo. 2.46% 7.69% 9.88% 11.3% 23.8% 0.00% 5.52% 13.8% ≤0.0001 0.0073

% Removal 24 mo. 4.10% 10.4% 9.88% 19.4% 28.6% 0.00% 7.30% 20.7% ≤0.0001 0.0003

% Removal Overall 9.40% 13.2% 12.3% 22.6% 28.6% 0.00% 11.3% 23.0% 0.0017 0.0087

OSA; Obstructive Sleep Apnea 1. P-values represent Chi-squared test for trend, One-Way ANOVA, or Log-Rank test with all 6 age groups used as categorical variables in statistical analysis. 2. P-values represent Chi-squared test, unpaired t-test, or Log-Rank test with binary ≥40 and ≤40 age groups in statistical analysis. 3. The 60-69 age group was excluded from analyses due to 0 hardware failures

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Figure Legends

Figure 1. Subject Motivation to Seek Treatment with Respect to Age.

A, Number of subjects with functional or aesthetic chief complaints sorted by age; B, Percentage

of subjects in each age group with functional or aesthetic chief complaints. From youngest to

oldest, subjects in these cohorts reported functional chief complaints 55.6%, 71.0%,

77.6%,78.7%, 87.8%, and 83.3% of the time. Motivation to seek treatment varied significantly

with respect to age (p ≤ 0.0001).

Figure 2. Length of Hospital Stay with Respect to Age.

A, Subjects over 40 had increased length of hospital stay in hours compared to subjects under 40

(p ≤ 0.0001); B, Length of hospital stay in hours varied significantly with respect to age (p =

0.0002). Subjects over 40 spent significantly more hours in the hospital compared to subjects in

≤19, 20-29, and 30-39 (p ≤ 0.05). Subjects 50-59 spent significantly more hours in the hospital

compared to subjects ≤19 and 20-29 (p ≤ 0.05). (**** = p ≤ 0.0001).

Figure 3. Incidence of Post-Operative Hardware Removal in Subjects Over and Under 40.

A, Subjects over 40 had significantly higher incidence of hardware removal 6 months post-

operatively (p = 0.0245); B, 12 months post-operatively (p = 0.0073); C, 24 months post-

operatively (p = 0.0003); D, over the entire study period (p = 0.0087) censored at 10 years

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follow-up compared to subjects under 40. All comparisons were performed using the Log-Rank

test.

Figure 4. Incidence of Post-Operative Hardware Removal Stratified by Age.

A, The incidence of hardware removal significantly varied with respect to age 6 months post-

operatively (p = 0.0074); B, 12 months post-operatively (p ≤ 0.0001); C, 24 months post-

operatively (p = 0.0002); D, over the entire study period (p = 0.0087) censored at 10 years

follow-up. Subjects 60-69 were included in analyses but did not experience any hardware

failures and thus are not seen on the graphs. All comparisons were performed using the Log-

Rank test with Bonferroni correction.

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orthognathic surgery in patients over 40 years of age: indications and special considerations

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