A call for fixed standards: a decade of orthognathic surgery, biting into revision rates and metalwork removal

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.