Abstract
The removal rate of titanium miniplates following orthognathic surgery varies widely (3.2–27.5%) due to inconsistent study designs and mixed samples. Plate removal is not routinely conducted in the UK. A 2019–2020 meta-analysis reported a 13.4% removal rate, though regular audits are uncommon. This study evaluates whether audit of local plate removal rates against established benchmarks merits encouragement. A retrospective review was conducted of orthognathic surgery at a tertiary centre (2014–2024). Procedures included Le Fort osteotomy, bilateral sagittal split osteotomy (BSSO), bimaxillary osteotomy (BIMAX), genioplasty, and other mandibular osteotomies. All patients received two postoperative doses of dexamethasone and intravenous antibiotics. Data collected included demographics, smoking status, surgical site, re-plating, and antibiotic use. The primary outcome was return to theatre (RTT) for plate removal or replacement. Chi squared, Fisher’s exact, and binomial tests were used to assess statistical significance. Over 10 years, 417 patients underwent 429 orthognathic procedures, including 12 revisions to achieve the desired skeletal and orthodontic outcome. Overall, metalwork removal/adjustment occurred in 46 cases, predominantly within the first year, with infection identified as the leading cause. The removal rate was 10.7% (46/429), consistent with the 13.4% benchmark (p = 0.12). Yearly rates generally aligned with the benchmark, except in 2021, when deviations were likely to have been influenced by COVID-19-related disruptions. Smoking (p = 1.0) and oral antibiotics on discharge (p = 0.09) were not significantly associated with plate removal rates. These findings validate the 13.4% benchmark for metalwork removal. Routine audit and inter-unit collaboration are vital for refining benchmarks and improving patient care.
Introduction
Titanium miniplates are the standard for internal fixation in orthognathic surgery due to their biocompatibility, strength, and stability. Although intended to remain in situ, removal is sometimes required, most commonly for infection, exposure, discomfort, or relapse. Reported removal rates range from 3.2% to 27.5%, reflecting variation in case mix, fixation systems, follow-up duration, and outcome definitions.
In a systematic review and meta-analysis of 19 studies including large UK cohorts (for example, Widar et al), Gómez-Barrachina et al reported an overall patient-level removal rate of 13.4%, proposed as an audit benchmark. However, substantial heterogeneity, particularly in indications for removal and follow up, limits its precision for UK service benchmarking; no pooled UK-specific benchmark currently exists. The 13.4% estimate therefore provides useful context but requires cautious application in UK service evaluation and governance.
The 2013 UK Commissioning Guide for Orthognathic Procedures identifies hardware removal as a postoperative complication, but captures it only through local audit without national benchmarking or central reporting. This contributes to variable practice, inconsistent patient counselling, and limited understanding of modifiable risk factors. Revision surgery also consumes theatre capacity, increases morbidity, and adds financial pressure, complicating service planning.
This 10-year review of orthognathic procedures at a high-volume UK tertiary centre provides robust longitudinal data to evaluate the applicability of the 13.4% benchmark within a UK context. By analysing local removal rates, temporal trends, and contributory factors, it demonstrates how routine audit can strengthen governance, inform service planning, and support the development of national standards. ,
Methods
A retrospective review was conducted of all orthognathic surgeries performed at a UK tertiary centre between January 2014 and January 2024, including Le Fort I osteotomy, bilateral sagittal split osteotomy (BSSO), bimaxillary (BIMAX) surgery, genioplasty, and other mandibular osteotomies. Procedures were consultant-led with trainee involvement, reflecting the unit’s role as a recognised training centre. Planned revisions for occlusal or skeletal optimisation were included, and the review was registered as a service evaluation in accordance with institutional requirements.
Rigid internal fixation used low-profile, off-the-shelf titanium plates (Synthes/Synthes Matrix; commercially pure titanium, ASTM F67 Grade 2). No patient-specific or custom-manufactured systems were used. Mandibular fixation typically comprised two 0.8 mm L-shaped plates with monocortical screws (5–6 mm), with alternative plates used selectively for complex splits. Maxillary fixation usually involved three to four 0.7–0.8 mm plates at the piriform rim and zygomaticomaxillary buttresses.
Perioperative care comprised two postoperative intravenous dexamethasone doses and prophylactic intravenous antibiotics, with oral antibiotics prescribed at discharge at the surgeon’s discretion.
Electronic records, operative notes, and radiographs provided demographics, smoking status, surgical site(s), and outcomes. The primary outcome was return to theatre (RTT) for titanium plate/screw removal or replacement. Exclusions were RTT for wire removal only, surgically-assisted rapid palatal expansion (SARPE)-only procedures, or cases under local anaesthetic.
Indications for metalwork removal were classified from contemporaneous clinical documentation as infection, discomfort, unintended aesthetic outcomes, unmet occlusal or skeletal goals, interference with planned surgery, reactive tissue or cystic changes, or hardware failure. Failed metalwork was defined as mechanical or functional fixation failure requiring removal or revision (for example, plate or screw loosening, migration, deformation, or exposure), excluding infection-related removal. Interference with planned surgery referred to hardware impeding access to revision or optimisation procedures (for example, within the surgical field of septorhinoplasty), while unintended aesthetic outcomes described hardware-related contour changes (for example, nasal flaring) and unmet occlusal or skeletal outcomes denoted clinically significant relapse or occlusal change.
Plate removal rates were calculated at the procedure level, defined as RTT for plate and/or screw removal or adjustment rather than per individual plate. Descriptive statistics summarised patient characteristics and removal rates. Categorical associations were assessed using chi squared or Fisher’s exact tests. A binomial test compared the observed removal rate with the 13.4% benchmark reported by Gómez-Barrachina et al (p < 0.05 = significant; p > 0.05 = aligned). IBM SPSS Statistics for Windows version 26 (IBM Corp) was used for all analyses.
Results
Patient demographics and overall return to theatre rate
Between January 2014 and January 2024, 417 patients underwent 429 orthognathic procedures, including 12 planned revisions for skeletal/occlusal optimisation. Forty-six procedures (10.7%) required RTT for metalwork removal or adjustment, typically involving both plates and screws. In one case, only screws were removed due to complete plate osseointegration; in two cases, plates were recontoured or partially sectioned, and were retained in the analysis.
The cohort included 217 females and 200 males; RTT occurred in 22 females (10.1%) and 19 males (9.5%) (OR: 1.07, 95% CI: 0.55 to 2.09, p = 0.87).
By age, most cases were 18–24 years old (n = 22/251), with the highest proportional rate in those aged 35–44 years (n = 2/22). Three of 124 cases occurred in the 25–34-year age group; none in those under 18 years (n = 8) or aged 45–54 years (n = 8). No patients aged ≥55 years underwent orthognathic surgery. Age band analysis showed no significant association (p = 0.21), but grouping into age <25 versus ≥25 years showed a higher removal risk in younger patients (OR = 2.84, p = 0.04).
Of 76 patients with cleft lip and/or palate, five underwent removal versus 36/341 non-cleft patients (OR = 0.60, p = 0.40).
Return to theatre (RTT): frequency, timing, and indications
A total of 46 RTT procedures were performed: 37 patients underwent one, three patients two, and one patient three. This yielded 41 first returns (RTT1), four second returns (RTT2), and one third return (RTT3); no patient exceeded three.
For RTT1 ( Table 1 ), most occurred within 24 months, peaking at 7–12 months (n = 11). Early returns (<6 months) accounted for eight cases, with a smaller peak at 25–36 months (n = 6); five occurred after 36 months. Stratification by follow-up interval ( Fig. 1 ) showed that at the 7–12-month peak (n = 11), infection (n = 5) and discomfort (n = 5) predominated. Of the four RTT2, three occurred at 7–12 months and one at >60 months; the single RTT3 occurred at 61 months for persistent discomfort.
Table 1
Timing of first return to theatre (RTT1). Data are number of patients.
| Months postoperatively | Frequency |
|---|---|
| 0–1 | 2 |
| 2–3 | 2 |
| 4–6 | 4 |
| 7–12 | 11 |
| 13–18 | 8 |
| 19–24 | 3 |
| 25–36 | 6 |
| 37–48 | 1 |
| 49–60 | 2 |
| >60 | 2 |
| Total | 41 |
Timing of metalwork removal (months) or adjustment causes at first return to theatre (RTT1). Cases are stratified by postoperative interval. Infection and discomfort predominated at the 7–12-month peak. Multiple causes could be recorded for a single case. RTT1 = first return to theatre.
Across all RTTs, 59 indications were recorded, with 13 patients having multiple reasons ( Table 2 ). Infection was most common (n = 21), followed by discomfort (n = 12), failed metalwork (n = 12), and occlusal/skeletal issues (n = 6). Less frequent were interference with planned surgery (n = 3), reactive/cystic changes (n = 2), and unintended aesthetic outcomes (n = 2). One patient requested removal without clinical indication due to neurodiversity. Later-stage RTTs were rare and typically linked to persistent symptoms or patient-specific factors.
Table 2
Reasons for metalwork removal or adjustment by type of return to theatre (RTT). Data are number of cases.
| Reason | RTT1 (first return) | RTT2 (second return) | RTT3 (third return) |
|---|---|---|---|
| Infection | 19 | 2 | 0 |
| Discomfort | 11 | 0 | 1 |
| Unintended facial aesthetic outcomes | 2 | 0 | 0 |
| Occlusal/skeletal issues | 5 | 1 | 0 |
| Plate in field of additional surgery | 2 | 1 | 0 |
| Reactive/cystic changes to plate | 1 | 1 | 0 |
| Failed metalwork | 10 | 2 | 0 |
| Patient request (not indicated) | 1 | 0 | 0 |
| Total | 51 | 7 | 1 |
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