Application of computer-aided design/computer-aided manufacturing and mixed reality technologies in a novel mandibular reconstruction plate system

Introduction

Following tumor resection in the oral and maxillofacial region, reconstruction using plates is essential to restore occlusion and facial appearance. Conventional methods involve bending the reconstruction plates during surgery, which prolongs the surgical time and makes it difficult to adapt the plates to the shape of the jawbone (1). With the advancement of three-dimensional (3D) printing technology, it has become possible to create a 3D model of the jawbone prior to surgery based on computed tomography (CT) imaging of the patient. By manually bending the plate using the model before surgery, surgical time has been reduced. However, multiple bending cycles can lead to a decrease in plate strength and metal fatigue, potentially resulting in plate fractures (2,3). Additionally, intraoperative adjustment of the plate is often necessary. To address these challenges, in recent years, virtual operations using preoperative CT data have been employed to determine resection lines and reconstruction plate design, followed by the use of patient-specific implants (PSIs) manufactured using metal 3D printers. The development of PSIs has led to reduced surgical time and improved surgical accuracy compared to the results of conventional methods (4). In Japan, Cosmofix^®︎, a patient-specific internal fixation plate, was launched in 2022 and is covered by health insurance. Currently, this is the only system in Japan that involves metal 3D printers for reconstruction. However, this system consists solely of patient-specific internal fixation plates and does not include osteotomy guides, making it difficult to perform precise bone cuts at planned locations. To address these limitations, we developed a custom osteotomy guide using computer-aided design (CAD)/computer-aided manufacturing (CAM) technology and an in-house 3D printer. The resulting osteotomy guide indicates the bone cutting lines on the bone surface; however, it cannot show the lines in deeper layers. Furthermore, Cosmofix^®︎ lacks a guide for regulating the angle of screw insertion during fixation. To address these issues, we applied mixed reality (MR) technology. MR combines real-world and virtual elements within one display, typically through head-mounted displays (HMDs) that overlay digital objects onto the physical environment using optical and video see-through methods (5). It anchors virtual data to real-world surroundings regardless of user movement, enabling real-time interaction. In the medical field, MR offers potential advantages by integrating patient-specific data with live observations, supporting procedural planning, navigation, training, and education (6).

MR technology has been applied to interventions in the maxillofacial region and has been reported to improve surgical accuracy and safety in orthognathic surgery (7,8). In addition, the usefulness of MR technology in surgical assistance for tooth extraction, implant placement, and lesion resection has been reported (9). Furthermore, in the field of education, its application in implant placement training has been shown to have beneficial effects on learning outcomes (10).

In this study, we developed a method to improve surgical accuracy by creating osteotomy guides and MR applications from preoperative CT data in conjunction with Cosmofix^®︎. The novel system was used both preoperatively and intraoperatively for reconstruction after tumor resection in a case of mandibular ameloblastoma.

Surgical techniques

Preoperative preparations

PSI Cosmofix^®

Prior to surgery, CT (Somatom Definition AS, Munich, Germany) was performed, and 3D images were reconstructed from 0.6-mm thick slice data. Based on the CT data, we conducted a web conference with an engineer to determine the resection range and design the plate (Figure 1A,1B). To confirm the fit of the reconstruction plate during surgery, we designed a plate with claw-like protrusions on the inner side, ensuring that the plate would not shift laterally when fitted into the resection site (Figure 1C-1E).

Figure 1 Preoperative preparation of PSI. (A,B) Determining the extent of resection. (C,D) Reconstruction plate design. Green arrows indicate the claw-like protrusions for confirming plate fit. (E) Fabricated reconstruction plate. PSI, patient-specific implant.

Osteotomy guides

Osteotomy guides were designed using Magics (Materialize, Leuven, Belgium) based on the data from the designed plates (Figure 2A,2B). STL files were created, and bone-cutting guides were fabricated using a 3D printer (Objet 260 Connex; Stratasys Ltd., Eden Prairie, MN, USA) (Figure 2C,2D). The guide was designed to fit the patient’s specific jawbone bulge shape and to guide the plate into place. Additionally, screw holes were positioned to serve as fixation points for the reconstruction plates. In designing the iliac bone osteotomy guide, the volume of the particulate cancellous bone and marrow (PCBM) insertion space within the reconstruction plate was preoperatively calculated, thus enabling a preoperative estimation of the required amount of PCBM for reconstruction. In addition, considering the possibility of secondary implant treatment after reconstruction, the cortical bone portion of the iliac crest was designed to be transplanted onto the PCBM. The osteotomy guide was designed to satisfy these requirements.

Figure 2 Preoperative preparation of osteotomy guides. (A,B) Osteotomy guide design. (C,D) Fabricated osteotomy guide.

MR application

The MR application was created using Holoeyes MD (Holoeyes Inc., Tokyo, Japan), a cloud service for developing applications for HMDs (Figure 3A). With Holoeyes MD, STL data created through segmentation can be uploaded to a cloud service, enabling the creation of virtual reality or MR applications viewable through a HMD in just a few minutes. The created application allows for the adjustment of the size and transparency of holograms and displaying cross-sections in any desired plane. Holograms can be projected three-dimensionally into the surgical field or used in preoperative conferences within a virtual space, enabling multiple users to simultaneously confirm the resection range, position of the inferior alveolar nerve, and direction of screw insertion in three dimensions. This allowed all surgeons to proceed with the surgery with a shared understanding (Figure 3B).

Figure 3 MR application. (A) Creation of MR applications using cloud services. (B) Preoperative conferences can be held in virtual space. MR, mixed reality.

Accuracy verification

The overlay and evaluation of the preoperative simulation and postoperative imaging data were performed using GOM Inspect (GOM, Braunschweig, Germany). Preoperative virtual operations were compared with CT scans taken 4 months postoperatively. The image data overlay was performed semiautomatically using the best-fit method after selecting three arbitrary points (11). The region of interest was defined as the contralateral healthy side, and the percentage of the bone surface error within 1 mm was measured (12).

Patient background

A 22-year-old male patient presented with mobility of the lower anterior teeth and discomfort while eating in September 2022 and visited a nearby clinic. He was referred to our hospital for further examination and treatment in October of the same year. The patient had no significant medical history. Physical examination revealed swelling in the mental region and a papery texture of the gingiva in the lower anterior teeth. Panoramic radiography revealed a radiolucency extending from the right first molar to the left second premolar of the mandible, with root resorption from the right first molar to the left second premolar (Figure 4A). Additionally, on contrast-enhanced CT, buccoglossal bulging of the lesion was noted, with contrast enhancement at the margins, and the internal structure was slightly heterogeneous, showing lower CT values than in the surrounding muscles (Figure 4B). Contrast-enhanced magnetic resonance imaging (MRI) revealed contrast enhancement at the margins, and the internal structure showed high signal intensity on T1-weighted images (Figure 4C). Ameloblastoma in the midline of the mandible was suspected, and a window biopsy was performed from the midline of the mandible, confirming the diagnosis of papillary ameloblastoma. Following a period of decompression, a reduction in the lesion size was observed. Consequently, a mandibular segmental resection was planned, extending from the right mandibular first molar to the left mandibular first premolar. After measuring the reduction following the windowing procedure, mandibular segmental resection was planned. In addition, nerve repair surgery, Cosmofix^®︎, and iliac bone-based mandibular reconstruction were planned. Furthermore, an osteotomy guide was fabricated using CAD/CAM technology in the hospital laboratory, and MR-guided surgical assistance was planned.

Figure 4 Preoperative imaging findings. (A) Panoramic X-ray findings. (B) CT findings. (C) MRI findings. CT, computed tomography; MRI, magnetic resonance imaging.

During a preoperative web meeting with the engineer, the resection range was determined to be from the right first molar to the left first premolar of the mandible (Figure 1B). Following virtual surgery to remove the tumor, a reconstruction plate with protrusions for fit confirmation was designed (Figure 1C-1E), and an osteotomy guide for the mandible was subsequently fabricated (Figure 2C,2D). The holes for fixing the iliac osteotomy guide are designed to serve as screw holes for fixing the plate, thus facilitating a two-stage implant restoration by placing the iliac crest on the PCBM. Accordingly, the area of the designed reconstruction plate was measured, and an osteotomy guide was fabricated such that the area of the iliac cortical bone, when divided, matched the area of the reconstruction plate (Figure 5A-5C). The screw insertion positions and lengths were set based on simulation data. In addition, a surgical splint was fabricated using preoperative CT data to reproduce the occlusion.

Figure 5 Preoperative preparation of iliac osteotomy guide. (A) Designing osteotomy guides using CAD. (B) The minimum amount of bone required for reconstruction is measured in advance. (C) Fabricated iliac osteotomy guide. CAD, computer-aided design.

Surgical findings

The surgeons in charge were equipped with HMD and confirmed the surgical plan and precautions to be taken in the virtual space before starting the surgery. The resection range was determined using an osteotomy guide to replicate the simulation, and mandibular resection was performed (Figure 6A,6B). The Cosmofix^®︎ was temporarily fixed with screws, and the surgical splint was fitted into the oral cavity. Using MR technology, we confirmed that there were no abnormalities in the 3D jaw position, resection range, or implant direction angle, and then we closed the oral cavity (Figure 6C,6D).

Figure 6 Intraoperative findings. (A,B) Placement of osteotomy guides. (C) Fitting the reconstruction plate according to the preoperative plan. (D) MR imaging enables 3D intraoperative confirmation of the position of osteotomy guides, reconstruction plates, and screw insertion direction. 3D, three-dimensional; MR, mixed reality.

Subsequently, the temporary fixation of Cosmofix^®︎ was removed, and nerve repair surgery was performed on both sides of the mental nerve using nerve regeneration induction tubes. Next, Cosmofix^®︎ was fixed using six 12-mm non-locking screws and two 14-mm non-locking screws. MR imaging was used to confirm that there were no abnormalities in the jaw position, and the PCBM harvested from the right ilium and harvested ilium dome was divided according to the design and implanted to perform mandibular reconstruction. The surgical time was 7 h 41 min, and the blood loss was 513 mL.

Accuracy verification

Comparison of preoperative virtual operation data with postoperative CT data at 4 months revealed a bone surface error within 1 mm in 94.1% of the sampling points on the right side and in 92.9% of the sampling points on the left side (Figure 7A,7B).

Figure 7 Postoperative accuracy evaluation. (A,B) Regarding bone surface error, the percentage of errors within 1 mm on the healthy right side is 94.1%, and the percentage of errors within 1 mm on the left side is 92.9%.

Postoperative course

One year after surgery, no abnormalities were observed on postoperative panoramic X-ray images or CT scans of the plates or bone fragments, and no signs of recurrence were noted (Figure 8A,8B). Continuity between the PCBM and the surrounding healthy bone was confirmed by CT 1 year postoperatively. Additionally, recovery of sensory nerve function was evaluated using the Semmes-Weinstein monofilament test. In the mental nerve sensory area, the threshold was 300 g on the right and 2 g on the left immediately after surgery and had improved to 2 g on the right and 1.4 g on the left 1 year postoperatively. Prosthetic restoration using mandibular dentures was performed, and both the masticatory function and aesthetic appearance had improved (Figure 9A,9B). Implant-supported prosthetic restorations are planned for the future.

Figure 8 Postoperative imaging findings. (A,B) Panoramic X-ray and CT showed that appropriate reconstruction was performed according to the preoperative plan. CT, computed tomography.

Figure 9 Postoperative findings. (A) The reconstruction plate provides an aesthetic facial appearance. This image is published with the patient’s consent. (B) The use of dentures allows for good chewing function.

Ethical considerations

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Tokyo Dental College, Tokyo, Japan (No. 1054 and date of approval is 5/31/2021). Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Comments

Conventional mandibular reconstruction plates require manual bending and intraoperative fitting adjustments. In addition, intraoperative fitting adjustments lead to prolonged surgical time and increased patient burden. Using CT data, the Cosmofix^®︎ used in this study was designed in advance based on conferences with engineers, enabling a good fit and an expected reduction in surgical time. In this case, we compared preoperative virtual operation data with postoperative CT data at 4 months postoperatively and verified their accuracy. The percentage of errors within 1 mm was 94.1% on the right side and 92.9% on the left side, indicating good results. In previous reports using PSI for mandibular reconstruction, the percentage of errors within 2 mm when overlaying preoperative virtual operation and postoperative CT data was 80.1% (11). This indicates the usefulness of the proposed method. In the present case, unlike previous reports, the use of a tray-type PSI in conjunction with MR technology may have contributed to enhanced surgical precision (13). Additionally, the titanium mesh tray shape created using additive manufacturing is superior in terms of cosmetic outcomes, such as accurately reproducing complex facial contours (4). The combination of titanium mesh trays and iliac cancellous bone marrow fragments has been cited as a method for accurately reproducing the complex morphology of the mandible; however, titanium mesh trays have been problematic because of tray fractures caused by stress concentration (14). To avoid this difficulty, we had the engineers perform a 3D finite element stress analysis during the simulation of the plate design to determine whether the plate was strong enough to withstand occlusal forces. As a result, the novel system proved to be not only aesthetically beneficial but also highly functional. In particular, for defects spanning the mandibular midline, as in the present case, this plate is considered superior in terms of both strength and aesthetics. The reason for developing this method is that, as of November 2025, Cosmofix^®︎ is the only PSI covered by insurance in Japan, and there is no comparable system with an osteotomy guide. Furthermore, neoadjuvant therapies such as BRAF inhibitors, which have been reported in recent years, were not covered by insurance and were therefore not performed this time (15). Therefore, we designed an osteotomy guide based on the plate data and manufactured it in-house using CAD/CAM technology. The new system also has the advantage of being less expensive than those produced via metal 3D printers. The osteotomy guide for the mandible was designed based on the data from the plate created using CT data. This allowed us to determine the positions and lengths of the screws in advance. Additionally, the holes for the screws used for temporary fixation during osteotomy were designed to serve as screw holes for plate fixation, thereby simplifying the surgical technique and improving accuracy. While it is possible to predetermine the screw insertion angle and depth by incorporating a drill sleeve into the osteotomy guide, we utilized MR technology in this case to verify the insertion angle, taking into account the potential for intraoperative bleeding from the bone marrow. Furthermore, a unique innovation of this study is that conventional tray-type reconstruction plates often have ambiguous areas of fit with the healthy side of the jawbone. However, by adding claw-like protrusions to the inner side of the designed reconstruction plate, the plate was properly aligned with the resection site during surgery, thereby reducing the time required for plate alignment. As an alternative approach, pre-resection placement and pre-drilling of a PSI can be highly effective for maintaining the original maxillomandibular relationship. However, this method was not feasible in the present case due to severe buccolingual bone expansion from the tumor.

The osteotomy guide for iliac bone harvesting was designed by calculating the surface area of the upper layer of the plate designed for two-stage implant restoration and matching it to the area of the iliac cortical bone to be harvested. This allowed for harvesting of the minimum amount of iliac bone necessary to fit the Cosmofix^®︎ top area. In this case, the reconstruction plate played an important role in maintaining facial morphology. Considering that future implant prostheses may impose additional stress on the mandible, the treatment plan was to retain the plate rather than remove it. Free vascularized bone flap grafting using deep circumflex iliac artery (DCIA) or fibula is one of the standard techniques for extensive mandibular defects (16). However, in this case, considering the patient’s young age of 22 and the fact that the tumor was benign, priority was given to achieving both aesthetics and function. In this technique, the morphology and strength of the mandible were secured with high-strength PSI (Cosmofix^®), and by grafting PCBM and cortical bone from the iliac crest, we were able to achieve good reconstruction results while avoiding complex surgery involving microsurgery.

The MR technology applied in this study has been used to assist in various surgical procedures (17). In maxillofacial interventions, such as tumor resection and upper extremity surgery to repair and reconstruct the joint, navigation surgery using MR technology has been performed with similar results and favorable outcomes (18,19). MR technology is also useful for preoperative discussions, enabling the attending physician to share key surgical points in three dimensions beforehand (6,20). In the case described herein, seven physicians from the tumor resection and iliac bone harvesting teams participated in the procedure. Using the Holoeyes MD, each surgeon was able to fully conceptualize the detailed surgical procedures and anatomical structures, enabling safe surgery. One advantage of this method is that it does not require a large navigation system and can be performed using only a HMD, thereby reducing costs. Moreover, because 3D spatial awareness can be maintained during surgery, contrast-enhanced CT imaging can be utilized to visualize vascular and neural structures, enabling even less-experienced surgeons to safely perform anatomically complex procedures. As the location of the lesion can be confirmed in three dimensions, the extent of the surgical incision may also be minimized.

The limitations of this method include the use of MR technology during surgery to overlay holograms with the surgical field or position holograms at the location of the indirect view to confirm the resection range, the position of the plates and screws, and the jaw position. This method allowed confirmation of the 3D position of the jawbone by manually superimposing a hologram onto the surgical field during the operation. However, there was no means to quantitatively evaluate the positional accuracy in real time. Therefore, further improvement of this method is warranted; for example, using registration markers to automatically overlay holograms onto the surgical field, which would further improve accuracy (21). Therefore, at present, MR technology should be regarded as an assistive tool rather than a standalone navigation system, and further technological development and validation studies are required to establish its clinical utility (22). In addition, because a Wi-Fi environment is required for preoperative discussions in a virtual space, ensuring a stable Wi-Fi environment in the operating room is important. Other limitations include the fact that using an HMD can cause eye strain and dizziness (23). Another consideration is the lighting in an operating room, which can interfere with the visibility of the holograms (24).

Conclusions

With this report of a mandibular reconstruction, we describe a novel system for mandibular resection surgery and plate insertion using a Cosmofix^®︎ titanium plate, an osteotomy guide fabricated in-house, and MR technology, achieving favorable outcomes.

Acknowledgments

We would like to extend our deepest gratitude to the medical staff of the Department of Oral Pathobiological Science and Surgery and the Department of Oral and Maxillofacial Surgery, Tokyo Dental College, Suidobashi Hospital.

Footnote

Funding: This research was funded by the Japan Society for the Promotion of Science (No. JP25K17088).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2026-0407/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Tokyo Dental College, Tokyo, Japan (No. 1054 and date of approval is 5/31/2021). Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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