## 4 Discussion
In contrast, Parketal have reported patient demand as the main reason for removal; in their study, the surgeon did not recommend elective plate removal, and surgery was only performed because of patient request or symptoms [5]. The frequency of patient request averaged 16.7% in the present study increasing in the second postoperative year. Furthermore, our patient survey revealed a high rate of patient satisfaction after removal. Benefit from removal surgery was claimed by 86% of all patients and 71.4% of the patients suffering from postoperative complications after removal as viewed from their own standpoint. Remarkably, most of the patients considered the burden of plate removal to be no more severe than leaving the plates in situ. This topic is not easy to evaluate, because a single person cannot experience both scenarios, namely, the removal and the permanence of the plates. In the literature, no evidence can be found forthe subjective benefit to patients after plate removal in maxillofacial surgery. [PERSON] et al. performed a similar survey regarding all bones with the highest removal rate at the ankle joint and the wrist. Surgeon recommendation was also the most common indication for removal. Patient satisfaction was based on the improvement of symptoms [22]. Considering the high patient satisfaction after elective removal, the policy of leaving asymptomatic plates in situ as the most beneficial option for the patient becomes questionable. Leaving the plates in situ is, for example, the routine practice in the United Kingdom, in Oman, and at the Department of Maxillofacial Surgery in Zurich [4; 23; 24]. Another study mentions geographical reasons as being a positive influence on the policy of removal [13]. [PERSON] et al. have observed that patients experiencing the chilly climate in Finland remark on their discomfort attributable to the cold sensitivity of the inserted plates [17]. However, a second surgery is always a risk for the patient, especially for elderly or multimorbid patients, and this risk needs to be taken into consideration. Removal surgery can be a difficult surgical procedure, for example, when the plates are overgrown by bone or because of systemic diseases of a patient. Moreover, the additional costs of routine removal surgery are considerable for the health system. It should be taken into consideration that an effective postoperative management is essential for the patient's well-being. Modern research is debating on pain caused by dental procedures. [PERSON] et al. report favorable effects of lornoxicam compared to flurbiprofen or placebo. A reduction of swelling by lornoxicam was not registered. Another study of [PERSON] et al. favors etoroxicam compared to diclofenac and placebo. However, both studies evaluated postoperative pain after third molar surgery [25; 26]. Ibuprofen was rated as equally effective for pain treatment compared to lornoxicam in another study. Moreover, non-steroidal anti-inflammatory drugs (NSAIDs) optimally dosed commonly provide a high patient satisfaction [27; 28]. The evaluation of postoperative discomfort after plate removal should be accomplished by further studies, since studies focusing this important aspect are lacking. A procedure-specific treatment is desirable [29]. The studies can profit by using internationally well-established pain scales, e.g., Numeric Rating Scale or Visual Analogue Scale [29]. Controversial opinions with regard to plate removal have also been expressed in orthognathic surgery. A meta-analysis of [PERSON] et al. revealed that plate removal was indicated in 13.4% patients. The main cause for removal was infection (6.6%) followed by plate exposure and thermal sensitivity. Similar to our study, the study of [PERSON] et al. evaluated risk factors predisposing patients to plate removal in orthognathic surgery. Significant risk factors were female sex, nicotine abuse and plates in the lower jaw. Except for the category of female sex, this observation is mostly congruent with our results [30].