Abstract
Objective
The aim of this study was to investigate the incidence of plate removal in orthognathic surgery patients and the reasons for their removal and to potentially identify the factors that may contribute to it.
Methods
A retrospective study included all patients who underwent orthognathic surgery at Selayang Hospital from January 2011 to December 2017. The variables of interest recorded included patient age, gender, the existing skeletal deformity, type of surgery undertaken and number and location of plates inserted and removed. In addition, the reasons for plate removal and duration between plate insertion and removal were also recorded.
Results
Ninety-seven patients with a mean age of 21.33 were included in the study. Nine patients with total of 33 plates had their miniplate fixation removed. Three patients underwent bi-maxillary surgery, and six patients underwent BSSO. The average time from insertion to removal was 22.33 months. The reasons for removal included pain, palpable and exposed plates, infection and on patient request.
Conclusion
We report a 9.28% incidence of plate removal in patients who undergo orthognathic surgery which is comparable to the existing literature.
Keywords: Orthognathic surgery, Plate removal, Titanium plate, Infection
Introduction
The use of titanium miniplate is widely used as a preferred method of fixation in the head and neck region. The introduction and subsequent description of the use of the miniplate [1, 2] gradually replaced wire osteosynthesis and maxillomandibular fixation. The use of said miniplates, however, is not without doubts as, despite of appearing clinically inert and exhibiting good biocompatibility compared to other materials, the presence of such plates over a long period of time may result in potential local and systemic effects [3].While there are authors who advocate the removal of asymptomatic plates [4], titanium miniplates are not routinely removed. The reasons for plate removal post-orthognathic surgery may include infection, wound healing complications, clinical irritation and a host of other reasons [5].
The aim of this retrospective study was to investigate the incidence of plate removal in orthognathic surgery patients and the reasons for their removal and to potentially identify the factors that may contribute to it.
Materials and Methods
This retrospective study included all patients who underwent orthognathic surgery at Selayang Hospital from January 2011 to December 2017. The variables of interest recorded included patient age and gender, the existing skeletal deformity, type of surgery undertaken and number and location of plates inserted and removed. In addition, the reasons for plate removal, duration between plate insertion and removal as well as any existing medical comorbidities or habits that may affect the outcome like smoking were also recorded.
Patients who underwent distraction osteogenesis or used resorbable fixation systems were excluded from the study. Antibiotic prophylaxis of Amoxicillin 1 g and Clavulanate 200 mg injection (Augmentin, Zuellig Pharma) was administered intraoperatively at induction and was continued 8 hourly in the ward. Amoxicillin 500 mg and Clavulanate 125 mg (Augmentin, Zuellig Pharma) tablet twice daily for 1 week was prescribed upon discharge. All patients had the surgery carried out intraorally, and no trochar was used for fixation of plates. No drains were placed post-operatively. All the plates used were made of titanium and were manufactured by De Puy Synthes. All patients regardless of surgery were fitted with a nasogastric tube for 3–5 days post-operatively. All patients were also placed in intermaxillary fixation for a minimum of 1 week post-surgery.
The data were analysed using SPSS version 22. Descriptive statistics were used along with Chi square tests. Statistical significance was set at P < 0.05 to be considered significant.
Results
A total of 100 patients underwent orthognathic surgery at our centre for the study duration. The most common skeletal deformity was Class 3 (72%). Nine patients were cleft lip and palate patients, and one was diagnosed with Treacher Collins syndrome. 53 patients (53%) underwent mandibular osteotomy (Bilateral sagittal split osteotomy), and 44 patients (44%) underwent bi-maxillary surgery. Three patients had a genioplasty concomitantly, and further three patients were excluded from the final analysis in view of them undergoing distraction osteogenesis (Table 1).
Table 1.
Descriptive statistics for the cohort of patients
| Age in years | Sex | Skeletal deformity | Surgery underwent |
|---|---|---|---|
| 17–31 (21.33) | 50 male/50 female | Class 1: 2 (2%) | BSSO: 53 (53%) |
| Class 2: 16 (16%) | Bi-maxillary: 44 (44%) | ||
| Class 3: 72 (72%) | Distraction Osteogenesis: 3 (3%) | ||
| Others: 10 (10%) | Patients with genioplasty: 3 |
Out of the final 97 patients analysed, nine patients (9.28%) had their miniplate fixation removed. Three patients underwent bi-maxillary surgery, and six patients underwent BSSO. One patient also had a genioplasty plate removed. A total of 33 plates were removed from these patients. Every patient underwent plate removal under general anaesthesia. The average time from insertion to removal was 22.33 months (range from 6 to 61 months). The reasons for removal included pain (2 patients), palpable and exposed plates (3 patients), infection (3 patients) and one on patient request. One patient who had exposed plate had loosened screws. None of the patients had fractured plate. No patient had pre-existing medical comorbidities. One patient smoked regularly (Tables 2, 3).
Table 2.
Summary of findings for patients who underwent plate removal
| Age | Sex | Skeletal deformity | Surgery underwent | No of plates inserted and removed | Time from insertion to removal (month) | Indication for removal |
|---|---|---|---|---|---|---|
| 29 | Male | Class 3 | BSSO | 2 | 6 | Plate exposure |
| 20 | Female | Class 3 | BSSO | 2 | 6 | Infection |
| 24 | Female | Class 3 | Bi-maxillary | 6 | 16 | Patient request |
| 18 | Male | Class 2 | BSSO with genioplasty | 3 | 11 | Plate exposure |
| 23 | Female | Class 3 | Bi-maxillary | 6 | 9 | Plate exposure |
| 19 | Female | Class 3 | Bi-maxillary | 6 | 61 | Infection with localised swelling |
| 17 | Male | Class 3 | BSSO | 2 | 30 | Infection |
| 22 | Female | Class 3 | BSSO | 2 | 52 | Pain |
| 20 | Female | Class 2 | BSSO | 2 | 10 | Pain |
Table 3.
Number of plates removed according to gender
| Plates | Male | Female | Total |
|---|---|---|---|
| Removed | 7 | 24 | 31 |
| Not removed | 182 | 163 | 345 |
| Total | 189 | 187 | 376 |
Discussion
The use of miniplate fixation in orthognathic surgery is now standard practice in order to obtain as stable a bony fixation as possible to ensure a stable result and minimisation of relapse. The use of titanium with its good biocompatibility has gained widespread acceptance not only in orthognathic surgery but in the management of fractures as well. At the present moment, there is no protocol established for the routine removal of miniplates after bony healing has concluded [6]. While the handling of these screws and plates during surgery may cause surgical damage to the hardware, there has been no indication that this would lead to necessitating plate removal [3]. Also the exposure of these plates and screws to the oral environment and functional forces may also lead to conditions that result in their subsequent removal.
In our study, the incidence of plate removal was 9.28%. The literature suggests approximately 10.6–19.2% of patients with plates in the maxilla and 10–24.8% of patients with plates in the mandible require removal of at least some of the hardware, with an overall incidence of 3.6–27.5% of plates placed for orthognathic surgery being removed [7].
There have been many reasons why plates need to be removed post-orthognathic surgery. In our study, plate exposure was the most common finding that resulted in plate removal. However, there was no pain or other signs of symptoms of inflammation associated with the exposed plate. The patients were advised to remove the exposed plate due to the increased risk of developing infection or inflammation from such hardware being exposed directly to the oral environment.
In the 2 patients who complained of “pain” around the plating area following BSSO, the plates were not exposed in the oral environment and were not palpable. The overlying mucosa also did not appear inflamed nor was there pus discharge. Nevertheless, the hardware was removed. Alpert and Selligson [4] suggested that temperature conduction could be a significant cause of morbidity leading to subsequent plate removal. While these two patients did not complain per se of temperature sensitivity, we believe that sensitivity could be interpreted as pain by certain patients. In our cohort, we have encountered certain patients who complained of discomfort over the hardware site during periods of cold weather or during eating foods of certain temperatures. Other studies in the literature, however, note that no patients had their hardware removed due to this complaint [8–10].
Three patients had infection around the hardware. Two patients out of the three had sinus tract formation from the resultant infection. The symptoms subsided after plate removal and concurrent medical management. None of the patients had visible pus discharge. One patient had localised swelling and maxillary sinusitis after bi-maxillary surgery. The disturbance of sinus mucosa integrity by a foreign body has been postulated as a potential reason resulting in the occurrence of sinusitis [11]. Superficial infection only occurred in 1 patient in our series. It has been reported that superficial infection may account for the majority of plate removal cases [5, 6, 12]. Only 1 patient in our cohort had smoking as a habit. Theodossy et al. [12] noted that smokers were 2.6 times more likely to develop infection at the hardware site resulting in its removal. Smoking has an adverse effect on wound healing in both the initial bone healing and later may act as a predisposing factor to developing infection over site of plating [13].
In our study group, 50% of patients who underwent plate removal had their plates removed within 1 year post-surgery. The recommend time for plate removal is after the unification of osteotomy segments which occurs at a minimum of 5 months post-injury [14]. At the time of plate removal, the bony fragments for all patients had united and were stable. Two of our patients had removal of plates and screws after 52 and 61 months, respectively. This might be attributed to soft tissue changes over time which may result in increasing prominence of osteosynthesis material that can result in irritation [5]. There was no difference in terms of difficulty whether plates were removed earlier or later after insertion.
All of the patients who undergo orthognathic surgery at our centre will be placed in intermaxillary fixation for a minimum of 1 week post-operatively. Falter et al. [5] noted a higher incidence of plate removal in their sample (27.5%) compared to previous studies, and they attributed this to micromotions at the osteotomy site that may provoke a reaction at the surgical area. In their study, however, they utilised a double plating method to increase the strength of fixation. Our patients utilised a single plate at each side for bilateral sagittal split osteotomies. In their sample, they also did not place the patients into intermaxillary fixation post-operatively which may lead to micromotions at osteotomy site that invoke a reaction at the surgical site. In our sample, all patients regardless of surgery type were placed in intermaxillary fixation post-operatively for a minimum period of 1 week.
In conclusion, we report a 9.28% incidence of plate removal in patients who undergo orthognathic surgery which is comparable to the existing literature. Females have a higher incidence necessitating plate removal. At our centre, we advocate only the removal of symptomatic plates, with the majority of removal occurring within a year of surgery.
Acknowledgements
We would like to thank the Director General of Health Malaysia for his permission to publish this article.
Compliance with Ethical Standards
Ethical Approval
Ethical approval was granted from Medical Research and Ethics Committee Ministry of Health, Malaysia.
Conflict of interest
The authors declare that they have no conflict of interest.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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