GP4b - Custom Titanium Plates as a Marker of Surgical Complexity in Orthognathic Surgery: Association With Operative Time, Length of Stay, and Intraoperative Fluid Requirements

Abstract: Purpose: Custom titanium plates are increasingly used in orthognathic surgery to facilitate precise skeletal repositioning, with surgeons citing accuracy (79.1%) and efficiency (77.5%) as primary reasons for adoption.¹ While existing literature suggests patient-specific plates may reduce operative time by eliminating intraoperative plate bending, these studies have not accounted for the possibility that custom plates are preferentially selected for anatomically complex cases.² Identifying reliable preoperative markers of surgical complexity has important implications for operative scheduling, anesthesia planning, and resource allocation. The purpose of this study was to determine whether custom titanium plate use as a surrogate marker of case complexity is associated with increased operative time, hospital length of stay (LOS), and intraoperative fluid requirements in patients undergoing orthognathic surgery, excluding SARPE procedures.

Methods: A retrospective chart review of 628 consecutive orthognathic surgery patients at the University of Pennsylvania (January 2019 to December 2024) was performed. SARPE patients were excluded (n = 117), yielding an analytic cohort of 511 patients (65.4% female, median age 23 years, range 14-74, median BMI 24.9?kg/m²). Custom plate use was identified by operative report. Primary outcomes included operative time, hospital LOS, and intraoperative fluid input and output. Secondary outcomes included hydromorphone and fentanyl use, blood loss, postoperative opioid requirements, return to the operating room, and complication rate. Mann-Whitney U tests were used for group comparisons. α = 0.05.

Results: Of 511 patients, 332 (65.0%) received custom titanium plates. The two groups were well matched at baseline for age (median 23 vs 24 years, P = .48), sex (66.3% vs 64.8% female), and BMI (25.0 vs 24.6 kg/m², P = .31). Procedure type distribution was comparable between groups. Custom plate cases had significantly longer operative times (median 210 vs 161 min, P < .001), greater intraoperative fluid input (1,600 vs 1,200 mL, P < .001), greater fluid output (742 vs 450?mL, P < .001), a more extended LOS distribution (P = .002), and higher postoperative oxycodone requirements (P = .003). There were no significant differences in intraoperative blood loss (P = .99), hydromorphone use (P = .09), fentanyl use (P = .74), return to the operating room (P = .18), or complication rate (P = 0.77).

Conclusion: Custom titanium plate use was a robust preoperative marker of surgical complexity, associated with a 30% increase in median operative time (210 vs 161 min, P < .001), significantly greater intraoperative fluid requirements, extended LOS distribution (P = .002), and higher postoperative opioid use (P = .003) in this cohort of 511 non-SARPE orthognathic surgery patients. While custom plates eliminate intraoperative bending, their placement remains technically demanding: BSSO fixation with custom hardware tends to require greater operative time than positional screw fixation, as the precision required for custom plate seating and additional fixation steps contribute to overall case length, potentially offsetting the time savings reported in less anatomically complex cases. Notably, custom plate use did not predict blood loss, intraoperative opioid requirements, or complications, suggesting that while these cases are operatively more demanding, they do not carry disproportionate hemorrhagic or acute analgesic risk when managed by experienced teams. These findings support using custom plate requirement as a preoperative planning variable to inform operative scheduling, anesthesia staffing, and fluid management protocols.


References

1. Heufelder M, Wilde F, Pietzka S, et al. Clinical accuracy of waferless maxillary positioning using customized surgical guides and patient-specific osteosynthesis in bimaxillary orthognathic surgery. J Cranio-Maxillofac Surg. 2017;45(9):1578-1585.

2. Ritto FG, Schmitt ARM, Pagnoncelli RM, de Moraes M. Surgical treatment of dentofacial deformities with computer-aided design/computer-aided manufacturing technology. J Cranio-Maxillofac Surg. 2018;46(11):1883-1890.