How Jaw Surgery Plates and Screws Work and Are Removed

Plates and screws used in jaw surgery are small pieces of metal or polymer fastened directly to bone to hold the repositioned segments in place while they heal. Most are made of titanium, which is lightweight, strong, and well tolerated by the body. Once installed, they are designed to stay permanently in most adult patients, though removal happens in a meaningful minority of cases for reasons ranging from infection to simple discomfort. Understanding what these fixation devices are made of, how they behave inside your body over time, and when they might need to come out can take a lot of the mystery out of the post-surgical experience.

What the Hardware Actually Does

When a surgeon cuts and repositions your jawbone during orthognathic surgery or fracture repair, the newly positioned bone segments need to be held rigidly while they fuse. That is the job of internal fixation hardware. Small titanium plates, usually a few centimeters long with pre-drilled screw holes, are contoured to the bone surface and secured with screws that grip into the bone. The rigidity matters because even small movements between bone segments can delay healing or lead to misalignment. A history of orthognathic surgery in North America notes that rigid internal fixation, along with virtual surgical planning, has made jaw surgery far more predictable and safe than it was decades ago.¹

The improved rigidity of plate fixation does come with trade-offs. Older techniques using wire fixation struggled with instability between bone fragments, but the newer plate systems introduced their own set of possible problems, including plates that become palpable under the skin, hardware that gets exposed through tissue, and occasional infection.² Plate size has decreased over the years to minimize those issues, though the forces generated by chewing muscles still impose real limits on how small and thin the hardware can go.

Titanium Versus Bioresorbable Plates

The vast majority of jaw surgery fixation uses titanium alloy. Titanium earns its dominance because it is strong relative to its weight, resists corrosion, and forms a stable oxide layer that the body generally tolerates. The main alternative is bioresorbable hardware, typically made from polymers such as poly-L-lactic acid (PLLA), which gradually dissolve in the body over months to years. The appeal of resorbable plates is obvious: if the material disappears on its own, you avoid the possibility of a second surgery for removal.

In practice, the evidence has not clearly crowned either material. A Cochrane systematic review comparing resorbable and titanium plates for orthognathic surgery found insufficient evidence to determine whether one is better than the other, with no clear difference in postoperative pain, patient satisfaction, plate exposure, or infection rates.³ A randomized trial of 101 patients with 192 osteotomies found that both materials produced comparable stability, with only three adverse reactions across the entire study, split between one resorbable case and two titanium cases.⁴

Bioresorbable plates do have their own unique drawbacks, though. Because PLLA is resistant to hydrolysis, it takes a long time to break down completely. One review noted that total resorption of PLLA does not occur within the first two years and can take over three and a half years in clinical settings.⁵ During that drawn-out breakdown process, some patients develop a delayed foreign body reaction. In one study of 234 patients treated with bioabsorbable plates, about 3.4% developed complications including palpable masses and focal swelling, appearing 9 to 23 months after surgery. Six of those patients required a second operation to remove fibrous tissue and remnants of incompletely degraded hardware.⁶ Another study treating condylar fractures with bioresorbable hardware reported swelling, screw breakage leading to malunion, and radiographic evidence of bone resorption at the fracture site.⁷

How Often Does Hardware Get Removed

This is one of the most common concerns people have after jaw surgery, and the answer varies a lot by institution and patient population. A seven-year retrospective study reported a roughly 9% incidence of plate removal following orthognathic surgery, with the average time from insertion to removal being about 22 months. Reasons included pain, plates that became palpable or exposed, infection, and patient request.⁸ A separate single-center study found a much higher removal rate of about 62%, but that figure included a large number of removals done simply at the patient’s request rather than for medical necessity. Of the cases driven by complications, infection and subjective discomfort were the most common triggers.⁹

Among patients treated for traumatic facial fractures, the pattern is similar. One study found that the most common reasons for removing plates were discomfort related to palpability, cold intolerance, and pain, accounting for about 72% of complication-driven removals.¹⁰ Cold intolerance is one patients rarely expect going in: the metal conducts temperature differently from bone and soft tissue, so some people feel a noticeable ache or sensitivity in cold weather.

What Happens to Tissue Around the Plates

Even though titanium is considered biocompatible, it is not biologically invisible. Research examining the soft tissue surrounding titanium plates after jaw surgery has consistently found metallic particles shed from the hardware. One study found varying degrees of fibrosis in the surrounding connective tissue, with pigmented debris ranging from about 55 microns down to dust-like particles of roughly 1 micron, all located outside cells. The pattern suggested that larger particles were breaking down into progressively smaller fragments over time.¹¹ An earlier ultrastructural study confirmed that within five to eight months of placement, titanium particles were already present in the scar tissue overlying the plates, likely shaved off during insertion or from mechanical interaction with surrounding tissue. Most particles were extracellular, though some showed signs of being taken up and processed by cells.¹²

For the overwhelming majority of patients, this particle shedding does not cause symptoms or clinically meaningful inflammation. But in rare cases, the titanium can provoke a genuine allergic response. One case report described a patient whose palmoplantar pustulosis, a skin condition involving scaling on the palms and soles, worsened after jaw surgery with titanium plates. Steroid treatment did not help, but replacing the titanium plates with absorbable ones resolved the itching and the skin symptoms nearly disappeared.¹³ True titanium allergy is uncommon, but if you develop unexplained skin symptoms after jaw surgery, it is worth raising with your surgeon.

Biofilm and Infection

One less-discussed aspect of metallic implants is their susceptibility to bacterial biofilm. Biofilm is a thin, stubborn layer of microorganisms that adheres to surfaces and resists normal immune defenses and antibiotics. Research examining removed miniplates from maxillofacial surgery patients has found biofilm on the majority of them. One study found biofilm evidence on 75% of plates and in 82% of patients examined, typically small patches less than 100 microns in diameter clustered around screw-hole junctions and surface irregularities.¹⁴ A more recent case series confirmed similar findings, with biofilm present in all ten patients studied and structures resembling dental biofilms found on the hardware surfaces.¹⁵

The presence of biofilm does not necessarily mean the patient will develop an infection. Many of these plates were removed for other reasons and the biofilm was an incidental finding. Still, when a plate does become infected, biofilm is often the reason it is hard to clear with antibiotics alone, and removal of the hardware may be the only definitive solution.

Screws and Plates on Imaging

If you need a CT scan or MRI after jaw surgery, the titanium hardware will show up. The good news is that titanium produces much less artifact on imaging than stainless steel. A study comparing different screw materials found that titanium screws produced artifacts of about 2 millimeters on CT, compared to about 2.6 mm for stainless steel. The gap widens dramatically on MRI: at 1.5 Tesla, titanium screw artifacts measured roughly 3.7 mm while steel screws produced artifacts of about 10.9 mm. At the stronger 3 Tesla field, steel artifacts ballooned to over 15 mm while titanium stayed around 4.4 mm.¹⁶ An earlier evaluation specifically looking at cranio-orbital implants confirmed that titanium produced the least artifact of any metal tested, and all titanium images were considered acceptable for detecting pathology.¹⁷

The practical takeaway: titanium jaw hardware will not prevent you from getting an MRI. The artifacts it produces are small enough that radiologists can usually read around them. You should always mention your hardware to the imaging facility, but you do not need to have it removed for routine scanning.

Fixation Technique and Stability

Surgeons have more than one way to fix jawbone segments together, and the choice of technique affects stability. In a bilateral sagittal split osteotomy, one of the most common jaw repositioning procedures, the main options are bicortical screws placed through both layers of bone, miniplates secured with shorter monocortical screws, or hybrid combinations. A systematic review and meta-analysis comparing bicortical screws with miniplate fixation for mandibular setback found that bicortical screws provided slightly better skeletal stability, but the difference was not statistically significant.¹⁸

Where the differences become more pronounced is in the specific plate configuration. A systematic review of biomechanical testing found that a single four-hole or six-hole miniplate was less stable than bicortical screws, hybrid techniques, double miniplates, or grid plates.¹⁹ In other words, if your surgeon uses miniplates, how many and where they are placed matters more than the basic choice between plates and screws. Most surgeons today use some combination based on the specific movements performed and the forces the bone will bear during healing.

Can Screws Damage Tooth Roots

This is a legitimate risk, particularly in upper jaw surgery where screws are placed near tooth roots. In one study of 61 patients undergoing conventional maxillary osteotomy, about 13% had at least one dental root injury detected on the post-operative CT scan, though the injured teeth showed no signs of complications during follow-up and none needed root canal treatment.²⁰ A separate study of 125 orthognathic surgery patients found a 12% incidence of root contact from fixation screws on post-operative panoramic radiographs, but again, long-term follow-up showed complete healing of the affected areas.²¹

So root contact happens in roughly one in eight patients with conventional technique, but it rarely causes lasting harm. Teeth have a surprising ability to heal from minor screw contact as long as the pulp is not directly penetrated. Patient-specific implants with pre-planned screw trajectories are reducing this risk further, as discussed below.

Custom Plates and 3D Printing

One of the biggest recent shifts in jaw surgery hardware is the move toward patient-specific plates designed digitally and manufactured via 3D printing or CNC machining. The advantage is that these plates are pre-bent to fit the patient’s planned bone position perfectly, which removes the intraoperative step of manually bending a stock plate. A study comparing 3D-printed titanium cutting guides with custom plates to conventional plating found that the custom approach was significantly more accurate, with a mean positioning discrepancy of about 0.5 mm compared to about 1.2 mm with conventional plates. Surgery time was also shorter, averaging roughly 5 hours and 45 minutes versus nearly 7 hours.²²

Another randomized trial comparing custom titanium plates with 3D-printed surgical splints for upper jaw osteotomy found that custom plates performed comparably on most positioning measurements but showed a significant advantage on one key dimension, the coronal plane. The custom plate group also had shorter surgical times.²³ The same technology virtually eliminated dental root injuries: in the study noted above, zero root injuries occurred in the patient-specific implant group compared to 13% with conventional plating.²⁴

The downside is cost. One systematic review reported that customized surgical guides and patient-specific plates ran approximately $780 compared to about $280 for conventional plates. However, planning time and intraoperative time were each shortened by roughly a third, which partially offsets the higher material cost through reduced operating room time.²⁵ Whether the technology is available depends heavily on the surgical center; it is increasingly common at academic medical centers but not yet universal.

Jaw Surgery Hardware in Children

Plates and screws behave differently in growing patients. A child’s jawbone is still developing, and there is genuine concern that rigid metal spanning a growth zone could restrict normal growth. A recent study found evidence that titanium plates do limit mandibular growth, but that growth recovers rapidly once the plates are removed.²⁶ A scoping review of titanium fixation in pediatric maxillofacial trauma noted that the influence on future growth could not be properly assessed due to short and inconsistent follow-up periods across existing studies.²⁷ The general approach in pediatric cases is to use the smallest adequate hardware and to plan for timely removal once the bone has healed sufficiently, rather than leaving plates in place indefinitely as is common in adults.

Emerging Materials Beyond Titanium and Resorbable Polymers

A newer class of material gaining attention is PEEK, short for polyether ether ketone, sometimes reinforced with carbon fiber (Cfr-PEEK). PEEK is a high-performance polymer that is radiolucent, meaning it does not produce imaging artifacts the way metal does, and its stiffness can be tuned closer to that of natural bone. A randomized clinical trial comparing custom 3D-printed PEEK plates with 3D titanium plates for mandibular angle fracture fixation found that the two achieved comparable clinical, radiographic, and functional outcomes.²⁸ A biomechanical study of carbon-fiber-reinforced PEEK for sagittal split advancement osteotomy found that it actually provided better stability than titanium when measured by displacement values.²⁹ A finite element analysis study suggested that Cfr-PEEK plates at 2 mm thickness could serve as an alternative to 1 mm titanium plates, reducing stress on the fixation system while providing more stable fixation than resorbable systems.³⁰

Meanwhile, researchers are also working on modifying the surface of titanium implants to improve performance. Techniques like sandblasting, acid-etching, nanotube formation through anodization, and coating with hydroxyapatite or bone-growth proteins aim to speed up bone integration and reduce infection risk.³¹ These are largely in the research and early clinical phases, but they represent a future where the plate itself actively helps bone heal rather than just holding fragments in place.