With regard to the letter of Tong and Shan, we agree about the potential for plate exposure through the skin. Nonetheless this event has not occurred to date, with the first patient we operated on using this technique now at the end of the third year of follow-up. In any case, if plate exposure occurs, the patient can be treated with a simple plate removal.
We have not observed fistulas either. On the contrary, we removed fistulas in three cases and used a platysma flap to cover the communication left in order to properly isolate the plate; no recurrence of the fistula has been observed to date in these cases (maximum follow-up time: 2 years).
Drilling into the non-necrotic bone may potentially expand the necrosis; again this has not yet been observed.
Regarding the concern for the onset of Ludwig’s angina, the suggested resection of the necrotic bone with immediate closure of the intraoral wound – a good option in the case of bone resection without plate reconstruction – would certainly provide a better condition for bone healing, but would also expose the patient to a higher risk of Ludwig’s angina than an open wound situation.
Resection alone without reconstruction leads to disfigurement of the lower third of the face and loss of occlusion in teeth-bearing patients. Feeding is possible but surely more difficult. Those problems are avoided by utilizing a reconstructive plate as suggested in our article .