## 5 Discussion  
In the present review, our purpose was to identify the potential implications that titanium-based alloys used for maxillofacial osteosynthesis could have upon the local and general health. Titanium is considered, and remains to be, a good alternative to other existing materials due to its high biological acceptance, mechanical and chemical characteristics. Maxillofacial fractures represent a frequent and challenging pathology in the clinical practice, requiring adequate treatment that establishes a proper function, continuity and aesthetic outcome. Internal bone fixation that uses minipilates and screws has a high impact upon the treatment, especially in the cases that have contraindications for the orthopaedic approach [11]. Titanium alloys minipilates and screws are routinely used in the reconstructive treatment in traumatology, orthognathic surgery and maxillofacial oncology.  
The advantages that the titanium-based alloy miniplates and screws used for osteosynthesis have are well-known but, the long-term impact has yet to be established. Recent research has focused on examining both the tissue surrounding the miniplates and the removed titanium materials in order to evaluate possible existing consequences. Although until recently the removal of the titanium devices has only been indicated when complications are associated with infection and exposure, the local cellular impact of the metallic particles is an actual concern [46]. Several studies reported that during the removal of the miniplates, the surrounding tissue presented a dark staining, proving the infiltration of metallic particles [79; 81; 83]. Further research affirmed the fact that these titanium particles can be easily transported via the lymphatic system into the local lymph nodes [80], and even to other organs [80].  
An existing local reaction was reported, and an immuno-inflammatory reaction was identified in the fibrous connective tissue deposits. Titanium was reported to induce an increased level of oxygen-free radicals, sustaining the start of an oxidative stress process. This aspect was evaluated by [PERSON] et al. [1], outlining the existence in the examined samples with altered protective mechanisms. Allergic reactions associated with titanium-based alloys are rare, and among them facial eczema was encountered [95; 96].  
The insecurity towards these types of materials used in maxillofacial osteosynthesis and their persistence in relation to human tissue determined clinicians to remove them once their purpose was accomplished.  
Taking into consideration the ongoing debate and implications related to the use of this type of alloy, scientists developed a new category of bioresorbable and bioactive materials as an alternative for the metal plates. Different types of bioresorbable materials such as polyglycolic acid (PGA), polylactic acid (PLLA), copolymers of PGA and PLLA, and hydroxyapatite incorporated in PLLA allow and stimulate the formation of new bone tissue, generating no mutagenic action [41]. Although their main advantage represented by the biodegradation characteristic is very appealing, the comparison studies between the two categories of materials--metallic alloys and bioresorbable--do not have enough follow-up. With higher refractive rates, weakness, and loss of implant strength, the decision of using bioresorbable materials is an important task for surgeons [39].  
Conceptualization, M.R. and A.R.; methodology, C.R.; data curation, D.N. and A.V.; writing--original draft preparation, M.R. and A.R.; writing--review and editing, L.-C.R., C.R.; visualization, D.N. and A.V.; supervision, L.-C.R. All authors have equal contributions, have read and agree to the published version of the manuscript.  
This research received no external funding.  
The authors declare no conflict of interests.