Int. J. Oral Maxillofac. Surg.

2009; 38: 731–735

doi:10.1016/j.ijom.2009.02.016, available online at http://www.sciencedirect.com

Clinical Paper
Osteosynthesis

The fate of titanium miniplates J. O’Connell1, C. Murphy1,

O. Ikeagwuani1, C. Adley2,
G. Kearns1,*

and screws used in maxillofacial

1
Department of Oral and Maxillofacial
Surgery, Mid Western Regional Hospital,
Limerick, Ireland; 2Department of
Microbiology, University of Limerick, Limerick,

surgery: A 10 year retrospective Ireland

study
J. O’Connell, C. Murphy, O. Ikeagwuani, C. Adley, G. Kearns*: The fate of titanium
miniplates and screws used in maxillofacial surgery: A 10 year retrospective study.
Int. J. Oral Maxillofac. Surg. 2009; 38: 731–735. # 2009 Published by Elsevier Ltd
on behalf of International Association of Oral and Maxillofacial Surgeons.

Abstract. The objective of this 10 year, retrospective study is to evaluate the

indications for the removal of titanium miniplates following osteosynthesis in
maxillofacial trauma and orthognathic surgery. All patients who had miniplates
placed in a Regional Oral and Maxillofacial Department between January 1998 and
October 2007 were included. The following variables were recorded: patient gender
and age, number of plates inserted, indications for plate placement, location of
plates, number and location of plates removed, indications for plate removal, time
between insertion and removal, medical co-morbidities, and the follow-up period.
During the 10 years of the study, 1247 titanium miniplates were placed in 535
patients. A total of 32 (3%) plates were removed from 30 patients. Superficial
Keywords: titanium miniplates; removal; osteo-
infection accounted for 41% of all plates removed. All complications were minor synthesis; trauma; orthognathic.
and most plates were removed within the first year of insertion. A low removal rate
of 3% suggests that the routine removal of asymptomatic titanium miniplates is not Accepted for publication 13 February 2009
indicated. Available online 21 March 2009

Monocortical miniplate fixation is an
accepted and reliable method of fixation
for patients with maxillofacial trauma
undergoing orthognathic surgery13.
LUHR20, SCHILLI28, SPIESSL30, MICHELET
et al23 and CHAMPY et al7 developed
internal fixation systems that were
designed to replace or supplement max-
illo-mandibular fixation in the treatment
of maxillofacial injuries and deformities.
Titanium miniplates have superseded
vitallium and stainless-steel plates
because they are reliable, and appear
clinically inert, causing little or no local
reaction. Despite their excellent clinical
performance, doubts have emerged about
their long-term behaviour in tissues and
their potential local and systemic side
effects19.
There is agreement that symptomatic
plates should be removed, but there is
no consensus among maxillofacial sur-
geons on the need for routine removal
of asymptomatic plates. Some authors
recommend removal1,6,23,30, while others
recommend retention unless clinically
indicated3,5,17,22. In 1991, the Strasbourg
Osteosynthesis Research Group (SORG)
produced the following recommendations:
‘A plate which is intended to assist the
healing of bone becomes a non-functional
implant once this role is completed. It may
then be regarded as a foreign body’. There
is no clear evidence that a plate causes
harm, but knowledge remains incomplete
so it is impossible to say that an otherwise

0901-5027/070731 + 05 $36.00/0 # 2009 Published by Elsevier Ltd on behalf of International Association of Oral and Maxillofacial Surgeons.
732 O’Connell et al.
symptom-less plate left in situ, is harm-
less.
SORG states that the removal of a non-
functioning plate is desirable ‘provided
that the procedure does not cause undue
risk to the patient’31. Ward Booth33 states
that interpretation of these recommenda-
tions means that for most patients there is
less risk in leaving symptom-less plates in
situ than removing them.
Alpert and Seligson1 advocate the
removal of asymptomatic bone plates fol-
lowing fracture repair, stating that they
then become a useless foreign body and
a potential source of problems once heal-
ing has occurred. In1996, Haug17 reported
that there was no association between
tumour formation or allergic reactions
and commercially pure titanium.
KATOU et al18 studied immuno-inflam-
matory responses to titanium miniplates
used in the treatment of mandibular frac-
tures and found that titanium particles
released from miniplates induce and main-
tain chronic inflammation and fibrous
encapsulation. They suggest that non-
functioning plates and screws should be
removed after healing.
WEINGART et al34, in a study on tita-
nium deposition in regional lymph nodes
after insertion of titanium screw implants
in the maxillofacial region, found a
raised titanium level in some regional
lymph nodes, but no foreign body or
toxic reaction was observed in the histo-
logical sections. In 1991, TOMAZIC et al32
found an association between titanium
particles and monocyte and macrophage
activation with release of bone resorbing
mediators, fibroblast stimulation,
impaired bone healing and impaired
immune responses.
LANGFORD and FRAME19, in a controlled
human plate retrieval study, found no
signs of corrosion or surface deterioration
on the retrieved plates and screws that had
been in the tissues for between 1 month
and 13 years. They found no evidence to
support the routine removal of titanium
miniplates due to corrosion up to 13 years
after insertion.
ROSENBERG et al26 showed the amount of
titanium deposition from miniplates was
small and pigmentation was asympto-
matic. There was no relation between
complications and pigmentation. It is their
opinion that changes in soft tissues near
titanium miniplates should not be inter-
preted as an indication to remove the
plates.
BRANEMARK et al4, in numerous long-
term studies, showed that titanium dioxide
did not produce any toxic side effects.
EPPLEY et al12 state that titanium does
not contraindicate the use of MRI, pro-
duces no high density scatter in CT, offers
no interference with complex three-
dimensional CT reconstruction, and is
compatible with radiography. Alpert and
Seligson1, state that the potential for arte-
facts remains as long as a plate remains in
place.
In common with other maxillofacial
units5,6,21,22, it is the policy at the authors’
hospital to remove titanium bone plates
only if they become symptomatic, in
response to patients’ requests, if they
impede further surgery or if they have
the potential to interfere with facial
growth. The purpose of this study is to
evaluate the incidence and reasons for
plate removal following the placement
of plates during maxillofacial trauma
and orthognathic surgery.
Patients and methods
This is a 10-year, retrospective study of
patients who had titanium bone plates
(Stryker Liebinger Micro Implants, Frei-
burg, Germany) placed in the Department
of Oral and Maxillofacial Surgery, Mid
Western Regional Hospital, Limerick, Ire-
land, between January 1998 and October
2007. The following variables were
recorded: patient gender and age, number
of plates inserted, indications for plate
placement, location of plates, number
and location of plates removed, indica-
tions for plate removal, time between
insertion and removal, medical co-mor-
bidities, and the follow-up period. The
specific medical comorbidities noted were
immunosuppressive conditions that may
predispose to infection and the need for
bone plate removal, diabetes, HIV disease,
steroid medication, chemotherapy or neo-
plastic disease. The reason for removal
was based on the surgeon’s clinical and
radiographic assessment, and the patient’s
symptoms. All information was obtained
from patient medical records and opera-
tion reports. The indications for plate
insertion were: maxillofacial fractures
and orthognathic surgery (Le Fort I and
mandibular sagittal split osteotomy, and
genioplasty).
All patients admitted with maxillofacial
trauma were treated using the same anti-
biotic and dietary protocol.
Patients with mandibular or maxillary
(Le Fort I and II) fractures are admitted for
surgery under general anaesthesia. The
interval between admission and definitive
fracture treatment is variable and based on
clinical presentation and other ongoing
hospital emergency surgical activity. All
patients are administered intravenous anti-
biotics on admission (amoxycillin/clavu-
lanic acid 1.2 g or clindamycin 600 mg 8
hourly if penicillin allergic) and through-
out the hospital stay. Patients complete a
5-day course of oral antibiotics on dis-
charge.
Patients with isolated and minimally
displaced orbitozygomatic complex frac-
ture are assessed in the Accident and
Emergency Department and in most
cases discharged with oral antibiotics
(amoxycillin/clavulanic acid 325 mg 8
hourly, clindamycin 150 mg 8 hourly if
penicillin allergic). These patients are
readmitted 5 days later for definitive
fracture treatment when the facial swel-
ling has reduced.
Orbitozygomatic complex fracture
patients are admitted, if the facial frac-
tures are associated with other significant
associated injuries such as head injury,
cervical spine injury, orthopaedic or
abdominal injuries, or with clinically
relevant ocular findings such as reduced
visual acuity, disabling diplopia. Occa-
sionally, social circumstances necessitate
hospital admission. On admission,
patients are administered intravenous
antibiotics (amoxycillin/clavulanic acid
1.2 g 8 hourly or clindamycin 600 mg 8
hourly if penicillin allergic) that are con-
tinued during the hospital stay. They are
prescribed oral antibiotics for 5 days fol-
lowing discharge.
Patients attending for orthognathic sur-
gery are admitted on the day of surgery
and treated with prophylactic intravenous
antibiotics at induction of general anaes-
thesia (amoxycillin/clavulanic acid or
clindamycin as above). Intravenous anti-
biotics are continued during the hospital
stay and a 5-day course of oral antibiotics
is completed on discharge.
All patients follow a similar postopera-
tive dietary regimen. In the presence of
intra-oral wounds, patients fast for 6 h
postoperatively followed by a period of
clear liquids for 48 h and advanced to a
soft diet, which continues for 6 weeks
postoperatively. All patients have a con-
sultation with a dietician during their hos-
pital stay.
Results
The results are outlined in Tables 1 and 2
and Fig. 1. During the 10-year period of
this study, 1247 titanium miniplates were
placed in 535 patients (428 (80%) were
male and 107 (20%) female). In total, 30
patients underwent plate removal; 26
(87%) were male and 4 (13%) female,
their mean age was 29 years (range 3–
72 years).
 Fate of titanium miniplates and screws in maxillofacial surgery 733

Table 1. Summary of plate placement and removal.

Plates placed Plates removed
Categories Quantity % Quantity % Number of patients
Trauma
Mandible 402 32.24 26 81.25 434
Orbito-zygomatic complex 306 24.54 3 9.37
Maxilla 92 7.38 2 6.25
Orthognathic surgery 101
Bimaxillary osteotomy 324 26 0 0
Mandibular sagittal split osteotomy 78 6.25 0 0
Le Fort I osteotomy 30 2.4 1 3.12
Genioplasty 15 1.2 0 0
Total 1247 100 32 100 535

Table 2. Summary of location and indications for plate removal.

Plates removed Indications for removal
Location of plate Quantity % Quantity %
Mandible 26 81.25 Infection 11* 42.3 %
Removal with a tooth 7 27
Plate exposure 2 7.7
Fibrous union 2 7.7
Temperature conduction 1 3.85
Plate fracture 1 3.85
Endosseous implant placement 1 3.85
Prior to orthognathic surgery 1 3.85
Orbito-zygomatic complex 3 9.37 Infection 1* 33.3
Palpable plate 1 33.3
Paediatric patient 1 33.3
Maxilla 3 9.37 Infection 1* 33.3
Endosseous implant placement 1 33.3
Paediatric patient 1 33.3
Total 32 100 32
*
13 patients required plate removal due to superficial infection, 8 (61%) were smokers.

Twenty six (81%) mandibular plates
were removed from 24 patients, 16
(62%) from the angle, 6 (23%) from the
parasymphysis and 4 (15%) from the
body. These figures represent a plate
removal rate of 4% for plates placed in
the mandible. Superficial infection
accounted for 42% of all plates removed
from the mandible.
Three (9%) plates were removed from
the maxilla in 3 patients. One (33%) was
anterior to the zygomatic buttress and 2
(67%) were from the posterior maxilla.
Fig. 1. Time between plate insertion and removal.
These figures represent a plate removal
rate of 1% of all plates placed in the
maxilla. Three (9%) plates were removed
from the orbito-zygomatic complex in 3
patients. All 3 plates were removed from
the fronto-zygomatic suture. These figures
represent a plate removal rate of 1% for all
plates placed in the orbito-zygomatic
complex. There were no medical co-mor-
bidities in patients who required bone
plate removal.
The indications for plate removal are:
superficial infection 13 (41%) plates (11
mandibular, 1 orbito-zygomatic, 1 maxil-
lary); removal associated with an
impacted or infected tooth 7 (22%) plates
and plate exposure 2 (6%) plates. Two
plates (6%) were removed in a single
patient with a bilateral fibrous union in
an edentulous mandibular fracture. The
plates were removed under general anaes-
thesia with bone graft reconstruction and
placement of longer bone plates. Two
plates (6%) were removed from two
patients prior to implant placement and
a further 2 plates (6%) were removed in
two paediatric patients to avoid any poten-
tial disruption of growth. Single bone
plates were removed in each of the follow-
ing groups: temperature conduction, plate
fracture, and prior to orthognathic surgery.
Excluding the plates removed due to a
fibrous union, all patients had plates
removed under general anaesthesia in a
day-case setting. All fractures were healed
at the time of plate removal and all
patients had complete resolution of their
signs/symptoms once the bone plate was
removed.
734 O’Connell et al.
The mean time between insertion and
removal was 19 months (range 2.5–68
months). The mean follow-up period
was 21 months (range 3–75 months).
Discussion
This retrospective study reports the inci-
dence and reasons for miniplate removal
in a population of 535 people. Most of the
plates removed in this study were in
patients presenting with maxillofacial
trauma (97%), particularly in those with
mandibular fractures (81%) (Table 1).
During the 10-year period, 1247 plates
were placed and 32 (3%) plates were
removed. Other studies report miniplate
removal rates of 6–14%.3,5,21,24,25,29
In the maxillofacial trauma group, 800
plates were placed in 434 patients and 31
(4%) plates removed. This compares
favourably with previous studies, which
report removal rates of 6–10% in trauma
patients.3,14,24,25
The low minplate removal rate in this
study may be related to the study popula-
tion and compliance with treatment.
Patients are managed using a strict anti-
biotic protocol, thus reducing the potential
for postoperative infection. The patients
also adhere to rigorous postoperative diet-
ary instructions leading to reduced mobi-
lity at the fracture sites. Patient
compliance is always an important issue
in patients with facial trauma and difficult
to assess. In this study, the patients with
mandibular fractures were managed with
preformed Erich arch bars to establish the
occlusion intraoperatively and enable the
use of guiding elastics postoperatively if
necessary2. All patients returned for
removal of the arch bars 6 weeks after
discharge and at regular intervals during
the preceding weeks. The use of arch bars
may provide an incentive for patients to
return for recall9. No patients had a history
of intravenous drug abuse, which is asso-
ciated with noncompliance and an
increased incidence of complications.
In this study, 81% (n = 25) of plates
removed were from the mandible and
64% (n = 16) of these plates were removed
from the angle. It is not surprising that
most plates were removed from the mand-
ible because 50% of plates used in trauma
cases are placed there, but it is interesting
that most of these were from the angle.
These findings concur with those of GAB-
15
RIELLI et al but differ from those of
MOSBAH et al24, where most plates were
removed from the parasymphysis region.
Other studies9,11,16 have shown that
angle fractures result in the highest fre-
quency of complications relative to other
mandibular fractures. Biomechanical
forces that occur in the angle region during
mastication may contribute to a higher
incidence of complications27.
Five plates (16% of all plates removed)
were removed concurrently with sympto-
matic impacted third molars. ELLIS10
demonstrated an increased rate of post-
operative complications when a tooth is
present in the line of mandibular angle
fractures. Removal of the tooth at the time
of fracture fixation may avoid the need to
remove the tooth and bone plate at a later
stage, but it may increase the risk of
damage to the inferior alveolar and lingual
nerves2. It is now the authors’ policy to
remove all third molars in the line of a
fracture, unless completely covered by
bone.
Superficial infection was the principal
reason for removal of plates in this study,
accounting for 40% (n = 13). This concurs
with other authors who found infection to
be the main cause of plate removal3,24,25.
In this study the mean time between plate
placement and removal due to infection
was 10.4 months. DOBBINS et al8, report
that there is some evidence that plates can
become colonised by blood-borne bac-
teria, which may increase the prevalence
of infection-associated symptoms. In the
13 patients requiring bone plate removal
associated with superficial infections, 8
(61%) were smokers suggesting a possible
relationship between smoking and the
development of infection related to the
bone plates and screws.
Alpert and Seligson1 anecdotally report
that temperature conduction, associated
with bone plates, is a significant cause
of morbidity and plate removal. In this
study, only one of 1247 plates placed was
removed due to temperature sensitivity.
Other studies3,21,24,25 found no examples
of plate removal due to thermal sensitivity.
39% of plates were removed within 6
months of insertion. The mean time
between insertion and removal was 19
months (range 2.5–68 months). MOSBAH
et al24, showed that 75% of plates placed
in trauma patients were removed within 6
months of insertion. In this study, almost
52% of plates were removed within 1 year
of insertion. BHATT et al3, demonstrated a
removal rate of 72% within the first year
after placement.
Only one of the plates placed during
orthognathic surgery was removed. It was
removed because of superficial infection
from a man who underwent a Le Fort I
osteotomy. These findings differ from
those of SCHMIDT et al29, who reported a
10% removal rate in patients who under-
went a Le Fort I osteotomy and BHATT
et al3, who in a retrospective study of
orthognathic patients, reported that 8%
of plates used were removed. MOSBAH
et al24 report a 9% removal rate in patients
who underwent orthognathic surgery pro-
cedures.
In this study, 2 plates were removed in
paediatric patients, one from the maxilla at
the zygomatic buttress and the second
from the frontozygomatic suture. The role
of miniplates in the treatment of maxillo-
facial fractures in the paediatric popula-
tion may be limited due to the concerns
over growth restrictions, stress shielding,
corrosion and palpability35. Resorbable
plates and screws may have a role in the
management of facial fractures in chil-
dren35. The authors remove miniplates
and screws routinely in the paediatric
population to avoid potential problems.
The question of whether to leave non-
functioning and asymptomatic plates in
situ remains. In this retrospective study,
the authors found that only 3% of mini-
plates placed over a 10-year period were
removed. All indications for removal were
minor and all plate removal was per-
formed under local or general anaesthesia
in a day-case setting. Based on the findings
of this study, in this population, an overall
bone plate removal rate of 3% does not
support the routine removal of asympto-
matic titanium miniplates used for osteo-
synthesis in the maxillofacial region.
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Address:
Gerard Kearns
Department of Oral and Maxillofacial
Surgery
Mid Western Regional Hospital
Limerick
Ireland
Tel.: +353 61 482304
E-mail: gerard.kearns@hse.ie