Three-dimensional printed titanium mesh combined with iliac cancellous bone in the reconstruction of mandibular defects secondary to ameloblastoma resection

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However, the precision and symmetry of this repair are deficient, and patients have a risk of vascular embolism, flap necrosis and donor site complications. Therefore, to explore an ideal alternative in mandibular reconstruction with high surgical accuracy and low complications is indispensable. Methods Seven patients with recurrent or large-scope ameloblastoma were enrolled in this study. All patients were provided with a fully digital treatment plan, including the design of osteotomy lines, surgical guides, and three-dimensional printed titanium mesh for implantation. With the assistance of a surgical guide, ameloblastomas were resected, and custom 3D printed titanium mesh combined with posterior iliac bone harvest was used in mandibular reconstruction. The surgical discrepancy between the surgical plan and the real result was compared. At the same time, the resorption rate of the implanted bone was evaluated. Results All patients completed the fully digital treatment process successfully without severe complications. Image fusion showed that the postoperative contour of the mandible was basically consistent with surgical planning, except for a slight increase in the inferior border of the affected side. The mean error between the intraoperative bone volume and the digital planning bone volume was 2.44%±2.10%. Furthermore, the bone resorption rates of the harvested graft 6 months later were 32.15%±6.95%. Conclusions The use of digital surgical planning and 3D-printed templates can assist surgeons in performing precise surgery, and the 3D-printed titanium mesh implant can improve the patient's facial symmetry. 3D printed titanium combined with posterior iliac cancellous bone graft can be regarded as an ideal alternative in extensive mandibular reconstruction. Virtual surgical planning Mandible reconstruction 3D-printing iliac cancellous bone surgical accuracy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 BACKGROUND Ameloblastoma (AM) is a rare benign odontogenic tumor of the jaw, and its incidence is about 1% of all head and neck tumors[ 1 ]. The tumor is most commonly found in the mandible (80%), located in the molar and ramus regions, and arises from epithelial and/or ectomesenchymal tissue participating in the formation of teeth[ 2 ]. It has the characteristic of easy recurrence, and larger or multiple recurrent tumors require segmental mandibular resection. The reconstruction of extensive mandibular defect is a challenge. The prevalent approach to reconstructing mandible defects involves the application of vascularized free bone flaps, such as fibula and iliac bone[ 3 ]. However, there are issues such as vascular crisis, flap necrosis, facial asymmetry, difficulty in dental restoration, etc. At the same time, there are complications, such as dysfunction and pain at the donor site[ 4 – 6 ]. Digital technology provides us with an optimal solution. Virtual surgical planning and 3D printing offer more effective and predictable reconstruction outcomes. In addition, the posterior iliac cancellous bone is commonly used in maxillofacial reconstruction. It can provide enough amounts of bone while also preserving the outer contours of the iliac bone. Moreover, compared to those who underwent fibula or iliac bone harvesting, patients who receive posterior iliac cancellous bone grafts generally experience less severe complications at the donor site[ 7 , 8 ]. For these reasons, this study was to explore the feasibility of 3D printed titanium mesh combined with a posterior iliac cancellous bone to repair mandibular defects caused by ameloblastoma, and surgical accuracy and long-term osteogenesis were evaluated. MATERIALS AND METHODS Patients Seven patients with large scope or recurrent mandibular ameloblastomas were enrolled in this study. All patients (4 males and 3 females; mean age 38.86 years old) underwent ameloblastoma resection and sequential mandibular reconstruction with 3D printed titanium mesh and posterior iliac cancellous bone grafts. This study was approved by the Ethics Committee of the Ninth People's Hospital (SH9H-2021-T65-1), and informed consent was obtained. Surgical planning For each case, clinical information was collected, including CT scans and dental plaster models. The CT scans had a pixel size of 0.45 mm x 0.45 mm, slice intervals of 1.25 mm, and a resolution of 512×512×231 (LightSpeed Ultra 16 spiral CT machine, GE Company, USA). The scan data was imported into ProPlan CMF 3.0 software (Materialise, Leuven, Belgium). The scope of ameloblastoma and osteotomy lines were defined in horizontal, sagittal, coronal plane, and 3D reconstruction models (Fig. 1 A). To ensure the precision of the procedure, the osteotomy templates were designed based on the location of the osteotomy line (Fig. 1 B). Frankfort horizontal plane (FH), which was formed by the overlying bilateral porions (P) and the left orbital point (OrL), was defined as the reference plane. Then the median sagittal plane (SP) was defined by the points of Sella (S), Nasion (N), and perpendicular to the FH in the patient's 3D reconstruction model. To reconstruct the defect, the median sagittal plane was used as a reference plane. Normal anatomic structures and the contour of the target area were mirrored from the unaffected side. Thus, the normal contour of the affected area was ascertained (Fig. 2 A). A virtual model of the titanium mesh restoration was designed based on the mirrored mandibular contour. (Fig. 2 B). Before surgery, all designed templates of the patient's mandible and osteotomy templates were saved as STL files and sent to a fully automated rapid stereolithography machine (SLA3500, 3D Systems, Texas, United States). Then they were printed using selective laser sintering (SLS) in polyamide, and the implant of titanium mesh was also printed (M2 cusing Multilaser, Concept Laser, German) (Fig. 3 ). Surgical procedure According to the surgical plan, the surgery was performed by accessing the inferior border of the mandible. The osteotomy templates were mounted on the buccal side of mandible as well as on the inferior border. According to the templates, the mandibular ameloblastoma was resected (Fig. 4 A, B). The 3D-printed titanium mesh was installed with the predrilled hole method (Fig. 4 C, D). Then cancellous bone graft was harvested from the right posterior iliac crest, and was filled into the titanium mesh (Fig. 5 ). Finally, the incisions in oral and submandibular region were tightly sutured. Evaluation In this study, the accuracy of osteotomy with the guidance of 3D printed osteotomy templates, the symmetry of patient's mandibular contour after surgery, and the resorption rate of the grafted bone 6 months after surgery were evaluated. To assess the surgical accuracy between digital planning and the actual outcome, image fusion of two models was performed. All superimposition and reference point determination processes were performed respectively using ProPlan software, in the “Scan registration wizard” of the “Segment” module and the “Measure and Analysis” of the “CMF/Simulation” mode. In the reconstructed model from postoperative CT scans, new osteotomy planes along the surgical incision were created (Fig. 6 A). These planes were then superimposed on the preoperative mandible model to obtain an approximation of the intraoperative bone volume (Fig. 6 B). The difference between this volume and the simulated bone volume in the surgery was used as an indicator to assess accuracy (Fig. 6 C). Using Geomagic Studio 2013 software allowed us to perform a 3D surface-to-surface matching process, which utilizes a least-mean-squared algorithm to align the actual postoperative mandible with the virtual surgical design. This process helps to confirm the precision of the virtual surgical design and ensures that the actual surgery meets the planned specifications. (Fig. 7 ). Patients with mandibular defects will continue to seek restoration of occlusal function after surgery, such as implant restoration. Therefore, the bone resorption rates in the grafted area also need attention. The preoperative and postoperative CT images were compared by measuring the volume of harvested graft (V0), and the volume of the bone grafted 6 months later (V6). And the bone resorption rates (RR)= (V0-V6)/V0*100%. RESULT With completely digital plans, all patients achieved satisfactory clinical results, and no severe infections or complications were occurred. All patients underwent CT scans six months after surgery (Fig. 8 ) and no tumor recurrence occurred. Combining the results of the model alignment, the postoperative contour of the patient's mandible was consistent with the surgical plan except for a slight increase in the inferior border of the affected side. The mean error between the intraoperative bone volume and the digital planning bone volume was 2.44%±2.10%`. And mean resorption rate of the bone grafted 6 months later was 32.15%±6.95% (Table 1 ). Table 1 Accuracy of postoperative results compared with virtual surgical planning and bone resorption rates of the bone grafted sample Gender/Age (years) The volume of bone resection (mm 3 ) The volume of bone grafted (mm 3 ) Digital Actual Error (%) V0 V6 RR 1 F/24 14136.63 14393.34 256.71 (1.82%) 18268.56 13463.15 26.30% 2 F/53 10817.81 11523.38 705.57 (6.52%) 13442.89 8612.43 35.93% 3 F/36 9949.12 10106.21 157.09 (1.58%) 14868.98 9106.65 38.75% 4 M/57 16505.47 16328.01 -177.46 (-1.08%) 18008.49 14442.32 19.80% 5 M/27 8581.26 8838.15 256.89 (2.99%) 10736.37 6254.12 41.75% 6 M/42 14975.48 15299.27 323.79 (2.16%) 20195.46 13954.27 30.90% 7 M/33 18364.92 18932.22 567.3 (3.09%) 22201.93 15192.67 31.57% Average 38.86 ± 11.61 13332.96 ± 3361.21 13631.51 ± 3350.45 298.56 ± 264.20 (2.44%±2.10%) 16817.53 ± 3705.05 11575.09 ± 3245.14 32.15%±6.95% V0, the volume of harvested graft; V6, the volume of the bone grafted 6 months later; DISCUSSION Based on the most recent 2017 WHO classification, several variations of ameloblastoma can be identified, including the traditional type (solid/multicystic – AMSMA), unicystic (AM-UA), and extraosseous/peripheral (AM-PA)[ 9 ]. It should be noted that all these subtypes are locally infiltrative and have the potential to progress to the malignant/quiescent form (AM-MA) [ 10 , 11 ]. Therefore, for AMSMA, a segmental resection with a margin of 1–2 cm has been favored[ 12 ]. However, the determination of the osteotomy line during traditional mandibular osteotomies is heavily reliant on the experience and judgment of the operating surgeon, which may result in inaccuracies and recurrence. In this study, with the assistance of preoperative digital design and 3D printed osteotomy templates, the volume of bone resection was basically consistent with preoperative design. This approach can minimize the reduction of normal mandibular bone tissue and tumor recurrence in patients, and favorable conditions were provided for the restoration of patients' occlusion and the dental restoration. The recommended approach for reconstructing mandible and soft tissue defects secondary to tumor resection is vascularized free bone flaps, including fibular free flap (FFF) or iliac crest flap (ICF) [ 13 ]. For autogenous bone grafts, the fibula is the preferred option for long bone or angle-to-angle jaw reconstructions, but for mandibular reconstructions, the iliac crest is deemed superior[ 14 ]. Both FFF and ICF procedures carry the risk of vascular embolism, flap necrosis, and postoperative complications in the donor area, which may harm the patient’s quality of life. According to recent research, individuals who receive either FFF or ICF procedures have been found to commonly experience a reduced joint range of motion, sensory impairments in the donor site, loading pain, and limited movement following surgery[ 15 – 17 ]. However, iliac cancellous bone is widely used as a donor site for correcting maxillofacial bone defects, especially posterior iliac bone [ 18 ]. It supplies more cancellous bone to restore the alveolar height of the affected area while minimizing alterations to the profile of the iliac bone[ 19 ]. A previous research study exploring the repair of alveolar defects showed a 48.91% resorption rate of iliac cancellous bone[ 20 ], whereas this study found the rate to be 32.15%, suggesting that iliac cancellous bone could be a viable option for repairing bone defects. In this study, it was observed that the reconstructed volume of the grafted iliac cancellous bone was greater than the volume of the bone block removed during the preoperative virtual surgery (Table 1 ). Previous research suggests that compared to other frequently used autogenous bone donor regions, the iliac bone has lower bone density and a more porous bone structure[ 21 ]. This can potentially result in a greater amount of bone volume at the reconstructed site after surgery. Reduction in the volume of implanted bone can be attributed to two factors: autoimmune reaction leading to bone resorption[ 22 ] and alterations in bone density in the reconstruction area[ 23 ]. Bone resorption commonly correlates with chronic inflammation, M1 macrophages activation, increased generation of reactive oxygen species (ROS), and extended periods of inflammation while bone is being regenerated[ 24 , 25 ]. Moreover, the grafted cancellous bone not only offers mechanical support but also a vast reservoir of bone marrow-derived mesenchymal stem cells (BMSCs)[ 26 ]. BMSCs' migration and differentiation from bone marrow are essential in transforming the cancellous bone's porous structure into a structurally compact form that progressively evolves into cortical bone. In recent years, digital techniques have made significant progress in mandibular reconstruction, providing more precise and direct approaches. However, current biomaterials are inadequate in bridging or filling the anatomic shape and structure of lost bone tissue, making them incapable of meeting surgical demands for larger critical-sized defects[ 27 ]. Nevertheless, 3D printing technologies in bone tissue engineering offer a revolutionary advancement in traditional treatments for large bone defects by overcoming these challenges[ 28 ]. Surgeons can calculate and analyze the size and volume of jaw defects via computer-aided design/computer-aided manufacturing (CAD/CAM) to design osteotomy lines using virtual surgery for patients with ameloblastoma. Among all metal materials, titanium and its alloys offer commendable biocompatibility, high strength-to-weight ratio, low modulus of elasticity, and exceptional corrosion resistance, making them suitable as scaffolds for bone growth and reconstructing significant bone defects.[ 29 ]. A 3D-printed titanium mesh should have adequate compressive capacity to avoid any probable collapse or displacement during bone defect restoration, ultimately providing appropriate space and mechanical support for new bone growth[ 30 ]. Additionally, the favorable metabolism of bone marrow mesenchymal stem cells, growth factors, and other substances that promote osteogenesis require sufficient blood supply, leading to extensive use of 3D-printed implants made from titanium and its alloys due to their ability to provide such adequate blood supply[ 31 ]. According to this study, the use of digital surgery planning and 3D-printed templates can assist surgeons in performing precise surgeries. The difference between virtual surgical planning and the real outcomes was within allowable limits. And surgeons who participated in the surgical planning and template design reported greater familiarity and confidence in performing the procedure. Although attaining satisfactory outcomes, the discrepancies in distance and volume are still observed, which may arise from multiple sources. Firstly, surgical errors can be minimized but not entirely eliminated. Secondly, the CT scan model might present minor distortions. Thirdly, slight discrepancies may be introduced during computer-aided planning and verification procedures. Finally, the deformation of osteotomy templates could also contribute to these inaccuracies. CONCLUSIONS Above all, this study investigated a novel approach utilizing a fully digital treatment methodology for the reconstruction of bone defects resulting from ameloblastoma resection. Moreover, the digital workflow exhibited high levels of predictability, accuracy and effectiveness, ranging from pre-treatment assessment to final restoration. Declarations Acknowledgements Not applicable. Authors’ contributions Zhiyang Zhao gathered and analyzed data and wrote the majority of the original draft. Hongbo Yu did orthognathic surgery and contributed to the original draft. The statistical analysis was completed by Shunyao Shen and Guanrong Ding. Meng Li designed the research and edited the draft. Hongbo Yu and Guofang Shen provided the study framework and reviewed the draft. All authors read and approved the final manuscript. Funding This work was supported by National Natural Science Foundation of China (81571022), Multi-center clinical research project of Shanghai Jiao Tong University School of Medicine (DLY201808), and Shanghai Natural Science Foundation（23ZR1438100）. Data Availability All data generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate This study was approved by the hospital institutional review board of Shanghai Ninth People’s Hospital (SH9H-2021-T65-1), and all procedures were carried out in accordance with relevant guidelines and regulations. The informed consent agreements were obtained from all patients. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Author details 1 Department of Oral and Craniomaxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai Jiao Tong University; National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology; Shanghai Research Institute of Stomatology. 2 Department of Radiology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, China References Masthan KM, Anitha N, Krupaa J, Manikkam S: Ameloblastoma . J Pharm Bioallied Sci 2015, 7 (Suppl 1):S167-170. Sozzi D, Cassoni A, De Ponti E, Moretti M, Pucci R, Spadoni D, Canzi G, Novelli G, Valentini V: Effectiveness of Resective Surgery in Complex Ameloblastoma of the Jaws: A Retrospective Multicenter Observational Study . 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Cite Share Download PDF Status: Published Journal Publication published 20 Sep, 2023 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Major revision 07 Aug, 2023 Reviews received at journal 05 Aug, 2023 Reviewers agreed at journal 02 Aug, 2023 Reviewers invited by journal 02 Aug, 2023 Editor assigned by journal 02 Aug, 2023 Editor invited by journal 16 Jun, 2023 Submission checks completed at journal 16 Jun, 2023 First submitted to journal 09 Jun, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3043139","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":210589135,"identity":"a140bf2b-ad26-4bb1-9be3-52ab90ca32f5","order_by":0,"name":"Zhiyang Zhao","email":"","orcid":"","institution":"Department of Oral and Craniomaxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai Jiao Tong University; National","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhiyang","middleName":"","lastName":"Zhao","suffix":""},{"id":210589136,"identity":"52848b50-f7a5-47e5-b476-771c9ee0c630","order_by":1,"name":"Shunyao Shen","email":"","orcid":"","institution":"Department of Oral and Craniomaxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai Jiao Tong University; National","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shunyao","middleName":"","lastName":"Shen","suffix":""},{"id":210589137,"identity":"0f5ddd14-7c60-4c16-ab33-abe71fcc68f3","order_by":2,"name":"Hongbo Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvUlEQVRIiWNgGAWjYDACCR7mxz8MbOTY2NsPEK2FzZihIs2Yj+dMAtFaGKQZzhxOnCfhYECcDoPbvQeMC9vS0tskGBIYflRsI0LLnXMJj2e22eS2STceYOw5c5sILTdyDAx429Jy22QOJDAzthGpRYK37XA6m0SCAfFapHnOHE4gXovkjbw0wxkVaYZtwEA+SJRf+G7kHn7wwcBGXr69/eCDHxVEaFE4gMQ5gEMRKpBvIErZKBgFo2AUjGgAAAylQCruv3ETAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Oral and Craniomaxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai Jiao Tong University; National","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hongbo","middleName":"","lastName":"Yu","suffix":""},{"id":210589138,"identity":"dca157b4-edd5-445f-a594-18749a1ccfd5","order_by":3,"name":"Guofang Shen","email":"","orcid":"","institution":"Department of Oral and Craniomaxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai Jiao Tong University; National","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Guofang","middleName":"","lastName":"Shen","suffix":""},{"id":210589139,"identity":"00e20296-9570-4344-9e49-2a0172dd5cb5","order_by":4,"name":"Meng Li","email":"","orcid":"","institution":"Department of Oral and Craniomaxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai Jiao Tong University; National","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Meng","middleName":"","lastName":"Li","suffix":""},{"id":210589140,"identity":"ff32059c-3494-40a2-a944-2fd65b9a2977","order_by":5,"name":"Guanrong Ding","email":"","orcid":"","institution":"Department of Radiology,Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Guanrong","middleName":"","lastName":"Ding","suffix":""}],"badges":[],"createdAt":"2023-06-09 11:59:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3043139/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3043139/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-023-03386-0","type":"published","date":"2023-09-20T15:00:34+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":39101314,"identity":"239abd52-396b-4e41-9350-74c91f442bb0","added_by":"auto","created_at":"2023-06-26 17:47:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":849748,"visible":true,"origin":"","legend":"\u003cp\u003eA clear view of the range of mandibular ameloblastoma (A), and the osteotomy templates (B).\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3043139/v1/07c44028482099132c1e3036.png"},{"id":39101321,"identity":"cb0adb12-e8d0-4d72-aa1c-d7344562cc56","added_by":"auto","created_at":"2023-06-26 17:47:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":785099,"visible":true,"origin":"","legend":"\u003cp\u003eThe 3D titanium mesh reconstruction model of the mandible. (A) The contour of the affected side of the mandible (blue) was mirrored from the unaffected side. (B) The 3D titanium mesh reconstruction model of the mandible was designed.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-3043139/v1/18d3160f4659460f3a467deb.png"},{"id":39104098,"identity":"c92f352b-991d-479c-8b9b-c8acfe236136","added_by":"auto","created_at":"2023-06-26 18:03:17","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1691539,"visible":true,"origin":"","legend":"\u003cp\u003eAll models and templateswere printed on a 3D printer: osteotomy templates, original mandible model, and titanium mesh.\u003c/p\u003e","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-3043139/v1/81fdbae111538494a3b3000b.png"},{"id":39101315,"identity":"0fa3cd02-3901-4788-a178-c59fd3e38ccb","added_by":"auto","created_at":"2023-06-26 17:47:17","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":3330843,"visible":true,"origin":"","legend":"\u003cp\u003eResection of tumor and installation of titanium mesh. (A) The osteotomy templates were mounted. (B) The tumor was resected. (C, D) Titanium mesh after the installation was displayed in different angles.\u003c/p\u003e","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-3043139/v1/1d275410fde62da880abe48e.png"},{"id":39102852,"identity":"fddb4c6f-6f37-4df6-b749-3d03eca0de8b","added_by":"auto","created_at":"2023-06-26 17:55:17","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1998173,"visible":true,"origin":"","legend":"\u003cp\u003eThe harvest and placement of cancellous bone from the iliac bone.\u003c/p\u003e","description":"","filename":"figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-3043139/v1/03ffeb08bce7d2a1aeeb703e.png"},{"id":39102850,"identity":"61533267-b6ab-4f59-94bf-724df98bf2f8","added_by":"auto","created_at":"2023-06-26 17:55:17","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":491501,"visible":true,"origin":"","legend":"\u003cp\u003eVolume of bone resection during surgery. \u0026nbsp;(A) The osteotomy planes along the surgical incision were created. (B) The osteotomy planes were then superimposed on the preoperative mandible model. The blue plane is the bone resection plane during surgery, while the green plane is the bone resection plane in digital planning. (C) The block of bone resection during surgery was shown, and different areas from the digital planning are indicated by red arrows.\u003c/p\u003e","description":"","filename":"figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-3043139/v1/dba32deb60eba7c89c71552f.png"},{"id":39101317,"identity":"d9e2d981-5ade-49a2-b3d3-d3ae021f324b","added_by":"auto","created_at":"2023-06-26 17:47:17","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":1111067,"visible":true,"origin":"","legend":"\u003cp\u003eDiscrepancy analysis of dental alignmentbetween simulation and real result.\u003c/p\u003e","description":"","filename":"figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-3043139/v1/bef563c4771f31f6cccc34e3.png"},{"id":39101320,"identity":"6005b494-6a0e-45d1-8b57-8a409a646a3c","added_by":"auto","created_at":"2023-06-26 17:47:17","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":2008690,"visible":true,"origin":"","legend":"\u003cp\u003eThe CT images at seven days post-operation (upper) and six months post-operation (lower) Additional CT images taken at the same horizontal position were also displayed, with red arrows indicating the cancellous bone of the ilium.\u003c/p\u003e","description":"","filename":"figure8.png","url":"https://assets-eu.researchsquare.com/files/rs-3043139/v1/c41719e9553ca987209eb0cf.png"},{"id":43640302,"identity":"f39d247f-6078-4801-bca5-178427841043","added_by":"auto","created_at":"2023-09-25 15:04:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":8847493,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3043139/v1/3aa1dafe-8907-46de-84ca-42d00acfb7cd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Three-dimensional printed titanium mesh combined with iliac cancellous bone in the reconstruction of mandibular defects secondary to ameloblastoma resection","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eAmeloblastoma (AM) is a rare benign odontogenic tumor of the jaw, and its incidence is about 1% of all head and neck tumors[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The tumor is most commonly found in the mandible (80%), located in the molar and ramus regions, and arises from epithelial and/or ectomesenchymal tissue participating in the formation of teeth[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It has the characteristic of easy recurrence, and larger or multiple recurrent tumors require segmental mandibular resection. The reconstruction of extensive mandibular defect is a challenge. The prevalent approach to reconstructing mandible defects involves the application of vascularized free bone flaps, such as fibula and iliac bone[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, there are issues such as vascular crisis, flap necrosis, facial asymmetry, difficulty in dental restoration, etc. At the same time, there are complications, such as dysfunction and pain at the donor site[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDigital technology provides us with an optimal solution. Virtual surgical planning and 3D printing offer more effective and predictable reconstruction outcomes. In addition, the posterior iliac cancellous bone is commonly used in maxillofacial reconstruction. It can provide enough amounts of bone while also preserving the outer contours of the iliac bone. Moreover, compared to those who underwent fibula or iliac bone harvesting, patients who receive posterior iliac cancellous bone grafts generally experience less severe complications at the donor site[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor these reasons, this study was to explore the feasibility of 3D printed titanium mesh combined with a posterior iliac cancellous bone to repair mandibular defects caused by ameloblastoma, and surgical accuracy and long-term osteogenesis were evaluated.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eSeven patients with large scope or recurrent mandibular ameloblastomas were enrolled in this study. All patients (4 males and 3 females; mean age 38.86 years old) underwent ameloblastoma resection and sequential mandibular reconstruction with 3D printed titanium mesh and posterior iliac cancellous bone grafts. This study was approved by the Ethics Committee of the Ninth People's Hospital (SH9H-2021-T65-1), and informed consent was obtained.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical planning\u003c/h2\u003e \u003cp\u003eFor each case, clinical information was collected, including CT scans and dental plaster models. The CT scans had a pixel size of 0.45 mm x 0.45 mm, slice intervals of 1.25 mm, and a resolution of 512\u0026times;512\u0026times;231 (LightSpeed Ultra 16 spiral CT machine, GE Company, USA). The scan data was imported into ProPlan CMF 3.0 software (Materialise, Leuven, Belgium). The scope of ameloblastoma and osteotomy lines were defined in horizontal, sagittal, coronal plane, and 3D reconstruction models (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). To ensure the precision of the procedure, the osteotomy templates were designed based on the location of the osteotomy line (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFrankfort horizontal plane (FH), which was formed by the overlying bilateral porions (P) and the left orbital point (OrL), was defined as the reference plane. Then the median sagittal plane (SP) was defined by the points of Sella (S), Nasion (N), and perpendicular to the FH in the patient's 3D reconstruction model. To reconstruct the defect, the median sagittal plane was used as a reference plane. Normal anatomic structures and the contour of the target area were mirrored from the unaffected side. Thus, the normal contour of the affected area was ascertained (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). A virtual model of the titanium mesh restoration was designed based on the mirrored mandibular contour. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBefore surgery, all designed templates of the patient's mandible and osteotomy templates were saved as STL files and sent to a fully automated rapid stereolithography machine (SLA3500, 3D Systems, Texas, United States). Then they were printed using selective laser sintering (SLS) in polyamide, and the implant of titanium mesh was also printed (M2 cusing Multilaser, Concept Laser, German) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure\u003c/h2\u003e \u003cp\u003eAccording to the surgical plan, the surgery was performed by accessing the inferior border of the mandible. The osteotomy templates were mounted on the buccal side of mandible as well as on the inferior border. According to the templates, the mandibular ameloblastoma was resected (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA, B). The 3D-printed titanium mesh was installed with the predrilled hole method (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC, D). Then cancellous bone graft was harvested from the right posterior iliac crest, and was filled into the titanium mesh (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Finally, the incisions in oral and submandibular region were tightly sutured.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation\u003c/h2\u003e \u003cp\u003eIn this study, the accuracy of osteotomy with the guidance of 3D printed osteotomy templates, the symmetry of patient's mandibular contour after surgery, and the resorption rate of the grafted bone 6 months after surgery were evaluated.\u003c/p\u003e \u003cp\u003eTo assess the surgical accuracy between digital planning and the actual outcome, image fusion of two models was performed. All superimposition and reference point determination processes were performed respectively using ProPlan software, in the \u0026ldquo;Scan registration wizard\u0026rdquo; of the \u0026ldquo;Segment\u0026rdquo; module and the \u0026ldquo;Measure and Analysis\u0026rdquo; of the \u0026ldquo;CMF/Simulation\u0026rdquo; mode. In the reconstructed model from postoperative CT scans, new osteotomy planes along the surgical incision were created (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eA). These planes were then superimposed on the preoperative mandible model to obtain an approximation of the intraoperative bone volume (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eB). The difference between this volume and the simulated bone volume in the surgery was used as an indicator to assess accuracy (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eC). Using Geomagic Studio 2013 software allowed us to perform a 3D surface-to-surface matching process, which utilizes a least-mean-squared algorithm to align the actual postoperative mandible with the virtual surgical design. This process helps to confirm the precision of the virtual surgical design and ensures that the actual surgery meets the planned specifications. (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients with mandibular defects will continue to seek restoration of occlusal function after surgery, such as implant restoration. Therefore, the bone resorption rates in the grafted area also need attention. The preoperative and postoperative CT images were compared by measuring the volume of harvested graft (V0), and the volume of the bone grafted 6 months later (V6). And the bone resorption rates (RR)= (V0-V6)/V0*100%.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"RESULT","content":"\u003cp\u003eWith completely digital plans, all patients achieved satisfactory clinical results, and no severe infections or complications were occurred. All patients underwent CT scans six months after surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig8\" class=\"InternalRef\"\u003e8\u003c/span\u003e) and no tumor recurrence occurred.\u003c/p\u003e \u003cp\u003eCombining the results of the model alignment, the postoperative contour of the patient's mandible was consistent with the surgical plan except for a slight increase in the inferior border of the affected side. The mean error between the intraoperative bone volume and the digital planning bone volume was 2.44%\u0026plusmn;2.10%`. And mean resorption rate of the bone grafted 6 months later was 32.15%\u0026plusmn;6.95% (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAccuracy of postoperative results compared with virtual surgical planning and bone resorption rates of the bone grafted\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003esample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender/Age\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eThe volume of bone resection\u003c/p\u003e \u003cp\u003e(mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eThe volume of bone grafted\u003c/p\u003e \u003cp\u003e(mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDigital\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eActual\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eError (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eV0\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14136.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14393.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e256.71 (1.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18268.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13463.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e26.30%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10817.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11523.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e705.57 (6.52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13442.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8612.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e35.93%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF/36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9949.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10106.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e157.09 (1.58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14868.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9106.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e38.75%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16505.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16328.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-177.46 (-1.08%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18008.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e14442.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e19.80%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8581.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8838.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e256.89 (2.99%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10736.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6254.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e41.75%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14975.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15299.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e323.79 (2.16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20195.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13954.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e30.90%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM/33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18364.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18932.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e567.3 (3.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22201.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15192.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e31.57%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.86\u0026thinsp;\u0026plusmn;\u0026thinsp;11.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13332.96\u0026thinsp;\u0026plusmn;\u0026thinsp;3361.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13631.51\u0026thinsp;\u0026plusmn;\u0026thinsp;3350.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e298.56\u0026thinsp;\u0026plusmn;\u0026thinsp;264.20\u003c/p\u003e \u003cp\u003e(2.44%\u0026plusmn;2.10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16817.53\u0026thinsp;\u0026plusmn;\u0026thinsp;3705.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11575.09\u0026thinsp;\u0026plusmn;\u0026thinsp;3245.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e32.15%\u0026plusmn;6.95%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eV0, the volume of harvested graft; V6, the volume of the bone grafted 6 months later;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eBased on the most recent 2017 WHO classification, several variations of ameloblastoma can be identified, including the traditional type (solid/multicystic \u0026ndash; AMSMA), unicystic (AM-UA), and extraosseous/peripheral (AM-PA)[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. It should be noted that all these subtypes are locally infiltrative and have the potential to progress to the malignant/quiescent form (AM-MA) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, for AMSMA, a segmental resection with a margin of 1\u0026ndash;2 cm has been favored[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the determination of the osteotomy line during traditional mandibular osteotomies is heavily reliant on the experience and judgment of the operating surgeon, which may result in inaccuracies and recurrence. In this study, with the assistance of preoperative digital design and 3D printed osteotomy templates, the volume of bone resection was basically consistent with preoperative design. This approach can minimize the reduction of normal mandibular bone tissue and tumor recurrence in patients, and favorable conditions were provided for the restoration of patients' occlusion and the dental restoration.\u003c/p\u003e \u003cp\u003eThe recommended approach for reconstructing mandible and soft tissue defects secondary to tumor resection is vascularized free bone flaps, including fibular free flap (FFF) or iliac crest flap (ICF) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. For autogenous bone grafts, the fibula is the preferred option for long bone or angle-to-angle jaw reconstructions, but for mandibular reconstructions, the iliac crest is deemed superior[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Both FFF and ICF procedures carry the risk of vascular embolism, flap necrosis, and postoperative complications in the donor area, which may harm the patient\u0026rsquo;s quality of life. According to recent research, individuals who receive either FFF or ICF procedures have been found to commonly experience a reduced joint range of motion, sensory impairments in the donor site, loading pain, and limited movement following surgery[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, iliac cancellous bone is widely used as a donor site for correcting maxillofacial bone defects, especially posterior iliac bone [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It supplies more cancellous bone to restore the alveolar height of the affected area while minimizing alterations to the profile of the iliac bone[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A previous research study exploring the repair of alveolar defects showed a 48.91% resorption rate of iliac cancellous bone[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], whereas this study found the rate to be 32.15%, suggesting that iliac cancellous bone could be a viable option for repairing bone defects.\u003c/p\u003e \u003cp\u003eIn this study, it was observed that the reconstructed volume of the grafted iliac cancellous bone was greater than the volume of the bone block removed during the preoperative virtual surgery (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Previous research suggests that compared to other frequently used autogenous bone donor regions, the iliac bone has lower bone density and a more porous bone structure[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This can potentially result in a greater amount of bone volume at the reconstructed site after surgery. Reduction in the volume of implanted bone can be attributed to two factors: autoimmune reaction leading to bone resorption[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and alterations in bone density in the reconstruction area[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Bone resorption commonly correlates with chronic inflammation, M1 macrophages activation, increased generation of reactive oxygen species (ROS), and extended periods of inflammation while bone is being regenerated[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Moreover, the grafted cancellous bone not only offers mechanical support but also a vast reservoir of bone marrow-derived mesenchymal stem cells (BMSCs)[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. BMSCs' migration and differentiation from bone marrow are essential in transforming the cancellous bone's porous structure into a structurally compact form that progressively evolves into cortical bone.\u003c/p\u003e \u003cp\u003eIn recent years, digital techniques have made significant progress in mandibular reconstruction, providing more precise and direct approaches. However, current biomaterials are inadequate in bridging or filling the anatomic shape and structure of lost bone tissue, making them incapable of meeting surgical demands for larger critical-sized defects[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Nevertheless, 3D printing technologies in bone tissue engineering offer a revolutionary advancement in traditional treatments for large bone defects by overcoming these challenges[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Surgeons can calculate and analyze the size and volume of jaw defects via computer-aided design/computer-aided manufacturing (CAD/CAM) to design osteotomy lines using virtual surgery for patients with ameloblastoma. Among all metal materials, titanium and its alloys offer commendable biocompatibility, high strength-to-weight ratio, low modulus of elasticity, and exceptional corrosion resistance, making them suitable as scaffolds for bone growth and reconstructing significant bone defects.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A 3D-printed titanium mesh should have adequate compressive capacity to avoid any probable collapse or displacement during bone defect restoration, ultimately providing appropriate space and mechanical support for new bone growth[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Additionally, the favorable metabolism of bone marrow mesenchymal stem cells, growth factors, and other substances that promote osteogenesis require sufficient blood supply, leading to extensive use of 3D-printed implants made from titanium and its alloys due to their ability to provide such adequate blood supply[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to this study, the use of digital surgery planning and 3D-printed templates can assist surgeons in performing precise surgeries. The difference between virtual surgical planning and the real outcomes was within allowable limits. And surgeons who participated in the surgical planning and template design reported greater familiarity and confidence in performing the procedure. Although attaining satisfactory outcomes, the discrepancies in distance and volume are still observed, which may arise from multiple sources. Firstly, surgical errors can be minimized but not entirely eliminated. Secondly, the CT scan model might present minor distortions. Thirdly, slight discrepancies may be introduced during computer-aided planning and verification procedures. Finally, the deformation of osteotomy templates could also contribute to these inaccuracies.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eAbove all, this study investigated a novel approach utilizing a fully digital treatment methodology for the reconstruction of bone defects resulting from ameloblastoma resection. Moreover, the digital workflow exhibited high levels of predictability, accuracy and effectiveness, ranging from pre-treatment assessment to final restoration.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZhiyang Zhao gathered and analyzed data and wrote the majority of the original draft. Hongbo Yu did orthognathic surgery and contributed to the original draft. The statistical analysis was completed by Shunyao Shen and Guanrong Ding. Meng Li designed the research and edited the draft. Hongbo Yu and Guofang Shen provided the study framework and reviewed the draft. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by National Natural Science Foundation of China (81571022), Multi-center clinical research project of Shanghai Jiao Tong University School of Medicine (DLY201808), and Shanghai Natural Science Foundation（23ZR1438100）.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the hospital institutional review board of Shanghai Ninth People\u0026rsquo;s Hospital (SH9H-2021-T65-1), and all procedures were carried out in accordance with relevant guidelines and regulations. The informed consent agreements were obtained from all patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1 Department of Oral and Craniomaxillofacial Surgery, Shanghai Ninth People\u0026rsquo;s Hospital, Shanghai Jiao Tong University School of Medicine; College of Stomatology, Shanghai Jiao Tong University; National Center for Stomatology; National Clinical Research Center for Oral Diseases; Shanghai Key Laboratory of Stomatology; Shanghai Research Institute of Stomatology.\u003c/p\u003e\n\u003cp\u003e2 Department of Radiology, Shanghai Ninth People\u0026rsquo;s Hospital, Shanghai Jiao Tong University, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMasthan KM, Anitha N, Krupaa J, Manikkam S: \u003cstrong\u003eAmeloblastoma\u003c/strong\u003e. \u003cem\u003eJ Pharm Bioallied Sci \u003c/em\u003e2015, \u003cstrong\u003e7\u003c/strong\u003e(Suppl 1):S167-170.\u003c/li\u003e\n\u003cli\u003eSozzi D, Cassoni A, De Ponti E, Moretti M, Pucci R, Spadoni D, Canzi G, Novelli G, Valentini V: \u003cstrong\u003eEffectiveness of Resective Surgery in Complex Ameloblastoma of the Jaws: A Retrospective Multicenter Observational Study\u003c/strong\u003e. \u003cem\u003eCancers (Basel) \u003c/em\u003e2022, \u003cstrong\u003e14\u003c/strong\u003e(19).\u003c/li\u003e\n\u003cli\u003ePiotrowska-Seweryn A, Szymczyk C, Walczak DA, Krakowczyk L, Maciejewski A, Hadasik G, Wierzgon J, Szumniak R, Drozdowski P, Paul P\u003cem\u003e et al\u003c/em\u003e: \u003cstrong\u003eFibular Free Flap and Iliac Crest Free Flap Mandibular Reconstruction In Patients With Mandibular 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Manero JM: \u003cstrong\u003eFunctionalization of 3D-Printed Titanium Scaffolds with Elastin-like Recombinamers to Improve Cell Colonization and Osteoinduction\u003c/strong\u003e. \u003cem\u003ePharmaceutics \u003c/em\u003e2023, \u003cstrong\u003e15\u003c/strong\u003e(3).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Virtual surgical planning, Mandible reconstruction,3D-printing, iliac cancellous bone, surgical accuracy","lastPublishedDoi":"10.21203/rs.3.rs-3043139/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3043139/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe reconstruction of large mandibular defects is a challenge, and the free vascularized bone flaps are most commonly used. However, the precision and symmetry of this repair are deficient, and patients have a risk of vascular embolism, flap necrosis and donor site complications. Therefore, to explore an ideal alternative in mandibular reconstruction with high surgical accuracy and low complications is indispensable.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSeven patients with recurrent or large-scope ameloblastoma were enrolled in this study. All patients were provided with a fully digital treatment plan, including the design of osteotomy lines, surgical guides, and three-dimensional printed titanium mesh for implantation. With the assistance of a surgical guide, ameloblastomas were resected, and custom 3D printed titanium mesh combined with posterior iliac bone harvest was used in mandibular reconstruction. The surgical discrepancy between the surgical plan and the real result was compared. At the same time, the resorption rate of the implanted bone was evaluated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll patients completed the fully digital treatment process successfully without severe complications. Image fusion showed that the postoperative contour of the mandible was basically consistent with surgical planning, except for a slight increase in the inferior border of the affected side. The mean error between the intraoperative bone volume and the digital planning bone volume was 2.44%\u0026plusmn;2.10%. Furthermore, the bone resorption rates of the harvested graft 6 months later were 32.15%\u0026plusmn;6.95%.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe use of digital surgical planning and 3D-printed templates can assist surgeons in performing precise surgery, and the 3D-printed titanium mesh implant can improve the patient's facial symmetry. 3D printed titanium combined with posterior iliac cancellous bone graft can be regarded as an ideal alternative in extensive mandibular reconstruction.\u003c/p\u003e","manuscriptTitle":"Three-dimensional printed titanium mesh combined with iliac cancellous bone in the reconstruction of mandibular defects secondary to ameloblastoma resection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-26 17:47:12","doi":"10.21203/rs.3.rs-3043139/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-08-07T08:02:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-08-05T07:41:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2657fd90-9075-4f8a-9db6-55a63a1422cd","date":"2023-08-02T23:35:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-08-02T23:14:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-08-02T23:03:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-06-16T15:38:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-06-16T15:37:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2023-06-09T11:45:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f256c656-d79c-4393-925e-4526c46de71a","owner":[],"postedDate":"June 26th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-09-25T15:02:21+00:00","versionOfRecord":{"articleIdentity":"rs-3043139","link":"https://doi.org/10.1186/s12903-023-03386-0","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2023-09-20 15:00:34","publishedOnDateReadable":"September 20th, 2023"},"versionCreatedAt":"2023-06-26 17:47:12","video":"","vorDoi":"10.1186/s12903-023-03386-0","vorDoiUrl":"https://doi.org/10.1186/s12903-023-03386-0","workflowStages":[]},"version":"v1","identity":"rs-3043139","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3043139","identity":"rs-3043139","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}