## 4 Discussion  
Some authors have stated that the lack of evidence indicating plate removal is attributable to the removal rate being low (3%) and the clinical indication for plate removal being unclear. Furthermore, they describe the removal surgery as the most expensive complication in maxillofacial traumatology [1; 9; 10; 15]. Although the practice of elective removal has become controversial nowadays, the present study has revealed that the complication rate after plate removal is low (13.3% \(\overline{n}=31\)). In this regard, we should mention that the surgeons of this study recommend plate removal after six months, as this leads to a lower rate of complications. Surgery is more difficult following an overgrowth of bone and is considered, among researchers, a complication of belated plate removal, especially in young patients [1; 5; 16]. Removal within a year or less after osteosynthesis is frequently reported [8; 5; 14; 17; 18]. The most common complication after osteosynthesis was hypesthesia in this study. Hypesthesia may not be the main problem of the osteosynthesis, because it can be caused by the trauma itself. On exclusion of hypesthesia as a complication, the complication rate was lower in our study (17.2%, \(\overline{n}=40\)). We did not differentiate between hypesthesia before and after the osteosynthesis more precisely, as plate removal was the central issue of the study. The high complication rate including hypesthesia in our study is different from that of other studies in which infection has been reported as the most common complication [2; 13; 15; 19]. In the investigation of [PERSON] et al. who studied a population of 164 patients undergoing osteosynthesis from 2004 to 2007, smoking was suggested as the main reason for the high infection rate that they observed. The patients were administered with perioperative antibiotics [10]. Palpability is also reported as a highly common complication [3; 12]. [PERSON] et al. state that frontozygomatic fractures are a risk factor for the palpability of plates because of the anatomical properties of this region. Nevertheless, the number of patients with plates at the frontozygomatic suture was high in their study. [PERSON] et al. noted a high rate of palpability for supraorbital and infraorbital fractures and proposed that the discomfort was related to the thin soft tissue in this area. Wound dehiscence was the second most common complication (20.2%) in the present study, and palpability occurred in less than 5% of the patients. A probable explanation for the high rate of wound dehiscence is the large number of mandibular fractures in our study. [PERSON] et al. reported moreover that patients with mandibular fractures suffer more pain than patients with midface fractures [20]. However, surprisingly, the number of supraorbital and infraorbital fractures was also high, although the rate of palpability was low compared with other studies. In the current investigation, we identified mandibular, nasal, and orbital fractures and smoking habits to be statistically significantly associated with more complications (e.g., wound dehiscence, postoperative hemorrhage). We noted that the complication rate of plate removal was lower than the rate after osteosynthesis, but the literature is lacking with regard to postoperative complications after removal. Only [PERSON] et al. have reported that plate-associated complications are reduced after removal surgery [3]. Surgeon recommendation as the main indication for removal in our investigation is contrasts with data from other studies [10; 15; 18; 21] but can be deduced from the policy of our department whereby we advise patients to undergo elective removal. Most surgeons no longer recommend elective removal. The indication for removal is consequently more often a symptom in other studies, especially with respect to infection.