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Design Workflow for Mandibular Reconstruction. Opportunities and Limitations of In-house Virtual Surgical Planning



Cranio-maxillofacial surgery boosted the development of medical 3D printing due to intensive use of patient-specific medical devices. The aim of this paper is to describe and assess a hospital-based design method for a mandibular reconstruction and to give an overview on in-house virtual surgical planning (VSP).


Design was demonstrated on a case of mandibular osteonecrosis fracture using a dedicated software in a step-by-step manner. Evaluation was done by model surgery followed by a dimensional accuracy evaluation of the experimental model surgery result in comparison with the virtually planned reconstruction. Model scanning and dedicated software were used to assess deviations, including potential printing errors. Based on the obtained results and previous published data, items related to opportunities and limitations of the promoted method were discussed focusing on accuracy, time, costs and regulations.


The in-house protocol led to a two-day production period for all the patient-specific surgical gear, with an 11.7 EUR cost of printing material and an estimated initial investment of over 24,000 EUR. Accuracy evaluation by comparing the 3D scanned result with the virtual planned reconstruction suggested most deviations between ± 1.2 mm with most concentrated deviations around + 0.20 mm. Limited exceptions were recorded out of ± 2.2 mm range.


Based on the analyzed data, we consider our method a viable alternative solution to outsourced VSP because the surgeon can independently implement the workflow in the hospital, ensuring immediate availability of patient-specific medical devices. However, further clinical, cost-effectiveness and device safety evaluations need to be performed.

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  1. 1.

    Louvrier, A., Marty, P., Weber, E., Euvrard, E., Chatelain, B., Barrab’e, A., & Meyer, C. (2017). How useful is 3D printing in maxillo-facial surgery? Journal of Stomatology, Oral and Maxillofacial Surgery.

    Article  PubMed  Google Scholar 

  2. 2.

    Tack, P., Victor, J., Gemmel, P., & Annemans, L. (2016). 3D-printing techniques in a medical setting: A systematic literature review. Biomedical Engineering Online, 15, 1–21.

    Article  Google Scholar 

  3. 3.

    Jacobs, C. A., & Lin, A. Y. (2017). A new classification of three-dimensional printing technologies: Systematic review of three-dimensional printing for patient-specific craniomaxillofacial surgery. Plastic and Reconstructive Surgery, 139(5), 1211–1220.

    CAS  Article  Google Scholar 

  4. 4.

    Rustemeyer, J., Melenberg, A., & Sari-Rieger, A. (2014). Costs incurred by applying computer-aided design/computer-aided manufacturing techniques for the reconstruction of maxillofacial defects. Journal of Cranio-Maxillofacial Surgery, 42, 2049–2055.

    Article  PubMed  Google Scholar 

  5. 5.

    Ganry, L., Hersant, B., Quilichini, J., Leyder, P., & Meningaud, J. P. (2017). Use of the 3D surgical modelling technique with open-source software for mandibular fibula free flap reconstruction and its surgical guides. Journal of Stomatology, Oral and Maxillofacial Surgery, 118, 197–202.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Cosma, C., Balc, N., Moldovan, M., Morovic, L., Gogola, P., & Miron-Borzan, C. (2017). Post-processing of customized implants made by laser beam melting from pure Titanium. Journal of Optoelectronics Advanced Materials, 19(11–12), 738–747.

    CAS  Google Scholar 

  7. 7.

    Martelli, N., Serrano, C., Van Den Brink, H., Pineau, J., Prognon, P., Borget, I., & El Batti, S. (2016). Advantages and disadvantages of 3-dimensional printing in surgery: A systematic review. Surgery (United States), 159, 1485–1500.

    Article  Google Scholar 

  8. 8.

    Roser, S. M., Ramachandra, S., Blair, H., Grist, W., Carlson, G. W., Christensen, A. M., Weimer, K. A., & Steed, M. B. (2010). The accuracy of virtual surgical planning in free fibula mandibular reconstruction: Comparison of planned and final results. Journal of Oral and Maxillofacial Surgery, 68, 2824–2832.

    Article  PubMed  Google Scholar 

  9. 9.

    Numajiri, T., Morita, D., Nakamura, H., Tsujiko, S., Yamochi, R., Sowa, Y., Toyoda, K., Tsujikawa, T., Arai, A., Yasuda, M., & Hirano, S. (2018). Using an in-house approach to computer-assisted design and computer-aided manufacturing reconstruction of the maxilla. Journal of Oral and Maxillofacial Surgery, 76, 1361–1369.

    Article  PubMed  Google Scholar 

  10. 10.

    Song, C., Yang, Y., Wang, Y., Wang, D., & Yu, J. (2014). Research on rapid manufacturing of CoCrMo alloy femoral component based on selective laser melting. International Journal of Advanced Manufacturing Technology, 75, 445–453.

    Article  Google Scholar 

  11. 11.

    Msallem, B., Sharma, N., Cao, S., Halbeisen, F. S., Zeilhofer, H.-F., & Thieringer, F. M. (2020). Evaluation of the dimensional accuracy of 3d-printed anatomical mandibular models using FFF, SLA, SLS, MJ, and BJ printing technology. Journal of Clinical Medicine, 9, 817.

    Article  PubMed Central  Google Scholar 

  12. 12.

    Barone, S., Casinelli, M., Frascaria, M., Paoli, A., & Razionale, A. V. (2016). Interactive design of dental implant placements through CAD-CAM technologies: From 3D imaging to additive manufacturing. International Journal on Interactive Design and Manufacturing, 10, 105–117.

    Article  Google Scholar 

  13. 13.

    Honigmann, P., Sharma, N., & Okolo, B. (2018). Patient-specific surgical implants made of 3D printed PEEK: Material, technology, and scope of surgical application. BioMed Research International.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Evins, A. I., Dutton, J., Imam, S. S., Dadi, A. O., Xu, T., Cheng, D., Stieg, P. E., & Bernardo, A. (2018). On-demand intraoperative 3-dimensional printing of custom cranioplastic prostheses. Oper Neurosurgery, 15, 341–349.

    Article  Google Scholar 

  15. 15.

    Bosc, R., Hersant, B., & Carloni, R. (2017). Mandibular reconstruction after cancer: An in-house approach to manufacturing cutting guides. International Journal of Oral and Maxillofacial Surgery, 46, 24–31.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Liu, Y., Xu, L., Zhu, H., & Liu, S.S.-Y. (2014). Technical procedures for template-guided surgery for mandibular reconstruction based on digital design and manufacturing. Biomedical Engineering Online, 13, 63.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Spaas, C., & Lenssen, O. (2019). Economic analysis of a low-cost virtual surgical planning protocol for mandibular reconstruction: A case series. British Journal of Oral and Maxillofacial Surgery, 57, 743–748.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Zavattero, E., Fasolis, M., & Novaresio, A. (2020). The shape of things to come: in-hospital three-dimensional printing for mandibular reconstruction using fibula free flap. The Laryngoscope.

    Article  PubMed  Google Scholar 

  19. 19.

    Valding, B., Zrounba, H., Martinerie, S., May, L., & Broome, M. (2018). Should you buy a three-dimensional printer? A study of an orbital fracture. The Journal of Craniofacial Surgery, 29, 1925–1927.

    Article  PubMed  Google Scholar 

  20. 20.

    Otero, J. J., Vijverman, A., & Mommaerts, M. Y. (2017). Use of fused deposit modeling for additive manufacturing in hospital facilities: European certification directives. Journal of Cranio-Maxillofacial Surgery, 45, 1542–1546.

    Article  PubMed  Google Scholar 

  21. 21.

    Morrison, R. J., Kashlan, K. N., Flanangan, C. L., Wright, J. K., Green, G. E., Hollister, S. J., & Weatherwax, K. J. (2015). Regulatory considerations in the design and manufacturing of implantable 3D-printed medical devices. Clinical and Translational Science, 8, 594–600.

    Article  PubMed  PubMed Central  Google Scholar 

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The authors would like to thank Daniel Jamgossian from Eurocom Invest SRL, Cluj-Napoca, Romania for the support in providing the infrastructure and assistance necessary for scanning the study models.


This paper was partially supported by the Human Capital Operational Programme agreement POCU/380/6/13/123927 financed from the European Social Fund (contract no. 56437/24.07.2019.)

Author information




All authors contributed to the study conception and design. Conceptualization: DO, HR. Methodology: DO, MH, HR. Formal analysis and investigation: DO, CC. Writing—original draft preparation: DO. Writing—review and editing: MH, RR, MC, CC, HR. Funding acquisition: CC. Resources: HR, RR. Supervision: HR, MH.

Corresponding author

Correspondence to Calin Rares Roman.

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Informed consent was obtained from all individual participants included in the study.

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Patients signed informed consent regarding publishing their data.

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Ostas, D., Hedesiu, M., Roman, C.R. et al. Design Workflow for Mandibular Reconstruction. Opportunities and Limitations of In-house Virtual Surgical Planning. J. Med. Biol. Eng. 41, 482–493 (2021).

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  • Three-dimensional printing
  • In-house
  • Virtual surgical planning
  • Cutting guides
  • Mandibular reconstruction

JEL classification

  • 10—General