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ePlasty: Vol. 9
Causes and Incidence of Miniplate Removal Following Le Fort I Osteotomy
Afshin Haraji,a Mohammad Hosein Kalantar Motamedi,b and Nima Moharamnejadc

aDepartment of Oral and Maxillofacial Surgery, Azad University of Medical Sciences, Tehran, Iran; bTrauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran; and cPrivate practice, Tehran, Iran


Correspondence: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Aim: This study assessed the causes and incidence of miniplate removal during a 5-year period after Le Fort I osteotomy. Patients and methods: One hundred forty-two patients had plates inserted for fixation of the maxilla after Le Fort I osteotomy between 2001 and 2004. The Le Fort I segment was rigidly fixed with four 2-mm titanium miniplates and 16 screws. They were followed 1 to 5 years for plate complications and need for plate removal. Results: Fifteen of 142 patients (10.6%), 9 females and 6 males, required plate removal. The minimum time period between insertion and removal was 4 months and the maximum period was 18 months. Causes for removal were as follows: infection (40%), pain (13.3%); sinusitis (13.3%); sensitivity to temperature change (13.3%); palpability of plate (13.3%); and phobia (6.8%). Conclusion: In this study, the number of miniplates removed was small and required removal no sooner than 4 months postoperatively (after complete bony union), thus not compromising healing. There is no evidence from this study to support the routine removal of titanium miniplate after Le Fort I osteotomy, rather they should be removed when indicated.


Use of rigid fixation in oral and maxillofacial surgery has become a routine for the last 3 decades.1 Titanium miniplates facilitate orthognathic, craniofacial, and reconstruction surgeries. The benefits of using rigid fixation are stability of the osteotomized segment, obviating the need for intermaxillary fixation, patient comfort, and less possibility of complications in comparison with maxillomandibular fixation (such as aspiration and respiratory distress). However, there exists much controversy with regard to plate removal after healing. Champy et al1 suggested that plates be removed 3 months after insertion. Many authors do not support this suggestion.26 Allowing rigid fixation to remain may pose disadvantages such as infection, temperature sensitivity, sinusitis, palpability (by patients), and nerve and dental injuries.6,7 In 1987, Beals and Munro8 showed that only 1% of 74 patients who underwent craniofacial surgery required plate removal. In 1992, Francel et al9 reported infection in 12% of facial trauma patients who had jaw reconstruction mandating plates and screws to be removed. Exposure of the plate into the oral cavity is a common cause of removal. The aim of this study was to assess the causes and incidence of miniplate removal during a 5-year period after Le Fort I osteotomy.

MATERIALS AND METHODS

One hundred forty-two patients had plates inserted for fixation of the maxilla after Le Fort I osteotomy between 2001 and 2004. Every patient had surgery for similar deformities, with 2 miniplates placed bilaterally (L-form with 4-hole 2-mm diameter miniplates and 7-mm screws were used). The Le Fort I segment was rigidly fixed with four 2-mm titanium miniplates and 16 screws.

All plates were inserted in the zygomatic buttress and piriform rim. Age, sex distribution, incidence, and causes for plate removal were recorded during this period. They were followed 1 to 5 years for plate complications and indications for plate removal.

RESULTS

Fifteen of 142 patients (10.6%), 9 females and 6 males, required plate removal. The minimum time period between insertion and removal was 4 months and the maximum period was 18 months. Causes for removal were infection (40%), pain (13.3%), sinusitis (13.3%), sensitivity to temperature change (13.3%), palpability of plate (13.3%), and phobia (6.8%).

The mean age of patients was 21 years (range = 18–32 years). In 15 patients (10.6%), 1 or more plates were removed. Of these patients who had plates removed, 9 (60%) were female (mean age = 24 years) and 6 (40%) were male (mean age = 25 years). Time interval between plate insertion and removal was 13.5 months (ranging from 4 to 18 month; Fig 1).

Figure 1. Time interval between plate insertion and removal.

The major causes for removal were as follows: infection due to wound dehiscence's and exposure of the plate in the oral cavity (6 patients, 40%), pain (2 patients, 13.3%), sinusitis (2 patients, 13.3%), sensitivity to temperature change (2 patients, 13.3%), palpability of the plate (2 patients, 13.3%), and patient phobia in asymptomatic patients (1 patient, 6.8%), as shown in Figure 2.

Figure 2. Reasons for plate removal.

DISCUSSION

During the last 2 decades, plates and screws for rigid fixation in Le Fort I osteotomy has become routine in the treatment of dentofacial deformities worldwide. Rigid fixation with plates and screws, however, is not without complications (infection, pain, dehiscence, etc). The controversy regarding retention of asymptomatic bone plates used for orthognathic surgery is ongoing. Many centers1,10,11 have advocated the routine removal of miniplates, whereas in other centers,12,13 they are routinely left in place. This study indicated several causes for plate removal, such as infection, plate loosening, palpability, temperature sensitivity, sinusitis, pain, and patient request (without clinical symptoms). We opted to focus only on Le Fort I osteotomy patients because the maxilla is immobile.

In this study, the patients were mostly young (mean age = 21 years) and healthy women (63%). In the current study, 10.6% of plates inserted were removed. Several article analyzed the rates of plate removal in a study made up of both orthognathic and trauma patients, and a few analyzed the rates of plate removal in orthognathic surgery, especially Le Fort I osteotomy alone. Bruzual14 in a study reported a lower plate removal rate (7%). In another study, Manor and Chaush15 found that 12% of plates inserted were removed.

The postoperative time of plate removal is controversial in the literature. In this series, the average interval between plate insertion and removal was 13.5 months. According to Mosbah et al,12 most plates were removed in trauma patients within 6 months following treatment, whereas Francel et al9 and Bakathir et al16 founded this rate was 9.4 and 11.5 months, respectively. In our study, time interval between plate insertion and removal was longer than the other studies; this may be because trauma patients have various types and severity of injury, soft-tissue coverage, contamination, etc.

In this study, infection was the major cause of plate removal (40%). Bhatt et al13 and Rallis et al17 founded that the chief cause for plate removal was infection (50% and 46%). This low infection rate was similar to our study.

In Le Fort I osteotomy, continuity of sinus mucosa is disturbed, the sinus is entered, and possibility of maxillary sinusitis is increased. Kahnberg and Engstrom7 demonstrated that in 44 patients who had Le Fort I osteotomies with wire osteosynthesis, 90% of patients had sinus mucositis after surgery. After 6 month, 50% of patients showed bilateral sinus inflammation. In our study, only 2 patients had continual sinusitis and, for this reason, fixation hardware had to be removed. After removal, sinusitis resolved.

Thermal sensitivity was another complication that was reported. Thermal sensitivity commonly accompanied pain. Alpert and Seligson10 showed that thermal sensitivity was a seasonal complication and had unknown cause. In this study, 2 patients presented with this problem and both of them were cured after plate removal.

Several authors reported vague pain after surgery. Mosbah et al12 reported the rate of pain of 14%, whereas Bhatt et al13 reported pain in 24%. Our result showed pain to be the cause of plate removal in 2 patients (13.3%).

Palpable plates are among one of the reasons for plate removal; in this study, 2 patients (13.3%) had plates removed for this reason. Rallis et al17 reported 19% of plates removal for this reason, whereas Bhatt et al13 reported an 11% rate.

CONCLUSION

On the basis of this study, the number of miniplates removed was small and required removal no sooner than 4 months postoperatively (after complete bony union), thus not compromising healing. There is no evidence from this study to support the routine removal of titanium miniplate after Le Fort I osteotomy, rather they should be removed when indicated.

REFERENCES

1. Champy M, Loddé JP, Schmitt R, Jaeger JH, Muster D. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg. 1978;6(1):14–21.

2. Horster W. Experience with functionally stable plate osteosynthesis after forward displacement of the upper jaw. J Maxillofac Surg. 1980;8(3):176–81.

3. Steinhauser EW. Bone screws and plates in orthognathic surgery. Int J Oral Surg. 1982;11(4):209–16.

4. Wardrop WD, Wolford LM. Maxillary stability following downgraft and/or advancement procedures with stabilization using rigid fixation and porous block hydroxyapatite implants. J Oral Maxillofac Surg. 1989;47(4):336–42.

5. Jackson IT, Somers PC, KJar JG. The use of Champy miniplates for osteosynthesis in craniofacial deformities and trauma. J Plast Reconstr Surg. 1986;77(5):729–36.

6. Brown JS, Trotter M, Cliff 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(4):306–15.

7. Kahnberg KE, Engstrom H. Recovery of maxillary sinus and tooth sensibility after Le Fort I osteotomy. Br J Oral Maxillofac Surg. 1987;25(1):68–73.

8. Beals SP, Munro IR. The use of miniplates in craniomaxillofacial surgery. J Plast Reconstr Surg. 1987;79(1):33–8.

9. Francel TJ, Birely BC, Ringelman PR, Manson PN. The fate of plates and screws after facial fracture reconstruction. J Plast Reconstr Surg. 1992;90(4):568–73.

10. Alpert B, Seligson D. Removal of asymptomatic bone plates used for orthognathic surgery and facial fractures. J Oral Maxillofac Surg. 1996;54(5):618-21.

11. Cawood JI. Small plate osteosynthesis of mandibular fractures. J Oral Maxillofac Surg. 1985;23:77–91.

12. Mosbah MR, Oloyede D, Koppel DA, Moos KF, Stenhouse D. Miniplate removal in trauma and orthognathic surgery—a retrospective study. Int J Oral Maxillofac Surg. 2003;32(2):148–51.

13. Bhatt V, Chhabra P, Dover M. Removal of miniplates in maxillofacial surgery: a follow-up study. J Oral Maxillofac Surg. 2005;63(6):756–60.

14. Bruzual LM. Rigid fixation following Le Fort I osteotomy [abstract]. J Oral Maxillofac Surg. 1996;54(suppl 3):99.

15. Manor Y, Chaush G. Risk factor contributing to symptomatic plate removal in orthognathic surgery patients. J Oral Maxillofac Surg. 1999;57:679–82.

16. Bakathir AA, Margasahayam MV, Mohammad Al-Ismaily. Removal of bone plate in patients with maxillofacial trauma. J Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105(5):32–7.

17. Rallis G, Mourouzis C, Papakosta V, Papanastasiou G, Zachariades N. Reasons for miniplate removal following maxillofacial trauma: a 4-year study. J Craniomaxillofac Surg. 2006;34(7):435–9.

JOURNAL INFORMATION ARTICLE INFORMATION
Journal ID: ePlasty Volume: 9
ISSN: 1937-5719 E-location ID: e45
Publisher: Open Science Company, LLC

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