J Oral Maxillofac Surg

57:679-682, 19Y9

Risk Factors Contributing to Symptomatic

Plate Removal in Orthognathic
Surgery Patients
Yifat Manor, DMD, * Gavriel Cbaushu, DMD, MSc, 7’
and Shlomo Taicher, DMDf

Purpose: This study analyzed the fate of miniplates in orthognathic surgery and defined risk factors that
eventually result in plate removal.
Patients and Methods: The outpatient clinic files of 70 patients who had undergone orthognathic
surgery were reviewed. All osteotomies were rigidly fixed with stainless steel or titanium miniplates.
Study variables included age, gender, plate material, site of plates, and reasons for plate removal.
Results: Of 260 plates used for fixation, 31 were removed (12%). When all factors were considered
together, only age was statistically significant. Patients older than 30 years of age were more likely to have
plate removal (22% vs 9%). Only when each factor was considered separately were gender and plate
material statistically significant. Females (15.4% vs 6.7%) and stainless steel plates (15.5% vs 6.7%) were
more prone to plate removal. Although more plates were removed from the buttress (15.5%) and chin
(14.5%) compared with the piriform area (6.4%), this was not statistically significant.
Conclusions: Age can be defined as a primary risk factor for plate removal, whereas gender and plate
material are secondary. Although age and gender are not controllable, the use of titanium plates and
infection control may lower the number of symptomatic plates and the need for their removal.

Plates and screws for fixation of the facial skeleton from the facial skeleton is controversial,ld yet which
have been used for more than a century. Their use plates will become symptomatic is completely upre-
started in Europe in the late 1970s and in North dictable.
America in the late 1980s. l The purpose of this study was to analyze the
Most of the available data regarding the fate of outcome of miniplate usage in the orthognathic sur-
miniplates used for bony fixation has been published gery and to define risk factors leading to signs or
in the orthopedic literature.2 However, thousands of symptoms that eventually result in plate removal.
miniplates are being used yearly by oral and maxillofa-
cial surgeons all over the world. Surprisingly, a review
of the literature showed much philosophy and mini- Patients and Methods
mal data regarding the success or failure of miniplates
Outpatient clinic Nes of 70 patients (26 males and
used in the maxillofacial area.
44 females) who had undergone orthognathic surgery
Although there is agreement that symptomatic plates
in the Department of Oral and Maxillofacial Surgery at
should be removed, removal of asymptomatic plates
the Chaim Sheba Medical Center between March 1988
and August 1996 were reviewed. The patients’ ages
ranged from 17 to 40 (mean, 25 years). Their medical
“Resident, Department of Oral and Maxillofacial Surgery, The histories indicated that no oral pathology or any
Chaim Sheba Medical Center, Tel Hashomer, Israel. compromising systemic conditions existed preopera-
JyResident, Department of Oral and Maxillofacial Surgery, The tively. Diagnoses included vertical maxillary excess
Chaim Sheba Medical Center, Tel Hashomer, Israel. (VME) (10 patients), VME with mandibular retrogna-
*Head, Department of Oral and Maxillofacial Surgery, The Chaim thia (13 patients), VME with mandibular prognathism
Sheba Medical Center, Tel Hashomer; and Head, Department of (eight patients), VME with maxillary hypoplasia and
Oral and Maxillofacial Surgery, The Maurice and Gabriella Gold- mandibular prognathism (three patients), VME with
schleger School of Dental Medicine, Tel Aviv University, Israel. maxillary hypoplasia (four patients), maxillary hypopla-
Address correspondence and reprint requests to Dr Manor: sia (four patients), maxillary hypoplasia with mandibu-
Department of Oral and Maxillofacial Surgery, The Chaim Sheba lar prognathism (10 patients), mandibular progna-
Medical Center, Tel Hashomer 5X21, Israel. thism (nine patients), mandibular retrognathia (two
0 1999 American Association of Oral and Maxillofocial Surgeons patients), maxillary prognathism with retrusive chin
027%2391/99/5706-0008$3.00/O (two patients), and transverse mandibular asymmetry
680 RISK FACTORS FOR PLATE REMOVAL

pain due to screw loosening. All of the exposed plates

resulted in local infection and were therefore in-
cluded under the infection category. Study variables
Minimal Maximal Average
Skeletal Skeletal Skeletal included age, gender, plate material, and site of plates.
Surgical No. of Change Change Change A forward stepwise (Wald) logistic regression model
Procedure Procedures (mm) (mm) (mm) was used to determine which set of variables may
affect the fate of the miniplates.
Maxillary
impaction 49 2 8 4.9 ? 1.6
Maxillary
advancement 26 2 8 3.9 t 1.8
Results
Maxillary down- Of the 260 miniplates placed in 70 patients, 3 1 were
grafting 6 2 4 3.1 + 0.8 removed (12%). Table 2 presents the correlation
Maxillary setback 5 3 4 3.8 2 0.4
Reduction between the four potential risk factors and plate
genioplasty 10 2 7 4.6 +- 1.4 removal. When the influence of all factors was consid-
Advancement ered, only age was statistically significant (P < .05:
genioplasty 38 3 8 5.3 +- 1.2 4 = .0125). Patients olders than 30 years of age were
Sliding more prone to have plates removed (22% vs 9%). Only
genioplastv 6 4 8 62 1.8
when each factor was considered separately were
gender and plate material (stainless steel vs titanium)
statistically significant (P < .05). Females (15.4% vs
(five patients). Table 1 describes the variety of surgical 6.7%) and stainless steel plates (15.5% vs 6.7%) were
procedures performed and their associated postopera- more prone to plate removal. Although more plates
tive changes. Internal fixation was performed with were removed from the buttress area (15.5% and chin
either stainless steel or titanium miniplates and mono- (14.5%), compared with the piriform area (6.4%), this
cortical screws. There were 155 L-shaped plates, 56 was not statistically significant. Diagnosis, the surgical
straight plates, 21 T-shaped plates, 20 Y-shaped plates procedure, plate shape, and the magnitude of the
and eight H-shaped plates used. Most of the Le Fort I skeletal change were not correllated with the percent-
osteotomies were fixed with two Y-, T-, or L-shaped age of plates removal.
plates in the buttress area and two L-shaped or straight Reasons for plate removal were mentioned for only
plates in the piriform area. Patients with vertical 26 of the 31 plates removed: 60% for local infection,
ramus osteotomies that were fixed with maxilloman- 20% for palpation, 12% for pain, and 8% for loosening.
dibular fixation or sagittal split osteotomies that were Table 3 presents the relation between the known
fixed with maxillomandibular fixation and upper bor- reasons for plate removal and age, gender and plate
der wiring were excluded. Genioplasties were fixed material. Infection (10%) and palpation (8%) were the
with Y-, L-, or H- or T-shaped plates. Every plate was predominant reasons for plate removal in patients
fixed with four screws. All plates were inserted and older than 30 years of age. The main reason for plate
removed by an intraoral approach. removal in patients younger than 30 was local infec-
The patients had frequent follow-up during the first tion (5%). In males, the sole reason was infection,
6 months and every 6 months thereafter up to 8 years. whereas in females all four reasons for plate removal
Indications for plate removal included local infection were found. The use of stainless steel plates did not
presenting as pain, swelling, fistula or pus formation, result in higher infection rates than titanium plates.
or any combination of the latter; palpability of the The main reasons for removal of stainless steel plates
plate distressing the patient; and plate mobility and besides infection were palpation (3%) and loosening

Age Gender Plate Material Site of Plate* Total

Plates O-29 30+ Female Male Stainless Steel Titanium 1 2 3 (n = 260)

In situ 182 47 132 97 131 98 82 88 59 229

Removed
Number 18 13 24 7 24 i.7% 15 6 10 31
Percentage 9% 22% 15.4% 6.7% 15.5% 15.5% 6.4% 14.5%
P value .00704t .03490* .03134* .11422
*l, Zygomaticomaxillary buttress; 2, piriform area; 3, chin.
tStatistically significant when all the factors are included in the regression model.
#Statistically significant as the only factor included in the regression model.
MANOR, CHAUSHU, AND TAICHER 681

Gender is a secondary risk factor. The 2:l ratio of

females to males included in this study group may
account for the higher percentage of plate removal
PlateMaterial compared with other studies.1x3,7 Many factors ac-
Age @-I Gender stainless counted for plate removal in females, and infection
Reasons >30 <30 Male Female Steel Titanium was the only reason for plate removal in males. A
possible explanation is that women pay more atten-
LOCal
infection (%) 10 4.9 6.7 5 6 5 tion to themselves than men.
Pain (%) 0 1.5 0 3 0.6 2 Plate material is another secondary risk factor. The
Palpation (%) 8.4 0 0 3.2 3 0 1.5:1 ratio of stainless steel to titanium plates in this
Loosening (%) 3.4 0 0 1.3 1.2 0 study could be another reason for the high ratio of
plate removal. Infection (6%) and palpation (3%) were
the reasons for removal of stainless steel plates. For
(1.2%) and the sole reason for titanium plate removal titanium plates, infection (5%) and pain (2%) were the
besides infection was pain. reasons for removal. Surprisingly, infection rates were
similar with both plate materials. Stainless steel plates
are larger and more massive than titanium plates, and
Discussion
their accommodation is more difBcult. For that reason,
The current study focused on the variety of poten- they have a greater tendency to be palpable.
tial risk factors leading to plate removal. The contro- Studies regarding plate material emphasize the fact
versy regarding retention of asymptomatic bone plates that titanium plates are superior to other materials.
used for orthognathic surgery is ongoing.*-6 There is Moberg et al9 found in monkeys that titanium plates
no question that symptomatic plates should be re- do not release elements that are potential sensitisizers,
moved. In the English language literature, no discus- making their removal unnecessary. Weingart et allo
sion of the risk factors leading to signs or symptoms found in dogs that titanium plates release fine particles
and eventually to plate removal could be found. that reach the regional lymph nodes, but without
In this study, the orthognathic patients were mostly causing any signs of inflammation or foreign body
young (mean, 25 years) and healthy, with an almost reaction. In the current study, more plates were
2:l female predominance. Of 260 miniplates placed, removed from the buttress and chin areas than to the
31 (12%) were removed. We were unable to find a piriform area. However, this finding was not statistical
previous study relating to risk factors leading to plate significant. France1 et al” found 12% plate removal in
removal in a group of patients after orthognathic trauma cases due to infection and exposure of the
surgery procedures. Several articles analyzed the rates plates placed in the buttress area and mandible.
of plate removal in a study made up of both orthog-
Torgersen et all2 examined 15 patients with stainless
nathic and trauma patients. Two of the studies pre- steel plates that were used for mandibular fractures. In
sented a lower removal rate (7%3 and < 1%‘) and one
four patients (26%), the plates were removed because
study presented a higher rate (22%9 than what was
of pain and in one each for infection, inadequate
found in this study. Two studies analyzed plate re-
occlusion, ulcers in the denture area, and a tingling
moval after Le Fort I osteotomy, with a 6.8%’ and 1 1%8
sensation. The main reason for plate removal in this
rate of plate removal. In both studies, the main reason
study was infection (60%). This emphasizes the fact
for removal was palpation of the plates.
that when a foreign material is introduced into the
The results of the current study indicate that age
human body, the chances of infection are high, and
was the only statistically significant risk factor when
control of infection is critical.
all potential risk factors were evaluated, and gender
and plate material were statistically significant only
when evaluated as the only potential risk factors. Age
can therefore be defined as a primary risk factor, and References
gender and plate material are secondary risk factors. 1. Haug RH: Retention of asymptomatic bone plates used for
Age as a primary risk factor correlates with the orthognathic surgery and facial fractures. J Oral Maxillofac Surg
findings of Brown et al. 3 54:611, 1996
2. Alpert B, Seligson D: Removal of asymptomatic bone plates
In the current study, infection (10%) and palpation used for orthognathic surgery and facial fractures. J Oral
(8.4%) were the main reasons for plate removal in lMaxillofac Surg 54:615, 1996
patients older than 30 years of age. This could 3. Brown GS, Trotter M, CR& J, et al: The fate of miniplates in
facial trauma and orthognathic surgery: A retrospective study.
accounted for by a higher risk of infection in older Br J Oral Maxillofac Surg 27:306, 1989
patients and by the fact that the skin is less elastic, 4. Jackson IT, Adham MN: Metallic plate stabilisation of bone
rendering the plates more susceptible to palpation. grafts in craniofacial surgery. Br J Plast Surg 39:341, 1986
682 DISCUSSION

5. Persson G, HeIlem S, Nord PG: Bone plates for stabilizing Le 10. Weingart D, Steinmann S, Schilli W, et al: Titanium deposition
Fort I osteotomies. J Maxillofac Surg 14:69, 1986 in regional lymph nodes after insertion of titanium screw
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J Oral Maxillofac Surg

57:682, 1999

Discussion
Risk Factors Contributing to SORG started from the premise that, based on the present
Symptomatic Plate Removal in state of our knowledge, all materials should be removed
once they have completed their functional role. SORG
Orthognathic Surgery Patients equally recognized that removal of plates, especially if
general anesthesia was needed or if the plates were placed
Peter Ward Booth, FDS, FRCS in remote sites, may have significant morbidity. The authors
Consultant Maxillofacial Surgeon, The Queen Victoria Hospital of this article also document some of these problems.
NHS Trust, West Sussex, United Kingdom; e-mail: SORG produced the following recommendations at their
[email protected] Symposium held in Volendam, Netherlands, November
1991:
This paper dips its proverbial toe into the controversial “A plate which is intended to assist the healing of bone
area of plate removal. The authors provide some excellent becomes a nonfunctional implant once this role is com-
“hard” information on the risk factors leading to plate pleted. It may then be regarded as a foreign body.
removal because of symptoms. This confirms the earlier While there is no clear evidence to date that a plate causes
work. While such clarification is welcome, they have actual harm, our knowledge still remains incomplete. It is
perhaps avoided the real controversy; should we always therefore not possible to state with certainty that an
remove plates, “wait and see,” or always use resorbable otherwise symptomless plate, left in situ, is harmless.
materials? The removal of a nonfunctioning plate is desirable pro-
Some years ago the Strasbourg Osteosynthesis Research vided that the procedure does not cause undue risk to the
Group (SORG) held a symposium of invited clinicians and patient.”
bioengineers (Prof Williams and Prof Hildebrand) to debate Interpretation of these recommendations, and assuming
this issue in depth. The prime conclusion was that there is titanium plates are used, means that for most patients there
no such manufactured material that is “bioinert”; this of is less risk in leaving symptomless plates in situ than
course includes the bioresorbables. Clearly, some materials removing them. This article, therefore, helps to identify
are more “bioactive” than others, but all produce some which patients are at greatest risk of needing plate removal
tissue reaction. The nickel content of stainless steel and but unfortunately it does not answer the critical question of
vitallium, for example, make them potentially more hazard- whether it is wise to leave nonfunctioning, symptomless
ous than titanium. Bioresorable materials, once degraded plates, in situ. The events surrounding certain types of
and excreted, are of course no longer present, but their silicone breast implants ensures that this topic must not be
degradation is certainly a very active biologic process. forgotten, and this article contributes to this debate.