Do Custom Titanium plates eliminate relapse?

[Ivano95]

Hello,

im undergoing a 1 cm bimaxillary advancement in a few weeks, but have faced a major contradictory point and really need some advice.

I have 2 options for surgery. one is to use custom titanium plates and ones to use normal screws and plates.

Id like to know if the following statements iv been told are true or not. since each surgeon would have their own bias.

CUSTOM TITANIUM:

PROS:
Zero relapse, Very accurate.

Removal of plates after 6 months.

CONS:
very large pieces of titanium. Would have to cut out soft tissue for placement.

No room for changing the surgical plan once everything is built. For example, if during the surgery, the plan that was intended would give you a weird mouth position/shape, you would have absolutely no room for augmenting the plates. This is very bad for specific cosmetic preferences. Technology cant predict soft tissue yet.

Results are always mediocre/good. Never bad, but rarely great.



NORMAL PLATES

PROS:
Highly flexible surgical plan, in terms of what I just explained in the cons of the custom titanium plates.

CONS:
Relapse could be very likely in my case which is 1cm of advancement. But the surgeon has told me that with proper bone graft to the cut sites and splinting there really isn't much risk of relapse.



The only major breaking point for me would of course be relapse. The doctors who do normal plates have told me that the claim that custom titanium would have no relapse is utterly false. But the surgeon who does custom titanium claims, ''Zero relapse''.


If custom titanium wouldn't have relapse, then the aesthetic points go out of the window. But if the relapse is the same, then id definitely go with normal plates for maximum aesthetic benefits.

Putting these complications aside, Custom titanium plates would cost around 30-40k. and that's only the hardware. So paying this much for something that wouldn't absolutely eliminate relapse isn't a smart move.


If anyone has any info on this, Please let me know. I really don't want to regret this decision.

Thanks in advance.

[kavan]

Seems to me that keeping the plates in should cut down on relapse and the only reason to remove plates would be infection or extrusion (as in showing through or causing pain later down the line due to too much metal in them.) So, seems to me, one might be more likely to want to remove the custom ones later down the line than the smaller ones.

You also mention doctorS (as in PLURAL of more that one doctor) have told you a 'no relapse' claim for the customs is a false claim. So your question reduces to one of should you believe the doctorS (plural, more than one) who contend it's a false claim or the ONE doctor who contents his claim is true.

Now, I'm no expert in knowing technical details as to relapse as a function of custom vs normal, but personally, if I were making a choice as to WHICH expert/s to DEFER to as in the  the ONE doctor who contends 'no relapse' with customs vs. the NUMBER of doctors who contend that the statement is FALSE, I would want to make DAMN SURE the one contending 'no relapse' had a history of good ethics in relaying information before I defered to him over the NUMBER of others who told you his contention was false. This is especially so if the situation is something where he GAINS more income via the claim he's giving to you.

[Ivano95]

Seems to me that keeping the plates in should cut down on relapse and the only reason to remove plates would be infection or extrusion (as in showing through or causing pain later down the line due to too much metal in them.) So, seems to me, one might be more likely to want to remove the custom ones later down the line than the smaller ones.

You also mention doctorS (as in PLURAL of more that one doctor) have told you a 'no relapse' claim for the customs is a false claim. So your question reduces to one of should you believe the doctorS (plural, more than one) who contend it's a false claim or the ONE doctor who contents his claim is true.

Now, I'm no expert in knowing technical details as to relapse as a function of custom vs normal, but personally, if I were making a choice as to WHICH expert/s to DEFER to as in the  the ONE doctor who contends 'no relapse' with customs vs. the NUMBER of doctors who contend that the statement is FALSE, I would want to make d*mn SURE the one contending 'no relapse' had a history of good ethics in relaying information before I defered to him over the NUMBER of others who told you his contention was false. This is especially so if the situation is something where he GAINS more income via the claim he's giving to you.

Thank you for responding kavan,

The only issue that I have in this whole situation, would be that, I wouldn't expect a doctor to openly lie about such a huge claim. Relapse is very common and fairly inevitable, And claiming to eliminate that, would be ground breaking I assume.

Im trying to reach out to every surgeon mentioned on this board to fact check this claim, But they themselves could even have their own bias of using normal plates.

Do you know Why custom titanium plates are used instead of normal plates and screws?

[kavan]

Thank you for responding kavan,

The only issue that I have in this whole situation, would be that, I wouldn't expect a doctor to openly lie about such a huge claim. Relapse is very common and fairly inevitable, And claiming to eliminate that, would be ground breaking I assume.

Im trying to reach out to every surgeon mentioned on this board to fact check this claim, But they themselves could even have their own bias of using normal plates.

Do you know Why custom titanium plates are used instead of normal plates and screws?

They are used when precise exactness is needed in situations where there would be NO 'wiggle room' at all. But that ASSUMES the doctor needing to use them is honest and has no rep as a scam artist. End of story.

[april]

Honestly, if it were me and I was going to be paying $30-40k just for custom plates alone, I would use the normal plates.

I've been looking into custom plates too and came across this paper which sort of gives an overview of sorts. There also seems to many different 'systems' out there and some are machine-cut, some are 3d printed. From what I gather from here some other benefits are: better control over vertical movement, no errors introduced by wonky condyles, the ability to place screws over areas of best-quality bone, no plate bending and less surgery time.

http://orthofacial.es/wp-content/uploads/2017/09/custom-machined-miniplates.pdf

There's alot in the article but this is where they mention that in large advancements custom plates alone cannot offer perfect stability.

"Achieving stability of the fragments that have undergone osteotomy and avoiding relapse are the next goals. The rigid fixation has shown its advantages over other osteosynthesis systems, being necessary when lowering movements of the maxilla are performed or in great maxillary advancements. The OPS considers such stability by fabricating the miniplates from highly rigid grade 5 titanium machined from a titanium block and fixating them to good quality bone on the anterior midfacial buttress. The custom miniplates are machined to perfectly fit to the surface of the midfacial bone with no need for molding, which would compromise their properties. In theory, these advances should improve on conventional osteosynthesis systems. However, in light of our study’s results, it is evident that, by themselves, they are not enough to provide perfect stability, especially when operating near the limits of skeletal movement, such as in cases of great advancements for OSA. In these severe cases, it is highly likely that early adaptive changes occur, especially at the dentoalveolar level, prompted by the surgical intervention itself. Thus it is not surprising that morphologic changes occur between the time of surgery and the time of postoperative CT. Several factors can play an important role in the early postoperative period, and these will influence final outcomes. Examples include the bone quality, the stability of the achieved occlusion, neuromuscular adaptation or secondary elastic therapy, and temporomandibular joint stability. Improving our knowledge of these factors and their destabilizing effects might represent one of the greatest challenges in OGS"

They also had normal miniplates available as backup. Not sure if that's standard, but you'd hope so!

"During surgery, maxillomandibular occlusal splints and an osteosynthesis system with conventional miniplates were available, in case we were unable to use the custom OPS."

[Ivano95]

Honestly, if it were me and I was going to be paying $30-40k just for custom plates alone, I would use the normal plates.

I've been looking into custom plates too and came across this paper which sort of gives an overview of sorts. There also seems to many different 'systems' out there and some are machine-cut, some are 3d printed. From what I gather from here some benefits are: better control over vertical movement, no errors introduced by wonky condyles, the ability to place screws over areas of best-quality bone, and less surgery time.

http://orthofacial.es/wp-content/uploads/2017/09/custom-machined-miniplates.pdf

There's alot in the article but this is where they mention that in large advancements custom plates alone cannot offer perfect stability.

"Achieving stability of the fragments that have undergone osteotomy and avoiding relapse are the next goals. The rigid fixation has shown its advantages over other osteosynthesis systems, being necessary when lowering movements of the maxilla are performed or in great maxillary advancements. The OPS considers such stability by fabricating the miniplates from highly rigid grade 5 titanium machined from a titanium block and fixating them to good quality bone on the anterior midfacial buttress. The custom miniplates are machined to perfectly fit to the surface of the midfacial bone with no need for molding, which would compromise their properties. In theory, these advances should improve on conventional osteosynthesis systems. However, in light of our study’s results, it is evident that, by themselves, they are not enough to provide perfect stability, especially when operating near the limits of skeletal movement, such as in cases of great advancements for OSA. In these severe cases, it is highly likely that early adaptive changes occur, especially at the dentoalveolar level, prompted by the surgical intervention itself. Thus it is not surprising that morphologic changes occur between the time of surgery and the time of postoperative CT. Several factors can play an important role in the early postoperative period, and these will influence final outcomes. Examples include the bone quality, the stability of the achieved occlusion, neuromuscular adaptation or secondary elastic therapy, and temporomandibular joint stability. Improving our knowledge of these factors and their destabilizing effects might represent one of the greatest challenges in OGS"

They also had normal miniplates available as backup. Not sure if that's standard, but you'd hope so!

"During surgery, maxillomandibular occlusal splints and an osteosynthesis system with conventional miniplates were available, in case we were unable to use the custom OPS."

Thank you so much for sharing this information!

Im slowly coming to this conclusion that these plates really aren't worth it. Accuracy is great, but it may be an aesthetic downside itself.

I might get some orbit/zygo work done in the future and if the plates were to stay in, I don't think that would be possible(they extend up to the infraorbital rims).

if my surgeon was not going to remove the plates afterwards, id just change my surgeon right now. Im also having a relatively huge advancement as well. its all very tempting and too good to be true. Get the surgery done, 1cm, take the plates out, no relapse, minimal nerve damage. im calling BS.

Im going to ask him for some kind of written reassurance and if he is confident enough to do that, then ill go with him. If hes trying to sell magic beans, with all the evidence going against him, im backing out asap.

[april]

Is the 6-month removal with this surgeon for both types of plates or just custom?

[Ivano95]

Is the 6-month removal with this surgeon for both types of plates or just custom?

he said that takes out both normal and custom plates at 6 months, and that normal plates always have some degree of relapse (the greater the advancement, the greater the relapse) but custom titanium ones never do.

[PloskoPlus]

Having the thickest stiffest plates won't help if the screws migrate together with the plates through the bone.

[Ivano95]

Having the thickest stiffest plates won't help if the screws migrate together with the plates through the bone.

Im not really sure what this means. Could you explain a bit?

btw, they're custom titanium plates and screws if it matters.

[april]

Having the thickest stiffest plates won't help if the screws migrate together with the plates through the bone.

Plates through the bone. How often does this happen? Would it be considered rare?

[kavan]

Plosko might be referring to what I referred to which is extrusion, something where because the plates are LARGE, they could be more likely to irritate the soft tissue covering them and 'extrude'/espose through so that they cause pain such as a lot of sensitivity to cold. That or they could irritate the bone where the bone starts covering up the plates making them more problematic to remove. Can't speak for him other than to say that having a LARGER (custom) plate in there is more likely to irritate in some way than a smaller one.

Besides all the particulars of this could be a MOOT POINT if one has established they don't 'need' the large customs in the first place and because the purported 'need' was based on false information that they 'eliminate relapse'.