British Journal of Oral and Maxillofacial Surgery (1999) 37, 110–112

© 1999 The British Association of Oral and Maxillofacial Surgeons

BRITISH JOURNAL OF ORAL & M A X I L L O FA C I A L S U R G E RY

Policy of consultant oral and maxillofacial surgeons towards removal of

miniplate components after jaw fracture fixation: pilot study

I. R. Matthew, J. W. Frame
Department of Oral Surgery, University of Birmingham, School of Dentistry, Birmingham, UK

SUMMARY. A pilot study was undertaken to find out the policy of the 23 consultant oral and maxillofacial
surgeons in the West Midlands towards removal of miniplates after jaw fractures had healed. All 23 replied. Two
consultants did not use miniplates; the other 21 respondents used titanium systems, and two also used a stainless
steel system. None of the 21 respondents routinely removed all miniplates. The estimated total of miniplates
removed after the fracture had healed ranged between 5% and 40% (mode 5%). The main indications for removal
were wound infection or dehiscence, before construction of a prosthesis, patients’ concern about permanent retention
of an implant, and thermal conductivity. We conclude that miniplates and screws are removed mainly to treat
symptoms caused by the implants.

INTRODUCTION RESULTS

There has been uncertainty in the past about the
need to remove miniplates and screws routinely fol-
lowing satisfactory healing of jaw fractures.
Cawood1 recommended routine removal of stainless
steel miniplates after 3 months to avoid the plate
interfering with jaw function. In a retrospective
study of 279 Champy miniplates used routinely as
permanent implants, Brown et al.2 challenged the
practice of routine removal of stainless steel mini-
plates 3 or 4 months after insertion. Iizuka and
Lindqvist3 routinely removed stainless steel plates
about a year postoperatively because there were no
grounds for leaving a foreign metal object in situ
after the bone had healed. Moberg et al.4 advised
removal of nickel-chromium and cobalt-chromium
alloy implants after satisfactory healing, because
metal elements released from the surface could
induce allergic sensitization. It has, however, been
suggested that titanium and titanium alloys are suit-
able for use as permanent maxillofacial implants
because their biocompatibility is superior to that of
stainless steel.5,6 Rosenberg et al.7 removed titanium
miniplates only if the patient had symptoms, or if
they became infected or the wound broke down.
Anecdotal evidence from audit data suggested that
miniplate components are not removed routinely in
the West Midlands. The principal aim of this prelimi-
nary study was to establish the policy of consultant
oral and maxillofacial surgeons who use miniplating
systems towards removal of the components after jaw
fractures had healed. Other aims were to analyse fac-
tors that influenced the choice of miniplating system
and the decision to remove non-functional miniplate
components after the fracture had healed. The study
was undertaken by postal questionnaire that was sent
to the 23 consultants in oral and maxillofacial surgery
in the West Midlands.
All 23 questionnaires were returned. Two consultants
did not use miniplates, while the other 21 respondents
used titanium plates; two (10%) also used stainless
steel plates. Systems from nine different manufactur-
ers were used. Seventeen consultants (81%) had access
to more than one titanium miniplating kit. The
Martin titanium miniplating system (Gebrüder
Martin GmbH & Co, Tuttlingen, Germany) was the
most commonly used, by 15 (71%) of consultants.
Ease of use was the most important factor that
influenced the choice of plating system for all the
respondents. The cost of components was the second
most common factor for 18 consultants (86%). Choice
was also influenced by the quality of service from the
supplier for 15 (71%), biocompatibility of the
implants and their suitability for permanent retention
(n = 9, 43%), and free loan of the instrument toolkits
(n = 2, 10%).
None of the consultants reviewed patients indef-
initely, and the mean period for follow-up was 12
weeks (range 4–32). None of the respondents rou-
tinely removed all miniplates and screws. The mean
total of implants removed was 13% (range 5–40%;
mode 5%). The reasons given for removal of miniplate
components are shown in the Table. The timing of
removal of miniplates and screws was influenced
mainly by either the onset of signs and symptoms
from the implant site, or by a request from the patient
for removal. Clinical evidence of satisfactory union
was an important prerequisite.
Nine respondents (43%) used temporary maxillo-
mandibular fixation routinely to immobilize fractures
before fixation of miniplates. The arch bars, buttons, or
interdental wires were removed after a mean period of
5 weeks (range 2–8; mode 4). One respondent removed
the temporary fixation devices 2 weeks after removal of
the maxillomandibular fixation. Two consultants

110

Table – The indications cited by the 21 respondents for removal of miniplate components after the fracture had healed
Indication
Wound infection
Wound dehiscence – exposed implant
Before insertion of a prosthesis
Patient concerned about the presence of a retained implant (psychological reasons)
Thermal conductivity
Late removal of a tooth from the site of a fracture
Before insertion of endosseous implants
Before a secondary procedure, such as follow-up imaging, rhinoplasty or further resection
Tenderness on palpation over the site of an implant
Persistent paraesthesia because screws were too close to major nerve branches
removed the fixtures immediately if there was no sub-
condylar fracture; one stated that removal was delayed
if there was doubt about the adequacy of fixation, if
there was any likelihood of further injury during the
healing phase, or if the patient was likely to miss fol-
low-up appointments. If a screw fractured during inser-
tion or retrieval, 18 respondents (86%) would leave the
fractured piece of screw in situ, and 2 (10%) would
remove the fractured portion. One consultant had no
experience of screw fracture, but noted that retrieval of
all screws was usually possible, including those dam-
aged during insertion or retrieval.
DISCUSSION
The results of this study suggest that removal of mini-
plates and screws in the West Midlands is undertaken
mainly to treat symptoms caused by the implants.
Retrieval of all components may be impractical for all
patients as surgical access may be restricted – for
example, in the middle third of the face or base of
skull. Furthermore, the possible complications associ-
ated with their removal and the costs incurred in
removal may not justify the benefits derived. These
arguments lend support to the view that implants that
have not caused symptoms may be permanently
retained. However, most plates are accessible and may
easily be removed subsequently if a complication
develops.2
The ease of use, cost of components and the qual-
ity of service provided by the supplier were important
influences on the choice of a miniplating system. In
view of the numbers of miniplates left in place, fewer
consultants than expected (n = 9, 43%) were influ-
enced by the biocompatibility of the implants and
their suitability for permanent retention.
Almost 40 years ago, Scales et al.8 recommended
that all stainless steel orthopaedic appliances should
be removed, because it was impossible to assess the
extent of corrosion from an implant that might be
harmful to the host. The quality of modern implant
materials has improved, but metal is still released into
the tissues from stainless steel and titanium miniplate
components.4,7 Nevertheless, titanium is relatively
resistant to the uniform corrosion, pitting attack, and
crevice corrosion associated with stainless steel
implants.9 Corrosion resistance is a prerequisite of bio-
compatibility, but does not necessarily guarantee it.10
Policy on removal of miniplates after jaw fracture fixation 111
Number (%) of mentions
20 (95)
12 (57)
10 (48)
4 (19)
4 (19)
3 (14)
3 (14)
2 (10)
1 (5)
1 (5)
Titanium is also widely used for implants because
it is thought to confer a state of biological inactivity,
or ‘biological indifference’.10 However, metallic frag-
ments released from the implants into adjacent tis-
sues may stimulate a sustained mild or moderate
chronic inflammatory response.11 Metal ions released
from an implant may act as haptens and, after cou-
pling to tissue components, may cause cell-mediated
immune reactions.12 Although allergic sensitization
to titanium has been reported, the incidence seems to
be low.13
One respondent noted that bone occasionally
forms over titanium or stainless steel miniplates, mak-
ing their removal difficult or even impossible.
Conversely, some screws and plates are found to be
loose on retrieval. There does not seem to be any
causal relationship between loose screws or plates and
intraoperative events. A possible explanation for an
implant loosening may be the local effect of cytokines
or proteolytic enzymes that are capable of inducing
bone resorption, and are produced by activated
macrophages after exposure to particulate metal
debris at the bone-implant interface.14 This is thought
to be the mechanism responsible for aseptic loosening
of total joint replacements. However, Torgersen et
al.15 emphasized that the tissue reaction seen in soft
tissues retrieved after healing of jaw fractures is
milder than that seen in failed orthopaedic implants.
Thermal damage may occur even during careful
drilling of the screw hole, and may eventually lead to
the screw loosening by aseptic necrosis.16
Mini-plates are removed in the West Midlands to
treat clinical symptoms caused by the implants; oth-
erwise they are left in place. This is in line with the
recent (1991) recommendations of the Strasbourg
Osteosynthesis Research Group that the removal of
non-functioning titanium plates is desirable only if
the procedure to remove the plate does not cause any
undue risk to the patient. Clinicians may think that
the risk of an additional general anaesthetic to
remove the plate outweighs the disadvantages of
leaving it in place (Ward-Booth RP, personal com-
munication, 1997).
Titanium is favoured as an implant material
because of its biological compatibility. Although it is
intrinsically safe,10 our knowledge of the long-term
tissue response remains incomplete, suggesting the
need to maintain a cautious approach to its use as
a permanent implant.17,18 It may be advisable to
112 British Journal of Oral and Maxillofacial Surgery
consider recording the batch numbers of the plates
and screws in the patient’s hospital records, in the
same way as for titanium osseointegrated implants.
This information may be useful in the future if there
are complications or concerns about its components.
Acknowledgements
We thank the consultants in oral and maxillofacial surgery in the
West Midlands for taking part in this preliminary survey.
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The Authors
I. R. Matthew MDentSc, BDS, FDSRCS
Lecturer in Oral Surgery
J. W. Frame PhD, BDS, FDSRCS
Professor of Oral Surgery
The University of Birmingham
School of Dentistry
St. Chad’s Queensway
Birmingham B4 6NN
UK
Correspondence and requests for offprints to: Mr I. R. Matthew
Paper received 28 July 1997
Accepted 18 August 1997