Number: 029
(Updated)

Subject: Occlusal Adjustment

Date: April 26, 2018 

Important note

This Clinical Policy Bulletin explains how we determine whether certain services or supplies are medically necessary. We made these decisions based on a review of currently available clinical information including:

• Clinical outcome studies in the peer-reviewed published medical and dental literature
• Regulatory status of the technology
• Evidence-based guidelines of public health and health research agencies
• Evidence-based guidelines and positions of leading national health professional organizations
• Views of physicians and dentists practicing in relevant clinical areas
• Other relevant factors

We expressly reserve the right to revise these conclusions as clinical information changes, and welcome further relevant information.

Each benefits plan defines which services are covered, excluded and subject to dollar caps or other limits. Members and their dentists will need to refer to the member's benefits plan to determine if any exclusions or other benefits limitations apply to this service or supply.

The conclusion that a particular service or supply is medically necessary does not guarantee that this service or supply is covered (that is, will be paid for by Aetna) for a particular member. The member's benefits plan determines coverage. Some plans exclude coverage for services or supplies that we consider medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the federal government or CMS for Medicare and Medicaid members.

Policy

Aetna considers occlusal adjustment to be part of and inclusive to restorative, prosthodontic and endodontic services. Occlusal adjustment is appropriate during any phase of periodontal therapy, except in the case of acute conditions. Occlusal adjustment (limited and/or complete) is considered to be therapeutic for the treatment of etiologic factors of occlusal trauma. The procedure enables patients to maintain a comfortable and functional dentition. Aetna does not consider occlusal adjustment the sole treatment modality for the management or prevention of a temporomandibular disorder (TMD).

Background

Occlusal adjustment (odontoplasty) is the reshaping of occlusal surfaces of teeth to create a harmonious contact relationship between maxillary and mandibular teeth. A primary objective of occlusal adjustment is improvement of the functional relations of the dentition in such a way that the teeth and the periodontium will receive uniform stimulation and the occlusal surfaces of the teeth will be exposed to an even physiologic wear.¹

The rationale for doing an occlusal adjustment can be grouped into the following categories:

1. Elimination of traumatic occlusion
2. Stabilization of orthodontic results
3. Establishment of an optimal occlusal pattern prior to extensive restorative procedures

Complete (full-mouth) occlusal adjustments are performed to achieve functional relationships and improve masticatory efficiency. It may be necessary to perform odontoplasty to occlusal surfaces of numerous teeth to establish or maintain occlusal harmony. Treatment is directed toward the elimination or minimization of excessive force or stress placed on the teeth and/or tooth.

Occlusal adjustments are necessary when they are essential to reduce or eliminate traumatic occlusion or when teeth are compromised from loss of periodontal support. Occlusal adjustments may be integral to a comprehensive restorative treatment or part of treatment to correct skeletal and occlusal disharmonies. A complete occlusal adjustment may require multiple visits, is considered part of comprehensive orthodontic treatment and is integral to orthognathic surgery.

Occlusal adjustments are of limited value as the sole treatment modality for the management or prevention of TMD. Scientific evidence does not support the performance of occlusal adjustment as a general method for treating a non-acute TMD, bruxism or headaches. Literature suggests that temporary reversible measures be attempted prior to permanent irreversible disengagement procedures.

Mounting of diagnostic casts, analysis and diagnosis are considered integral to the complete adjustment.

Codes²

D9951 – occlusal adjustment - limited
D9952 – occlusal adjustment - complete

Revision Dates

Original policy: January 17, 2006
Updated: September 21, 2007; August 24, 2009; October 4, 2010; January 23, 2012; December 4, 2012; January 13, 2014; January 26, 2015; February 17, 2016; March 15, 2017; April 26, 2018
Revised: October 13, 2008

The above policy is based on the following references:

¹ Ramfjord SP, Ash MM. Occlusion. Philadelphia:W.B. Saunders Company; 1966: 249.

² American Dental Association. CDT 2017 Dental Procedure Codes.*

³ American Academy of Periodontology. Parameter on occlusal traumatism in patients with chronic periodontitis. J Periodontol. 2000 May;71(5 Suppl):873-5.

⁴ Koh H, Robinson PG. Occlusal adjustments for treating and preventing temporomandibular joint disorders. The Cochrane Database of Systemic Review. 2003; Issue 1. Art. No.: CD003812. DO1: 10.1002/14651858.CD003812.

⁵ Ziebert GJ, Donegan SJ. Tooth contacts and stability before and after occlusal adjustment. J Prosthet Dent. 1979 Sep;42(3):276-81.

⁶ Bell WE. Clinical Management of Temporomandibular Disorders. Chicago: Year Book Medical Publishers, Inc; 1982: 194-195.

⁷ Wrumble MK, Lumley MA, McGlynn FD.Sleep related bruxism and sleep variables: a critical review.J Craniomandibular Discord Facial Oral Pain 1989 3: 152-158.

⁸ Okeson JP. Management of Temporomandibular Disorders and Occlusion. Third ed, ST. Louis, Mosby 1993.

*Copyright 2016 American Dental Association. All rights reserved.

Property of Aetna. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating health care professionals are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating health care professionals are solely responsible for medical advice and treatment of members.