Plate removal following orthognathic surgery

Bart Falter, MD,a Serge Schepers, MD, DDS,a,b Luc Vrielinck, MD, DDS,a
Ivo Lambrichts, DMD, PhD,c and Constantinus Politis, MD, DDS, MHA, MM,a,c Genk, Gent,
and Diepenbeek, Belgium
ST. JOHN’S HOSPITAL, GENT UNIVERSITY, AND HASSELT UNIVERSITY

Objectives. The objectives of this study were to analyze outcomes with miniplates in orthognathic surgery and define
risk factors resulting in plate removal.
Study design. Clinical files of 570 orthognathic surgery patients operated between 2004 and 2009 were reviewed: 203
had a bimaxillary operation, 310 a lower jaw osteotomy, and 57 an upper jaw osteotomy. Age, sex, and jaw
movement were analyzed. Reasons for hardware removal were recorded.
Results. Hardware was removed in 157 patients (27.5%). Seventy-eight patients (13.7%) needed removal because of
plate-related infection; 66 (11.6%) because of clinical irritation; 5 (0.9%) for dental implant placement; and 8 (1.4%)
for other reasons. Average time between operation and removal was 9.9 months. More women (31.7%) than men
(20.3%) had plates removed, but age was not a factor except with infection.
Conclusions. More than a quarter of patients developed complications from plates and screws, necessitating their
removal, and infection occurred in 13.7%. Prompt removal constituted adequate management. (Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2011;112:737-743)

Miniplates have been widely used in the osteosynthesis
of the lower and upper jaws during orthognathic sur-
gery since Champy et al.1 adapted the technique in
1978, as described by Michelet et al.2 In most units, it
is routine policy not to remove plates and screws fol-
lowing bony union unless doing so is clinically indi-
cated.3 In some units, however, the routine policy is to
remove plates and screws because late removal be-
comes very difficult as a result of bony overgrowth of
the plates.4 Many studies have investigated the removal
of miniplates in trauma cases, but relatively few studies
have focused exclusively on orthognathic surgery op-
erations. The reported incidence to date of plate re-
moval per patient in orthognathic surgery ranges from
10.0% to 18.5%5-9 in mandibular osteotomies and from
1.0% to 11.1%10-12 in maxillary osteotomies (Table I).
This retrospective study examined the rate of plate
removal from the maxilla and mandible, and the risk
factors that may contribute to it. The purpose was to
analyze the outcome of miniplate usage in orthognathic
surgery and to define risk factors leading to signs or
symptoms that eventually result in plate removal.
a
Oral and Maxillofacial Surgery, St. John’s Hospital, Genk, Belgium.
b
Oral and Maxillofacial Surgery, Faculty of Medicine, Gent Univer-
sity, Gent, Belgium.
c
Faculty of Medicine, Hasselt University, Diepenbeek, Belgium.
Received for publication Dec 18, 2010; returned for revision Jan 3,
2011; accepted for publication Jan 8, 2011.
1079-2104/$ - see front matter
© 2011 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2011.01.011
MATERIAL AND METHODS
Records for 570 consecutive patients operated be-
tween 2004 and 2009 were reviewed retrospectively
(Table II). All patients had undergone either a bimax-
illary, a Le Fort I, or bilateral sagittal split ramus
osteotomies (BSSO) performed by 1 of the 3 senior
staff members of the Department of Oral and Maxillo-
facial Surgery at St. John’s Hospital in Genk. Records
were included only of orthognathic patients for which
the same operative technique and the same postopera-
tive clinical attitude toward removal of osteosynthesis
material were applied.
The patients included 363 females and 207 males,
with a mean age at surgery of 26.7 years (Table III). A
total of 513 mandibular and 260 maxillary osteotomies
were evaluated, and 203 of the patients had a bimaxil-
lary operation. We studied the operative charts for age,
sex, the direction of the movement of the jaw, the
incidence of plate removal, and the type of plate that
was placed. Within the group that underwent plate
removal, we noted the indication for the removal, the
interval between operation and removal, if removal was
indicated in the upper or the lower jaw, and the side
(left/right) of the jaw that needed a removal.
This retrospective study had institutional review
board approval, and was conducted in compliance with
the Helsinki Declaration guidelines.
Operative technique
All of the BSSOs included in this study were per-
formed by 1 of 3 resident surgeon staff members. We

737
 OOOOE
738 Falter et al. December 2011

Table I. Review of reported incidence of plate removal after bilateral sagittal split ramus osteotomy and Le Fort I
procedures
No. of % patients No. of No. of
No. of patients Orthogn/ patients w/ w/ plate plates plates % plates
First author Year receiving plates trauma Area of jaw plate removal removal inserted removed removed
Beals10 1987 53 Orthogn Maxilla — — 200 2 1.0%
Schmidt11 1998 190 Orthogn Maxilla 21 11.1% 738 70 9.5%
Manor12 1999 70 Orthogn Maxilla — 260 31 12%
Bhat5 2003 172 Trauma Mandible 28 18.3% 308 51 16.6%
Bhat6 2005 153 Trauma Mandible 21 — 308 32 —
Nagase13 2005 266 Trauma Maxilla mandible 45 33.3% 497 135 27.2%
Theodossy7 2006 80 Orthogn Mandible 16 — 160 25 15.6%
Alpha8 2006 533 Orthogn Mandible — 10.0% — 6.5%
Kuhlefelt9 2010 153 Orthogn Mandible 29 18.6% 308 56 18.2%
Falter Present data 570 Orthogn Maxilla mandible 157 27.5% 3197 622 19.5%
Orthogn, orthognathic surgery; —, data not reported.

Table II. Number of patients with plate removal ac- screws distributed by Stryker (Kalamazoo, MI, USA)
cording to the type of surgery (5.0 mm).
BSSO Le Fort All wounds were sutured with polyglactin (Vicryl) in
only Bimaxillary only Total 2 layers. During all of 2009, all sagittal split wounds
No. of patients w/ 310 203 57 570 were perioperatively rinsed with a 10% povidone-io-
an osteotomy dine (iso betadine) solution with careful closure of the
No. of patients w/ 80 63 14 157 periosteum to achieve a 3-layered closure of the oper-
plate removal
% of plate 25.8% 31.0% 24.6% 27.5%
ation wound. This change did not improve the rate of
removal plate removal and was abandoned again in 2010. No
suction drainage was used in any case of a sagittal split
BSSO, bilateral sagittal split ramus osteotomy.
osteotomy.
The Le Fort I osteotomy was performed as described
by Epker and Fish.17 All patients received perioperative
Table III. Analysis of the need for plate removal for intravenous antibiotics, as well as a dose of methyl-
different variables prednisolone 125 mg intravenously. A second dose of
Plate Non-plate methylprednisolone was administered 8 hours after the
Total removal removal % first dose. Postoperatively, antibiotic treatment was
No. of patients 570 157 413 27.5 continued for 5 days. No intermaxillary fixation was
Male 207 42 165 20.3 used, except for light elastics on surgical hooks to guide
Female 363 115 248 31.7 the patient into the right occlusion during jaw move-
Average age 26.7 26.9 26.6
ments.
The follow-up always lasted at least 18 months
and included 1 consultation every week during the
first 6 weeks and 1 at 3 months, 6 months, and 1 year
performed the modified sagittal split osteotomy as de- postoperatively. During the first 6 weeks, a wafer
scribed by Epker14 and Falter et al.15 (occlusal splint) was retained in the mouth. Guiding
After completing the osteotomies on both sides in the elastics were placed only during these 6 weeks if the
lower jaw, a wafer was introduced onto the lower jaw, occlusion deviated from the desired result. If any
and intermaxillary fixation was ensured. Internal fixa- inflammatory wound reaction was seen at the oper-
tion was established with titanium miniplates and ation site during the first 6 weeks, a removal of the
monocortical screws of the 2.0 system, as described by plates was planned at 3 months after the operation
Tulasne and Schendel16 (Fig. 1). Almost all of the date. An “infectious” reaction was considered to be
miniplates used, with the exception of 12 Tekka-plates present whenever wound dehiscence over the plates,
(Tekka, Brignais, France), were from the Leibinger granulation tissue at the plate site, or an intraoral
miniplate system (Leibinger, Tuttlingen, Germany). fistula with pus at the plate site was observed. No
The monocortical screws placed before 2008 were from wound cultures were obtained in any case. A persis-
the Leibinger system (4.0 mm); after that time, we used tent swelling and redness at the osteosynthesis site
OOOOE
Volume 112, Number 6
Fig. 1. A, Panoramic radiograph showing miniplates in place after a bimaxillary operation. Use of 2 “long 4-hole plates” per side
in the lower jaw. B, Panoramic radiograph showing 2 fractured “long 4-hole plates” on the left mandibular ramus. Two “regular
6-hole plates” were used on the right mandibular ramus.
was considered to constitute an “inflammatory” re-
action necessitating removal of the plates, whether it
was accompanied by tenderness over the area or not.
In the results section, this indication is defined as
“clinical irritation.” No single case of extraoral in-
fection was seen. We did not encounter cold intoler-
ance to the plates, which Nagase and Courteman-
che13 mentioned as an indication for plate removal.
Statistical methodology
Survival analysis techniques were used for the data
analysis. The Kaplan-Meier estimator was used to de-
scribe the removal rate over time and the proportional
hazard model (PH model or Cox model) for the analysis
of the effect of the covariates. The SAS procedures
LIFETEST and PHREG were used, part of Version 9.2
Falter et al. 739
of the SAS System for Windows (SAS Institute Inc.,
Cary, NC, USA).
RESULTS
A total of 157 (27.5%) of the 570 patients had at least
a portion of the hardware removed because they either
requested removal or required removal secondary to
complications related to the plates or screws. Of the
3197 plates that were placed, 622 (19.5%) were re-
moved. The patients having hardware removal con-
sisted of 115 females (31.7% of all female patients) and
42 males (20.3% of all male patients). This difference
was significant (P ⫽ .0091).
In 78 patients (13.7%), the plates were removed
because of an infectious episode related to the presence
of the plates (Fig. 2). Sixty-six patients (11.6%) had
 OOOOE
740 Falter et al. December 2011

180 166
Dental implant 160
# pa
ents with plates remaining
140
120 # pa
ents with plates removed
Clinical irrita
on
Mandible 100
Maxilla 80 71

Infec
on 55
60
42 44
32 35
40 28 24
17 18 15
0 20 40 60 80 100 20 8 12
3 0
# pa
ents 0
<15 15-19 20-24 24-29 30-34 35-39 40-44 >44
Fig. 2. The reasons for plate removal and the number of
patients with plates removed. Fig. 3. Number of patients with plate removal according to
age group.

Table IV. Occurrence of all plate removals and occur-

rence of plate removals because of infections according
plates removed because of clinical irritation. All pa-
to patient age (3 age categories)
tients with complaints during the initial 6 weeks after
Patients Patients w/ plate
the operation had their plates removed after a healing w/ plate removal because
period of at least 10 weeks. In those cases, the removal Age No. removal, of infection, n
of the plates was bilateral, even if the occurrence of the groups, y osteotomies n (%) (%)
problems was unilateral. Eight patients (1.4%) re- ⬍25 327 87 (26.6) 36 (11.0)
quested removal for various reasons, including required 25-34 98 35 (35.7) 25 (25.5)
removal to enter the army, removal for a tooth extrac- ⬎34 145 35 (24.1) 17 (11.7)
tion, wound dehiscence, dysesthesia of the nerve, or a Total 570 157 (27.5) 78 (13.7)
malpositioning of the osteosynthesis material too close
to the inferior border of the mandible. One of the
patients had a fracture of both plates in the left mandi-
ble. In 5 patients (0.9%), the plates were removed episode (P ⫽ .0013). This finding was, rather remark-
before placement of a dental implant. Dental root inju- ably, not a linear phenomenon. It was especially the
ries, which require miniplate removal, did not occur. case in the age category of people between 25 and 35
The indications for removal also differed according years old and less so in those older than 35 and younger
to sex: 52 of the 363 females (14.3%) needed plate than 25 (Table IV). We also noted in general a slightly
removal because of an infectious episode, 55 (15.2%) higher risk for plate removal within the 25- to 35-
because of clinical irritation; 3 (0.8%) before placement year age group, but this was not a significant finding
of an implant, and 5 (1.4%) for other reasons. Among (P ⫽ .17).
male patients, 26 (12.6%) of the 207 patients had re- The average time from hardware placement to re-
moval of plates because of an infectious episode and moval was 9.9 months (range 2-65 months). Of the
only 11 (5.3%) because of clinical irritation; 2 patients removals, 79.6% occurred within the first year after the
had a removal (1.0%) before placement of an implant, operation. The average follow-up time was always at
and 3 (1.4%) for other reasons. least 18 months.
If we focus on removal because of an infectious When osteosynthesis material becomes more prom-
episode, there was no significantly higher risk for fe- inent with aging, because of soft tissue changes, this
male patients than for male patients (P ⫽ .54). Of the could be an additional reason for removal 1 or 2 de-
157 patients with plate removal, 54 had the plates cades after surgery. The follow-up period of this study
removed because a problem occurred on the left side, did not allow inclusion of these cases. The reported
41 because a problem occurred on the right side, and 62 incidence of removal is therefore an underestimation.
patients had a problem on both sides. Of the 157 patients with plate removal, 50 patients
The average age in the removal group was 26.9 years (19.2% of the 260 maxillary osteotomies) had a re-
(range 15-65 years) compared with 26.6 years (range moval of the plates from the upper jaw, and 127 (24.8%
14-65) for patients who had no removal (Table III). of the 513 mandibular osteotomies) needed removal
Generally speaking, age had no influence (P ⫽ .74) on from the lower jaw. Twenty of these patients needed a
the removal of miniplates (Fig. 3); however, it did removal in the upper and lower jaws, and were counted
significantly affect removal caused by an infectious within both groups. Also, 80 of the 157 patients
OOOOE
Volume 112, Number 6 Falter et al. 741

Table V. Occurrence of plate removal according to the 40.0

number of patients and the year of the osteotomy 35.0

% miniplates removed
Patients % bimaxillary % removals 30.0
w/ plate osteotomies because of 25.0
No. removal, compared infectious 20.0
Year patients n (%) with total episode Right side
15.0
2004 45 11 (24.4) 40.0 20.0 Le side
10.0
2005 83 23 (27.7) 38.6 12.0
5.0
2006 118 27 (22.9) 28.0 12.7
2007 122 27 (22.1) 32.8 10.7 0.0
2008 103 35 (34.0) 37.9 17.5 4H R 4H M 4H L 6H R
2009 99 32 (32.3) 40.4 13.1 Type of miniplate

Fig. 4. Percentage of miniplates removed in the lower jaw

had undergone exclusively a mandibular osteotomy
(25.8%), 63 a bimaxillary surgery (31.0%), and 14
(24.6%) exclusively a Le Fort operation (Table II).
Within the group of the mandibular osteotomies,
bimaxillary operations excluded, 279 patients had a
mandibular advancement, and 72 (25.8%) of these had
their plates removed. Twenty-one patients had a set-
back, and 6 patients had their plates removed (28.6%).
If a rotation in the movement of the lower jaw was
done, then the risk for plate removal was 29.0% (9/31).
In examining the patient records per year, we noted
a higher percentage of plates removed with patients
operated in 2008 and 2009 than in the previous years of
2004 to 2007 (Table V). This timing coincided with a
change in the screw design of the Leibinger screws.
The incidence of plate removal resulting from an in-
fectious episode showed no significant changes within
time (P ⫽ .53).
There was no correlation between the amount of
advancement and the risk of plate removal, but removal
rates differed according to the type of miniplate used
(Fig. 4). The statistical analysis revealed no significant
difference between the use of regular or long mini-
plates.
DISCUSSION
Various complications can arise after miniplate and
screw fixation, such as infection, miniplate fracture,
nonunion, and mental nerve paralysis or dysesthesia.18
Plate removal after orthognathic surgery varies between
1.0% and 18.6% of patients.7-11 Some German centers
advocate routine removal of titanium osteosynthesis
material after treatment of fractures or operations for
dysgnathia.4
Alpha et al.8 reported plate removal in only 10% of
its BSSOs, although they described “disturbance of
healing” in 26% of their patients. In our study, “distur-
bance of healing” was one of the indications to pursue
surgery (42% of all removals). Borstlap et al.19 reported
that 55% of plates were taken out within 8 months after
according to the type of miniplate and the side of placement.
4H R, 4 holes regular; 4H M, 4 holes medium; 4H L, 4 holes
large; 6H R, 6 holes regular.
an operation, but only 7% of these had to be removed
because of inflammation. They did not further specify
the reasons for removal among the other 48%. Kramer
et al.20 described the removal of osteosynthesis material
in 90% of their 1000 Le Fort I osteotomies but did not
include the indications for removal. Theodossy et al.7
reported a removal rate of 15.6%, but all of the plates
had to be removed because of infection. They defined
infection as pain, swelling, wound dehiscence, and pus
discharge in the region of the plates, which includes
both the indications of “inflammation” and “infection”
in our series.
We prefer to use miniplates for fixation of our os-
teotomies, which appears to be a safe and reliable
procedure and excludes certain disadvantages that are
seen with the use of bicortical screws, as has been
described by Borstlap et al.19 Some authors support the
use of 2 miniplates for 1 osteotomy site to reduce
complications,16,21 but others do not agree.22-24 In our
series, we used 2 miniplates for 1 osteotomy site.
This study shows a high incidence of plate removal
compared with the literature (Table I). One possible
reason could be that the placement of 2 plates per side
provokes a higher risk for plate removal. The place-
ment of the proximal segment screws away from the
inferior border of the mandible could raise the risk of a
disturbed healing.8 Our operative charts do not allow
comment on this issue. Whenever a disturbed healing
was encountered at an osteotomy site, both plates were
removed without notation of which screws were loose
and which were not. The placement of 2 plates neces-
sitates more stripping of soft tissues, both at the upper
border and at the lower border of the mandible, which
could affect the vascularization of the bone at the
osteotomy margin of the proximal segment.
Another reason for the high incidence of plate re-
moval in this study could be that the decision to remove

742 Falter et al.
the plates was made as soon as there was a minimal
margin of complaint, and we note that the relative
proportion of these indications differed between the
sexes. By keeping this threshold for removal rather low,
we were anticipating in most cases that any later re-
moval would be more complicated because of bony
overgrowth. Such overgrowth occurs in general when
the interval between placement and removal is longer
than 12 months.
Michelet et al.2 advocated a tight seal of the surgical
site with emphasis on closure of the periosteum at
fracture sites. As a meticulous closure was attempted in
all cases during one period (throughout 2009) without
any positive effect, this factor is not an issue in orthog-
nathic surgery.
Although the standard removal of all osteosynthesis
material is no longer promoted in the literature, contro-
versy remains about the long-term effect of titanium
miniplates, primarily in young adults.25-28 Despite their
excellent clinical performance, doubts have emerged
about their long-term behavior in tissues and their po-
tential local and systemic side effects.29 Because most
of our patients are younger than 30, we prefer to be
cautious regarding the long-term placement of the
plates. Further, because the removal of plates is asso-
ciated with low comorbidity, we always choose to
remove the plates within a minimal margin of com-
plaint, as noted.
A third possible explanation for the high removal
rates in this study is that our patients are not placed in
intermaxillary fixation (IMF) postoperatively. Al-
though the double-plating method gives a strong fixa-
tion that excludes the need for IMF, it is possible that
this practice results in micromotions at the fracture
site that provoke a reaction near the surgical wound.
From our results, we also note a significantly higher
number of plates removed with patients operated on in
2008 and 2009 compared with 2004 through 2007. The
screw design could be in play here. Monocortical fix-
ation starts at the proximal segment with a first fixation
point at the upper plate close to the osteotomy site.
Whenever we found an infection of the plates, this
screw was always involved, having lost its fixation,
with or without a loose bony fragment. It could be that
the manual tightening of this first screw was too tight,
causing microfractures close to the osteotomy site.
There also was a relatively higher number of bimaxil-
lary operations in these years that accompanied a higher
risk for plate removal, but this observation is not of-
fered as a conclusive explanation but rather noted as a
negative evolution.
The amount of advancement and the risk of plate
removal showed no correlation, but we did note that
removal rates differed according to the type of mini-
OOOOE
December 2011
plate that was used; however, analysis did not identify
a significant difference between using regular or long
miniplates. The length of the miniplate is a good mea-
sure for the dead space at the diastema of an advance-
ment osteotomy of the lower jaw. The transverse ap-
proximation of the proximal and distal fragment was
less with miniplates than with screw fixation of osteot-
omies. This could be an additional factor but was not
evaluated here.
There can be dead space because of a lack of bony
contacts between the proximal and distal bone frag-
ments, along with a diminished vascularity of the prox-
imal fragment at the osteotomy site. Under these con-
ditions, overtightening of the first screw placed close to
the osteotomy margin of the proximal bone fragment
could initiate compromised healing, leading to early
loss of tightening of the screw, which then could begin
to act as a foreign body.
Problems that required plate removal seemed to start
more on the left side than on the right, and it is possible
that the right-handedness of the surgeon might be a
factor. Dental root injuries resulting from miniplate
osteosynthesis, which require a removal of the screws
and plates, did not occur in our series, although the
reported incidence can be as high as 7.6% of all pa-
tients.30 These dental root traumas occur only in the
upper jaw or in the distal segment of the lower jaw.
In general, we found no significant correlation be-
tween age and the risk for plate removal, in line with
what has been reported by Kuhlefelt et al.9 This finding
is not, however, in line with Manor et al.,12 who re-
ported that age is a statistically significant linear risk
factor for plate removal among patients who had un-
dergone orthognathic surgery. It should be noted that
we found a significant but nonlinear correlation be-
tween age and removal (for the 25-35 age group) in the
specific group of cases in which infection necessitated
the removal.
CONCLUSIONS
This study reports an important percentage of pa-
tients (27.6%) developing complications from plates
and screws that required their removal. Bimaxillary
operations had higher removal rates than monomaxil-
lary operations, and women were more likely to have
their plates removed than men. Age had no significant
influence on miniplate removal, except in some cases
when an infectious episode caused the removals.
Almost 80% of the removed plates are removed
within the first year. One of the advantages of a rapid
removal is that all plates can be technically easily
removed in a procedure with low morbidity if they are
removed within this “window of opportunity.”
OOOOE
Volume 112, Number 6
REFERENCES
1. Champy M, Loddé JP, Schmidt R, Jaeger JH, Muster D. Man-
dibular osteosynthesis by miniature screwed plates via buccal
approach. J Maxillofac Surg 1978;6:14-21.
2. Michelet FX, Deymes J, Dessus B. Osteosynthesis with minia-
turized screwed plates in maxillo-facial surgery. J Maxillofac
Surg 1979;1:79-84.
3. Brown JS, Trotter M, Cliffe J, Ward-booth RP, Williams ED.
The fate of miniplates in facial trauma and orthognathic surgery:
a retrospective study. Br J Oral Maxillofac Surg 1989;27:306-15.
4. Mueller CK, Bader RD, Schultze-Mosgau S. Oral and maxillo-
facial injuries. Current concepts of treatment. Trauma Berufsk-
rankh 2010;12:208-14.
5. Bhatt V, Langford R. Removal of miniplates in maxillofacial
surgery: University Hospital Birmingham experience. J Oral
Maxillofac Surg 2003;61:553-6.
6. Bhatt V, Chhabra P, Dover MS. Removal of miniplates in
maxillofacial surgery: a follow-up study. J Oral Maxillofac Surg
2005;63:756-60.
7. Theodossy T, Jackson O, Petrie A, Lloyd T. Risk factors con-
tributing to symptomatic plate removal following sagittal split
osteotomy. Int J Oral Maxillofac Surg 2006;35:598-601.
8. Alpha C, O’Ryan F, Silva A, Poor D. The incidence of postop-
erative wound healing problems following sagittal ramus osteot-
omies stabilized with miniplates and monocortical screws. J Oral
Maxillofac Surg 2006;64:659-68.
9. Kuhlefelt M, Laine P, Suonimen-Taipale L, Ingman T, Lindqvist
C, Thorén H. Risk factors contributing to symptomatic miniplate
removal: a retrospective study of 153 bilateral sagittal split
osteotomy patients. Int J Oral Maxillofac Surg 2010;39:430-5.
10. Beals SP, Munro IR. The use of miniplates in craniomaxillofacial
surgery. Plast Reconstr Surg 1987;79:33-8.
11. Schmidt BL, Perrot DH, Mahan D, Kearns G. The removal of
plates and screws after le Fort I osteotomy. J Oral Maxillofac
Surg 1998;56:184-8.
12. Manor Y, Chaushu G, Taicher S. Risk factors contributing to
symptomatic plate removal in orthognathic surgery patients.
J Oral Maxillofac Surg 1999;57:679-82.
13. Nagase DY, Courtemanche DJ. Plate removal in traumatic facial
fractures: 13-year practice review. Ann Plast Surg 2005;55:
608-11.
14. Epker BN. Modifications in the sagittal osteotomy of the man-
dible. J Oral Surg 1977;35:157-9.
15. Falter B, Schepers S, Vrielinck L, Lambrichts I, Thijs H, Politis
C. Occurrence of bad splits during sagittal split osteotomy. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:430-5.
16. Tulasne JF, Schendel SA. Transoral placement of rigid fixation
following sagittal ramus split osteotomy. J Oral Maxillofac Surg
1989;47:651-2.
17. Epker BN, Fish LC. Dentofacial deformities: integrated orth-
odontic and surgical correction. St. Louis: Mosby; 1986.
18. Matthew IR, Frame JW. Policy of consultant oral and maxillo-
facial surgeons towards removal of miniplate components after
Falter et al. 743
jaw fracture fixation: pilot study. Br J Oral Maxillofac Surg
1999;37:110-2.
19. Borstlap WA, Stoelinga PJW, Hoppenreijs TJM, van’t Hof MA.
Stabilisation of sagittal split advancement osteotomies with mini-
plates: a prospective, multicentre study with two-year follow-up.
Part I. Clinical parameters. Int J Oral Maxillofac Surg 2004;
33:433-41.
20. Kramer FJ, Baethge C, Swennen G, Teltrow T, Schulze A,
Berten J, et al. Intra- and perioperative complications of LeFort
I osteotomy: a prospective evaluation of 1000 patients. J Cranio-
fac Surg 2004;15:971-7.
21. Levy FE, Smith RW, Odland RM, Marentette LJ. Monocortical
miniplate fixation of mandibular angle fractures. Arch Otolaryn-
gol Head Neck Surg 1991;117:149-54.
22. Schierle HP, Schmelzeisen R, Rahn B, Pyylik C. One- or two-
plate fixation of mandibular angle fractures? J Craniomaxillofac
Surg 1997;25:162-8.
23. Ellis E III. Treatment methods for fractures of the mandibular
angle. Int J Oral Maxillofac Surg 1999;28:243-52.
24. Siddiqui A, Markose G, Moos KF, McMahon J, Ayoub AF. One
miniplate versus two in the management of mandibular angle
fractures: a prospective randomized study. Br J Oral Maxillofac
Surg 2007;45:223-5.
25. Alpert B, Seligson D. Removal of asymptomatic bone plates
used for orthognathic surgery and facial fractures. J Oral Max-
illofac Surg 1996;54:618-21.
26. Haug RH. Retention of asymptomatic bone plates used for or-
thognathic surgery and facial fractures. J Oral Maxillofac Surg
1996;54:611-7.
27. Rubio J, Garcia-Alonso M, Alonso C, Alobera M, Clemente C,
Munuera L, et al. Determination of metallic traces in kidneys,
livers, lungs and spleens of rats with metallic implants after a
long implantation time. J Mater Sci Mater Med 2008;19:369-75.
28. Sarmiento-González A, Encinar J, Marchante-Gayón J, Sanz-
Mendel A. Titanium levels in the organs and blood of rats with
a titanium implant, in the absence of wear, as determined by
double-focusing ICP-MS. Anal Bioanal Chem 2009;393:335-43.
29. Langford RJ, Frame JW. Surface analysis of titanium maxillo-
facial plates and screws retrieved from patients. Int J Oral Max-
illofac Surg 2002;31:511-8.
30. Driemel O, Staudenmaier R, Buch RS, Schüsseltbauer U,
Wagener H, Reichert TE, et al. Dental injuries due to miniplate
osteosynthesis. Classification, treatment, management, compli-
cations, and prognosis. Mund Kiefer Gesichtschir 2005;9:330-5.
Reprint requests:
Constantinus Politis, MD, DDS
St. John’s Hospital
Oral and Maxillofacial Surgery
Reeweg 51
3600 Genk, Belgium
constantinus.politis@uhasselt.be