Oral and Maxillofacial Surgery

https://doi.org/10.1007/s10006-020-00889-w

CASE REPORT

Reconstruction of mandible using a computer-designed

3D-printed patient-specific titanium implant: a case report
Khaldoun Darwich 1 & Mohamad Bilal Ismail 1 & Mohammed Yamen Al-Shurbaji Al-Mozaiek 1 & Abdulhadi Alhelwani 2

Received: 21 April 2020 / Accepted: 22 July 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Reconstruction of mandibular defects after trauma or tumor resection is one of the most challenging problems facing maxillo-
facial surgeons. Historically, various autografts and alloplastic materials have been used in the reconstruction of these types of
defects. The use of individualized designed biomaterials has opened new possibilities in reconstructive surgery, and now, it is
possible to use the patient’s computed tomography (CT) to construct patient-specific implants (PSIs). A case of a large mandib-
ular tumor resection and reconstruction of the defect using a customized 3D-printed titanium implant is described. The treatment
had excellent postoperative esthetic and functional results without complications.

Conclusion
Because titanium implants are customizable, easily workable especially with help of 3D virtual planning techniques, bioinert, and
nonporous, they represent an ideal alloplastic material for mandibular reconstruction.

Keywords Mandibular reconstruction . 3D-printed titanium implant . Ameloblastoma . Patient-specific implant PSI . CAD–
CAM . Virtual surgical planning

Introduction the lower teeth, and the muscles of mastication, allowing the
functions of chewing, speaking, and breathing [1].
The mandible is an important element in the appearance of the Reconstruction of mandibular defects after trauma or tumor
human face, as it gives the distinctive shape of the face and resection is one of the most challenging problems facing max-
defines the frame of its lower third. The mandible plays an illofacial surgeons. Any deformity of the mandible leads to
essential role in protecting the airway, supporting the tongue, cosmetic and functional problems [2]. Loss of bone continuity
causes the mandible to shift toward the excised part due to the
tension caused by the remaining mastication muscles and soft
tissue contraction in addition to the formation of surgical scars
* Khaldoun Darwich [3, 4].
doctordarwich@gmail.com The mandibular reconstruction aims to restore the anatom-
ical and functional structure of the jaw as well as the patient’s
Mohamad Bilal Ismail
dr.bilalismail@gmail.com
psychological stability, as this loss can be caused by congen-
ital causes, accidents, diseases, or tumors [5, 6] .
Mohammed Yamen Al-Shurbaji Al-Mozaiek Usually, the reconstruction process of the defect caused by
dr.ymn_86@yahoo.com
the removal of part of the mandible is done directly during the
Abdulhadi Alhelwani surgery by adapting and fixing the titanium reconstruction
abdulhadi.iust@hotmail.com
plate, which requires an extensive time and effort by the sur-
1 geon thus lengthening the surgery time. In addition, this pro-
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry,
Damascus University, Damascus, Syria cedure is related to several complications, including the pos-
2 sible plate exposure and the postoperative infection.
Department of Imaging & Pathology/OMFS-IMPATH Research
Group, KU Leuven | Oral and Maxillofacial Surgery, Leuven, UZ, The success of minimally invasive reconstructive sur-
Belgium gery depends on prior evaluation of the bone loss, the

precise design and manufacture of the prosthetic model,
and the mastery of the surgical procedure [7]. In this con-
text, several materials are used in the manufacture of pros-
thetic models, but the most commonly used are acrylics
such as PMMA, or prosthetic models made from bone
grafts, or bone substitute materials such as hydroxyapatite
[8]. However, each method has its own problems and
complications, whereby bone grafts show different pro-
portions of bone resorption and recipient site complica-
tions [9], while models made from acrylic materials have
the possibility to be infected or immunologically rejected,
while bone-cement alternatives such as hydroxyapatite are
difficult to adapt and model [10]. Because of these disad-
vantages described previously, the search for the ideal
material was still ongoing. The use of titanium implants
in combination with three-dimensional virtual numerical
planning techniques and specific modeling of implants
consistent with the shape of bone loss (patient-specific
implants PSIs) in the maxillofacial area is promising
[11]. Given the fact that titanium implants are character-
ized by rigidity, stability, biocompatibility, and ease of
handling, their use in reconstructive surgery of the maxil-
lofacial area will be very popular [12].
Advances in medical imaging such as computerized to-
mography and magnetic resonance imaging have allowed
the production of a three-dimensional model of anatomical
tissue for several medical uses, including the design of surgi-
cal prosthetic models [13].
In the case of restoration mandibular bone defects,
computer-aided design and manufacturing methods have
several advantages, as they are well suited to the anatom-
ical region; they also reduce the time of surgery and pro-
duce a more appropriate esthetic appearance. On the other
hand, manual methods require more time for the design-
ing process while their success largely depends on the
skill of the surgeon.
The 3D CAD–CAM technique has made it possible to
execute virtual surgery together with implant designing.
This enables digital simulation, precise planning of sur-
gery, and designing of complex virtual models that are
printable [14, 15]. Manufactured patient-specific 3D-
printed replicas can be used to study complex pathologies,
to simulate procedures, to teach students, and to advise
patients [16]. The aim of the present 3D CAD–CAM is to
enable virtual visualization and virtual processing of a
person’s anatomy in order to support surgical assessment
and implant design [17, 18]. This in turn will shorten
operation time, speed up the recovery of the patient, and
improve the overall outcome.
Medical 3D CAD–CAM is considered as a process with
five consecutive stages: 3D imaging data, data conversion,
digital planning, manufacturing of implants, and actual sur-
gery [19].
Oral Maxillofac Surg
Case report
A 29-year-old male patient was referred to the hospital of oral
and maxillofacial surgery—Faculty of Dentistry—Damascus
University with recurrent ameloblastoma in the left mandible.
Initial diagnosis was carried out 5 years ago where the tumor
lesion presented itself in the left mandibular angle with a 3.7-cm
diameter (Histopathologic diagnosis: ameloblastoma, follicular
type). Surgical resection and a reconstruction plate were per-
formed back then. The plate was removed later on about a year
after the first surgery due to its movement and displacement
from its place, then the patient was absent from attendance for
follow-up for 4 years because of his travel, and then returned
with a condition of recurrence in the tumor (Fig. 1). The recur-
rence presented as bone-destroying lesion that extended from
the resection area to include the symphysis area and crossed the
midline to reach the right first premolar region, also affecting
the left condyle–bearing segment of the mandible.
Preoperative clinical and radiographic findings
The tumor recurrence in the aforementioned areas in the man-
dible and loss of facial appearance harmony and symmetry
due to the loss of the mandibular jaw line and the left man-
dibular angle lead to the deviation and limited movement of
the mandible as a result of impaired positioning of the left
condyle.
A swelling in the floor of the mouth appeared at the level
just below the apices of the lower incisors, with intermittent
pain in the area. CT scan imaging was done and sections were
studied at all levels where severe bone damage was observed
in the anterior area of the mandible medially to the old exci-
sion area.
A new biopsy was taken from the affected bone margin
area, and after combining information from the clinical, radio-
graphic, and histologic findings, it was clear that the patient
was suffering from a recurrence of the tumor in the anterior
portion of the mandible extending to the lower right first
Fig. 1 Panoramic X-ray of the patient when presented showing the initial
resection 5 years ago and the extent of bone destruction by the recurrent
ameloblastoma
Oral Maxillofac Surg
Fig. 2 Bone destruction visible in the anterior region of the mandible
premolar, with displacement and bone resorption in the con-
dyle and the remaining portion of the left ramus (Figs. 2 and
3). The treatment plan included the resection of the affected
portion of the mandible with safety margins reaching the right
second molar area, along with the resection of the remaining
displaced left condyle–bearing portion of the mandible.
If this large resection was performed without proper pros-
thetic work to restore the missing bone mass, it will result in
total facial deformation especially in the anterior chin and the
left angle of the mandible regions.
The option to use a regular reconstruction plate was avail-
able, but it would not have been enough to restore an esthetic
facial contour. In addition, it would not provide function, in
addition to the high risk of complications such as infection,
movement, and exposure of the plate that mandates its surgical
removal later on.
Moreover, the resulting defect was too large to be replaced
with an autogenous bone graft.
In this case, the decision was to perform the bone resection
alongside the use of modern 3D techniques by applying A
CAD–CAM titanium patient-specific implant (PSI).
Preoperative digital planning workflow
The workflow started with the processing of files in Digital
Imaging and Communications in Medicine (DICOM) format
obtained from the head and neck CBCT scan (PaX-i3D Green,
Fig. 3 Displacement of the left condyle portion of the previous resection
Vatech, Korea). The DICOM files were examined and proc-
essed. Using MIMICS software® (Materialise, Leuven,
Belgium), a segmented three-dimensional (3D) virtual model
of the patient’s hard tissue was obtained. The segmentation was
done with proper thresholding so that the software can imple-
ment the interpolation to produce virtual 3D replication of the
patient’s hard tissue. This made it possible for the surgeons to
perform virtual surgical planning (VSP) and provided a more
thorough view to plan the surgery and design the PSI.
Resection planning was performed according to the surgi-
cal principles of ameloblastoma tumor resection. Once the
planning and the final treatment decision was made, the
three-dimensional (3D) project of mandible was saved as stan-
dard tessellation language (STL) file so the computer-aided
design of the implant can be later carried on.
Computer-aided design of the PSI
Since the tumor deformed the mandibular anatomy rather uni-
laterally, the design of the implant could benefit from the
unaffected right side of the mandible. Using 3-MATIC soft-
ware ®(Materialise, Leuven, Belgium), the mirroring function
was used, and the implant was designed to retain and repro-
duce the hard tissue structure outlook. Implementing this de-
sign will postoperatively support a healthy and more normal
facial status. The virtual simulation of the implant was then
extended distally with 2-mm-thick wings with well-designed
holes to receive screws for retention on the remaining unaf-
fected right mandible. Holes within the PSI body are designed
to reduce weight and facilitate suturing the muscles around the
implant (Figs. 4, 5, 6, 7, 8, 9, 10, and 11).
Fig. 4 3D model of the patient’s facial bones
 Oral Maxillofac Surg

Fig. 9 Checking the symmetry at the skull level

Fig. 5 Isolating the affected mandible

Fig. 6 Performing virtual resection to the affected bone Fig. 10 Matching of the condylar part of the design with the glenoid fossa

Fig. 11 Checking the contour of the chin and the mandibular angle
Fig. 7 The remaining portion of the mandible

Fig. 8 PSI designed to achieve symmetry with the unaffected side of the
mandible Fig. 12 3D printing of the design with resin material
Oral Maxillofac Surg
Fig. 13 The PSI made using titanium metal printer
Fig. 14 Fit verification of the 3D printed titanium PSI on the resin replica
of the jaw
Computer-aided manufacturing and fit validation
Once the design has been completed and validated by the
surgeons, the implant was 3D-printed using the 3D CAD data
to produce physical titanium PSI. The implant was
manufactured by a technique known as “selective laser melt-
ing,” which is the selective fusion of titanium powder by a
laser beam. Grade 5 titanium alloy powder (Ti6AL4V) titani-
um 88–90% aluminum 5.5–6.5% vanadium 3.5–4.5% is used
in manufacturing the PSI. For final evaluation and fitting re-
hearsal, the remaining mandible was 3D-printed using in-
house 3D printer (Form 2; Formlabs Inc) in standard gray
resin (Dental SG resin; Formlabs Inc). The printed model
was rinsed with 92% isopropyl alcohol and completely
Fig. 15 Final matching
Fig. 16 Surgical incisions, submandibular approach, and preauricular
approach
Fig. 17 Bone cutting
polymerized as recommended by the manufacturer. The im-
plant showed a perfect fit to the remaining mandible, and
bone-cutting guides were fabricated to be used during the
surgery (Figs. 12, 13, 14 and 15).
Surgery
The surgery was approached with two incisions. The first was
2 cm below the inferior mandibular border starting from the
left angle of the mandible area crossing the midline and
reaching the right first molar level (submandibular approach).
The second incision was in front of the left ear, just the way it
is with temporomandibular joint surgeries (preauricular ap-
proach) (Fig. 16). The two incisions were not connected to
preserve the branches of the facial nerve from any traumatic
injuries. After “tissue retraction,” the bone-cutting guide was
used to perform the planned sectioning with precision
(Fig. 17).
Fig. 18 Excision of the affected portion of the jaw and the left condyle
 Oral Maxillofac Surg

Fig. 19 PSI fixed in place with 2.5-mm-diameter screws Fig. 22 Skin suturing

Fig. 20 Final position of PSI

Fig. 23 Patient’s final profile just at the end of the surgery

The anterior portion of the mandible was removed up to the

and no difference in the shape or location of the chin. The
border of the second left molar, and the left condyle was re-
facial nerve branches were intact, and the facial expression
moved with the remaining part of the ramus (Fig. 18).
movements were as effective as before. The opening and clos-
PSI was placed, and the artificial condyle was correctly
ing movements of the mouth were normal, and no complaints
placed in the glenoid fossa. Fixation was done using eight
appeared in the temporomandibular joint area, on both sides.
2.5-mm-diameter and 12-mm-length screws (Figs. 19, 20
Postoperative panoramic x-ray revealed a smooth mandib-
and 21). When the PSI took the preplanned position accurate-
ular contour imitating that of the opposite site of the mandible
ly, muscles were attached through the holes of the PSI, and the
(Fig. 24).
incision was sutured by layers with primary closure using 3–0
A postoperative CBCT image was performed, and new
vicryl (for muscular and subdermal layers) and 5–0 nylon (for
data with design data were imported into the Bluesky bio
dermal layer) suturing material (Figs. 22 and 23). The histo-
software to investigate the accuracy of the PSI positioning in
pathologic assessment confirmed a diagnosis of
comparison with the preoperative default design. Fixed refer-
ameloblastoma-follicular type and tumor-free margins.
ence points on the skull were identified in both the old and the
new 3D image and then matched together. 3D images show
Clinical outcome and protocol validation

The patient’s condition was evaluated and monitored for

18 months post op. Initial evaluation after surgery shows good
clinical results, perfect results at the level of facial symmetry,

Fig. 21 Intraoral view of the PSI just before closing the oral mucosa Fig. 24 Postoperative panoramic X-ray showing perfect PSI harmonic
wound fitting with jaw body
Oral Maxillofac Surg
Fig. 25 Marking fixed reference points on the skull to match design and
outcome
Fig. 26 The default design (blue) and the postoperative outcome (gray)
good fit and positioning of the PSI, with precise positioning of
the condyle in the articular fossa (Figs. 25, 26, 27 and 28).
Until the date of publication of this article, the observation
period extended for about 18 months during which the pa-
tient’s condition was monitored clinically and radiologically.
There is a significant improvement in the patient’s psycholog-
ical wellness and an increase in the quality of life, especially
after the manufacture of a removable denture that enhanced
the patient’s ability of eating and speaking, rehabilitated his
facial vertical dimension, and supported his lower lip (Figs.
29, 30, 31, 32, and 33). The clinical intraoral status is stable,
and there is no exposure of the implant or any inflammatory
manifestations, with good recovery and a decrease in the se-
verity of the surgical scar on the face.
Fig. 27 Lateral view of the match
Fig. 28 Frontal view of the match
Discussion
The indication for this intervention was the need for mandib-
ular reconstruction after a large bone resection due to recurrent
ameloblastoma, as other treatment plans such as reconstruc-
tion plates; revascularized bone grafts were rejected because
of the severe extension of the lesion.
This novel case was the first of its kind in Syria of mandib-
ular reconstruction after mandibulectomy using 3D-printed
custom-made titanium implant, taking advantage of the ability
of additive manufacturing of producing any complex form
with precision and efficiency. The proposed protocol can
serve as a template for designing and prototyping the surgical
prosthesis of any case with trauma or tumor associated with
bone loss that recommends surgical intervention and function-
al rehabilitation.
The main idea behind this protocol is the ability of
investing the medical imaging software in a predictable and
reproducible way. Such investment can come in many positive
Fig. 29 Facial profile 18 months after surgery

Fig. 30 Patient’s removable denture
returns such as producing patient-specific implants with high
accuracy and the ability of the rehearsal and evaluation of the
fixation technique so that optimal mechanical stability can be
safely obtained.
The utilization of the technologies behind the digital
workflow and the collaboration of different software packages
shortened the time needed in the operating room and provided
accurate representation of the tissue geometry. The surgical
work was performed with a time of 4 h and 20 min. Studies
indicate the need for a much longer work time in the tradition-
al reconstruction processes of similar cases [20].
Considerable advantages for the patient in terms of postop-
erative comfort in both short and long terms incorporating the
suggested treatment plan. No bone had to be harvested from
another site since the implant was designed and manufactured
in a way that it alone could restore the shape and functionality
of the diseased site. This 3D design was the perfect reconsti-
tution of the lower border, and consequently, the capacity to
restore a quality mandibular shape (especially in the chin area)
in comparison with conventional reconstruction plates. One
other major advantage was the ease to position the condyle
correctly intraoperatively.
Despite the popularity of reconstruction plates in such
cases, they hold the major disadvantage of the necessity to
be bent intraoperatively, leading to difficulties in regaining
original anatomy.
Other treatment options are the usage of a fixation plate
combined with bone graft augmentation from the hip or the
fibula [21]. However, the efficacy of this surgical procedure is
confined by short-term failure of the corresponding fixation
plate and the difficulty of modeling the fixation plate into the
desired shape during surgery, in addition to surgical trauma to
the patient and the possibility of more complications such as
infection, pain, edema, pathogenicity of the donor site, and
impaired mandible movement and in addition to the high pos-
sibility of exposure or resorption of the bone graft.
Fig. 31 Intraoral image showing the healthy status of the overlying soft
tissue after 18 months of the surgery
Oral Maxillofac Surg
Fig. 32 Left-side occlusion
Valuable to mention is the great accuracy in the conse-
quence of surgical work between virtual planning and surgical
application of PSI despite the relatively large workload.
Precision studies in the use of virtual surgical planning have
stated that accuracy decreases as the volume of bone loss
increases, especially if the loss includes one of the mandibular
condyles [22]. In the presented case, 3D virtual planning and
post-surgical 3D radiographs were matched to the accuracy
screening process, with an average displacement size of 2 mm.
Most studies indicate cooperation between medical soft-
ware engineers and the surgeon to perform virtual surgical
planning, determine bone-cutting locations, and accurately
design the PSI. This requires communication procedures, lon-
ger time in design and implementation, and sometimes plan-
ning flaws [23]. This is due to the engineer’s lack of knowl-
edge of surgical anatomy and the doctor’s inefficiency in
using the complex computer software used in these proce-
dures. In the presented case, the surgeons themselves made
the default planning and design of the PSI and the same ones
who performed the surgery and observation over a year and a
half.
Thanks to 3D design and the ability of 3D printing to create
almost every complex form, the titanium PSI offers a far better
anatomical shape with optimal physical properties for man-
dibular construction.
Titanium has the capacity to withstand the stress accompa-
nied with the physiological function of the mandible.
It became evident that CAD–CAM technologies are be-
coming a valuable pillar and gold standard in maxillofacial
reconstructive surgery. Many research teams have already em-
braced the value and evaluated the use of computer-aided
surgeries.
The introduction and availability of virtual 3D planning
systems made the 3D hard and soft tissue analysis reproduc-
ible and more convenient for the operator with higher degree
of accuracy.
Fig. 33 Right-side occlusion
Oral Maxillofac Surg
Conclusion
The presented case showed promising results of PSI using
CAD–CAM procedures for mandible reconstruction. The pre-
operative 3D planning provided higher accuracy and better
outcome. Further cases and studies are required to support
the validity of the suggested technique.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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