Virtual reduction and 3D printing in the management of edentulous atrophic mandibular fractures: case series and literature review

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The management of atrophic mandible fractures poses challenges due to the lack of stable occlusion and the inadequate bone volume. In this case series, we introduce a technique based on virtual surgical planning and in-house computer-aided design and manufacturing for surgical treatment of severe atrophic mandibular fractures. Methods . Between January 1sts 2022 and December 31st, 2024, eight patients with edentulous mandibular fractures were treated. Collected data included age, gender, cause of mandibular fracture, degree of atrophy according to Luhr's classification, site and type of fracture according to Ellis and Price, mean virtual planning and operative time, number of osteosynthesis plates, hospital stay length, adequacy of reduction according to Ramanathan and clinical outcomes. Results . Seven females and one male (mean age 82.6 years; range 80–92) were included. Six patients were classified as having class III atrophy, two as class II. The most frequent site of fracture was the body of the mandible. Mild, moderate, and severe displacement were observed respectively in three, two and three patients. Postoperative panoramic radiography showed good and very good reduction respectively in three and five patients. Virtual surgical planning and plate pre-bending took on average 90.5 minutes. Mean operative time was 135.3 minutes. Conclusion . Virtual fracture reduction and plate pre-bending on stereolithographic models stands out as a valuable tool for managing severe atrophic mandibular fractures. The authors believe this approach has potential to improve surgical time and accuracy in such complex cases with good cost-effectiveness and time efficiency. Mandibular fracture CAD/CAM technologies Virtual surgical planning Computer-guided surgery Edentulous mandible fracture Atrophic mandible fracture Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction The increase in life expectancy across Europe and developing countries, together with the adoption of more active lifestyles and the consequent increase in injuries among the elderly, is bringing a rise in the incidence of maxillofacial fractures in patients over 60 years of age [ 1 , 2 ]. This trend, combined with the growing prevalence of age-related conditions such as edentulism and mandibular atrophy, is sustaining a rise in the incidence of atrophic mandibular fractures [ 3 , 4 ]. According to AO principles and literature, the recommended treatment for severe atrophic mandibular fractures is open reduction and internal rigid fixation with load-bearing plate and locking screws [ 4 , 5 ]. This technique necessitates extensive exposure to achieve full visualization of the bone fragments and allows the placement and adaptation of a long reconstruction plate and its fixation on adequate bone. Therefore, an extraoral approach is often recommended, leading to prolonged surgery time in elderly patients that often present medical comorbidities [ 3 – 6 ]. Since the 1980s, the application of computer-aided design and manufacturing (CAD/CAM) in healthcare has revolutionized diagnostic and interventional medicine [ 8 ]. Virtual surgical planning (VSP) initially found application in maxillofacial reconstructive and orthognathic surgery, and its advantages in efficiency and accuracy, as well as morphological and functional outcomes, are well documented in the literature [ 7 – 13 ]. In the past decade, several authors have highlighted the potential of these technologies in cranio-maxillofacial trauma surgery, particularly for reducing surgical time, guiding fracture reduction, and predicting reconstruction outcomes [ 7 ]. Notably, midface and orbital trauma have benefited the most from these advancements, due to the complex surgical access required, the proximity to vital structures, and the high demands for both functional and aesthetic outcomes related to the eye [ 14 ]. Few authors have proposed the use of VSP and CAD/CAM in the treatment mandible fractures. The design of bone fragment repositioning guides [ 15 ] or occlusal splints based on an ideal occlusion achieved after virtual fracture reduction [ 16 , 17 ] is reported in literature, but both these techniques rely on dental occlusion, and therefore are not applicable to edentulous patients. The management of edentulous atrophic mandibular fractures utilizing VSP applications is documented only in few case reports [ 18 , 19 ] or small case series [ 20 , 21 ]. The primary objective of this study was to present the outcomes of VSP combined with CAD/CAM and 3D printing techniques in the surgical management of eight cases of atrophic mandibular fractures. Additionally, a review of the current literature is presented to contextualize these findings and highlight advancements in this evolving field. 2. Materials and Methods Between January 1st, 2022, and December 31st, 2024, eight patients with edentulous atrophic mandible fractures were treated at the Division of Maxillofacial Surgery, AOU Città della Salute e della Scienza, University of Turin, Italy. Patients with pathological fractures, as defined by Ezsias and Sugar [ 24 ], or who had been treated with bisphosphonates or other drugs that might have had an adverse effect on bone remodeling were excluded. Collected data included age, gender, cause of mandibular fracture, degree of atrophy according to Luhr's classification [ 25 ], site and type of the fracture (non-displaced; mild, moderate, or severe displacement according to Ellis and Price [ 3 ] — the most displaced fracture per patient was considered), number of osteosynthesis plates, mean virtual planning time, 3D printing time, operative time, hospital stay length, adequacy of reduction according to Ramanathan et al. [ 16 ], and complications. The minimum follow-up time was 3 months. 2.1 Pre-operative VSP VSP was conducted as follows: Virtual model: DICOM (Digital Imaging and Communications in Medicine) data of preoperative CT-scan of each patient were transferred to Mimics Innovation Suite® 24.0 (Materialise, Belgium) segmentation software. The thresholding and segmentation of the skull were conducted. The mandible was further segmented into individual fracture segments and their 3D stereolithography files (STL) were extracted. (Fig. 1 ). Then, virtual reduction was performed by manipulating the fracture segments in order to achieve optimal anatomical alignment using ProPlan CMFTM software (Materialise, Belgium) and an anatomic mandible STL model was obtained. (Fig. 2 a). 3D manufacturing: to transfer the plan information to the operating theatre the obtained anatomic mandible STL model was printed in our in-hospital 3D laboratory using FormLabs® resin 3D printer. (Fig. 2 b). Model surgery: A stock load-bearing device (MODUS® TRILOCK, Medartis, Switzerland) was preoperatively pre-bent on the obtained stereolithographic model. (Fig. 2 b). 2.2 Surgical Technique All surgeries were performed by the same senior surgeon, with assistance from two residents. Open reduction and internal fixation (ORIF) using an external approach were performed. Dissection was carried out in a subperiosteal plane to expose the mandibular fracture site, with careful preservation of the marginal mandibular branch of the facial nerve. Preservation of the superior and lingual attachments of the periosteum was ensured to maintain vascular supply. Each fracture reduction was achieved through temporary fixation using one 1.0 mm thick miniplate with monocortical screws (MODUS® TRAUMA 2.0, Medartis, Switzerland), positioned along the inferior border of the mandible, to maximize bone surface contact (Fig. 3 a). After reduction of all the fractures the pre-bent 2.0 mm thick plate was placed from symphysis to mandibular angle with at least three locking screws on each side of each fracture. In cases of bilateral fractures, an angle-to-angle plate was placed. (Fig. 3 b). Then, miniplates were removed. (Fig. 3 c). The adequacy of reduction was evaluated intraoperatively as the degree of separation between the fracture fragments after osteosynthesis according to Ramanathan et al [ 16 ] . All patients underwent a postoperative panoramic radiograph and clinical examinations at one week, one month and at three months after surgery to assess the clinical outcomes. (Fig. 4 ). 2.3 Informed consent Due to its retrospective nature, the study was exempt from formal IRB review (Intercompany Territorial Ethics Committee (CET), A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy). Informed consent was obtained from all individual participants included in the study. All procedures performed were in accordance with the 2002 Helsinki declaration. The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. 3. Results Seven out of eight patients were female. The mean age was 82.6 years (range 80–92). The etiology of trauma was a fall caused by slipping or tripping in all cases. Six patients were classified as having class III atrophy, and two as class II. All patients had multiple mandibular fractures, for a total of 19 fractures. The most common fracture site was the mandibular body, which was involved in at least one fracture in every patient. Mild displacement was observed in three patients, moderate displacement in two, and severe in three. Virtual surgical planning and plate pre-bending took on average 90.5 ± 10.5 minutes, but the time decreased from the first to the last patient (Table 1). Mean resin 3D printing time was 208 ± 3.4 minutes. Intraoperatively, the pre-bent plate demonstrated a good anatomical fit in all patients following proper reduction, with no need for further plate adaptation. The adequacy of reduction was judged intraoperatively as “very good” in five patients and “good” in three. The mean operative time was 135.3 minutes. Postoperative panoramic radiographs showed adequate reduction in all patients. The average post-surgery hospital stay was 2 days, contributing to an overall hospitalization duration of 4.6 days. All patients experienced postoperative edema and pain, which resolved within one week after surgery. None exhibited delayed wound healing, wound dehiscence, seroma, hematoma, or infection. At 3 months post-surgery, no patient presented injury to the marginal mandibular branch of the facial nerve. Mean follow-up was 16 months. Table 1. Characteristics of patients and fractures presented. N. Gender Age (y) N° of F. F. site F. Side Atrophy degree a Displacement b Adequacy of reduction c Planning time (m) 1 F 83 4 Body, Symphysis Bilateral III Mild Good 110 2 F 80 2 Body Bilateral III Severe Very good 106 3 F 83 2 Body, Condyle Right II Mild Good 90 4 F 92 2 Body Bilateral III Severe Very good 86 5 F 80 2 Body, Parasymphysis Bilateral II Moderate Very good 85 6 M 80 2 Body Bilateral III Moderate Very good 85 7 F 82 3 Body Bilateral III Severe Very good 82 8 F 81 2 Body Bilateral III Mild Good 80 F: fracture; y: years; m: minutes. a According to Luhr, 1996 [25] b According to Ellis and Price, 2008 [3] c According to Ramanathan et al, 2020 [16] 4. Discussion Edentulous mandibles fractures account for less than 5% of all mandibular fractures; however, they present unique clinical challenges [26]. The progressive alveolar bone resorption associated with edentulism results in reduced and sclerotic bone volume, poor vascularization, and the absence of stable anatomical landmarks [27]. Additionally, the lack of occlusal support eliminates a critical reference point for proper alignment of fracture segments and restoration of vertical dimension and the atrophic bone structure complicates the placement of rigid reconstruction plates and increases the risk of injury to the inferior alveolar nerve (IAN). These anatomical and biomechanical limitations make accurate anatomical reduction more difficult and raise the risk of local complications. Moreover, edentulous patients with mandibular atrophy are often elderly and frequently present with multiple comorbidities, which heighten both surgical and anesthetic risks [19, 21–23]. In light of these complexities, the use of virtual surgical planning (VSP) and computer-aided design/computer-aided manufacturing (CAD/CAM) technologies has emerged as a promising strategy to enhance the management of atrophic mandibular fractures [28, 29]. As early as 2010, Van Sickels and Cunningham reported favourable outcomes in mandibular fracture management using preoperatively bent plates on standard plastic mandibular models, which were subsequently adjusted intraoperatively to match patient-specific anatomy [30]. Although VSP was not employed in their study, the authors noted a reduction in operative time when plates were pre-contoured before surgery. In recent years, with the progressive development of new technologies, several authors have advocated the application of VSP and CAD/CAM-assisted approaches in the treatment of fractures of the atrophic edentulous mandible (Table 2) [18, 23]. Table 2. Literature review Patient (N, gender) Fractures (N, site) Atrophy degree a Surgical technique Outcomes Oliveira Brito et al, 2016 [19] 1, M 1, body n.r. EO approach, LBO Satisfactory reduction b Abbate et al, 2023 [20] 4, 50% F n.r. n.r. EO approach, LBO Accuracy: 100% c Caruso et al, 2024 [23] 5, 66% F 2, body + symphysis III EO approach, LBO Accuracy: 88.2% d 1, body 3, bil body, symphysis 1, body 2, body + symphysis Façanha de Carvalho et al, 2020 [18] 1, F 2, bil body III EO approach, LBO Good reduction e Maloney et al, 2019 [22] 2, F 2, bil body III EO approach, LBO Good reduction e 1, body Adequate reduction e Castro-Núñez et al, 2018 [21] 2, 50% F 1, body n.r. EO approach, LBO + temporary miniplates n.r. 1, body M: male; F: female; bil: bilateral; n.r.: not reported; EO: extra-oral; LBO: load bearing osteosynthesis. a According to Luhr, 1996 [25] b Evaluated on postoperative CT. c Reported as percentage of cases with discrepancies between predicted and postoperative bone segments position <1.5mm. d Reported as percentage of cases with discrepancies between predicted and postoperative bone segments position <2mm. e Evaluated on postoperative panoramic radiograph. A review of the literature confirms that these fractures occur more frequently in females and are most commonly located in the mandibular body. In all reported cases, the fractures were approached via an extraoral route and treated using load-bearing osteosynthesis. Virtual surgical planning (VSP) was consistently employed preoperatively to achieve virtual reduction of the fracture segments and to generate an STL model of the reconstructed mandible. This model was then 3D printed and used to pre-bend a load-bearing plate prior to surgery, with the exception of five cases reported by Caruso et al. [23]. In this case series, the digital mandibular model was utilized to design patient-specific titanium plates and drilling guides with notably high precision, achieving fragment positioning errors of less than 2 mm in 88.2% of cases. The authors also reported that the use of patient-specific implants (PSIs) facilitated accurate condylar seating and provided high predictability in screw placement, thereby reducing the risk of injury to the inferior alveolar nerve (IAN). Moreover, these custom plates were described as thinner than standard stock plates while maintaining sufficient mechanical strength, thus minimizing interference with future dental rehabilitation. The authors emphasized that this technique is particularly beneficial in cases of severe atrophy, comminuted fractures, or when bone grafting is required to bridge fracture gaps, as observed in several cases within the series [23]. However, the production of titanium PSIs remains both costly and time-consuming. Additionally, the design of accurate and unambiguous drilling guides can be particularly challenging in the absence of dental reference points. On the other hand, Façanha de Carvalho et al described the use of a pre-bent plate together with fragments repositioning guides [18]. However, in cases of non-comminuted fractures and without bony gaps, we believe that the fracture can be anatomically reduced using the pre-bent plate as a reference for proper positioning. Moreover, the repositioning guide described does not incorporate drilling references, therefore its primary advantage is stabilizing the fracture prior to placing the load-bearing plate; this can be achieved more efficiently and cost-effectively with the use of miniplates. In our study the use of a stock plate bent preoperatively on mandible model obtained from the virtual anatomic reduction of the fractures allowed for good reduction in all cases. Moreover, the in-house printing of the models enabled maintaining low costs, and the planning times were relatively short, didn’t depend on the number of fractures and decreased with the learning curve and training of dedicated personnel. Additionally, this process eliminated the lengthy intraoperative bending of thick plates. Although this study does not include an accuracy analysis, the same protocol demonstrated a very high accuracy in the case series by Abbate et al., where all the cases showed discrepancies of less than 1.5 mm between the virtual planning and postoperative CT [20]. On the other hand, in cases of comminuted fractures or those requiring bone grafts, when anatomic reduction is impossible, the use of drilling guides and custom plates as described by Caruso et al [23] could offer greater advantages, justifying the higher costs and production times of the PSIs. The integration of new technologies in the management of atrophic mandibular fractures offers a tailored approach that addresses many challenges associated with these complex injuries, with a potential reduction in operative times in a vulnerable population and a potential improvement in the clinical outcomes. The progressive availability of specific in-house tools for virtual surgical planning and 3D printing have allowed a simpler, quicker, and more cost-effective utilization of these technologies. Furthermore, with a short learning curve, the in-hospital 3D laboratory could also be considered a valuable tool for learning, as the virtual model allows the junior surgeons to simulate the operation and share the decision making with the senior surgeons. The implementation of preoperative planning enhances the accessibility of the procedure for less experienced surgeons, enabling them to perform it safely and achieve favorable outcomes even in their early cases. This is especially advantageous given the condition's low epidemiological prevalence, which limits the opportunities for younger surgeons to gain practical experience [4,18,21,22]. Despite the numerous advantages, the higher costs compared to conventional techniques are a significant consideration. Furthermore, the planning and fabrication process requires preparation time that can delay surgery by several days or weeks. However, for atrophic edentulous fractures, there is rarely an indication for immediate emergency treatment, making a brief delay usually not clinically significant. Despite the limited number of patients, this case series represents the largest cohort of edentulous atrophic multiple mandibular fracture patients treated with the aid of VSP. 5. Conclusion In conclusion, we believe that the use of a plate preoperatively bent on a stereolithographic model of the patient's mandible, obtained through virtual reduction of the fractures, should become part of the standard treatment protocol for atrophic mandibular fractures— especially when in-house 3D printing is possible. In cases of comminuted fractures or with significant bone continuity deficits, the use of drilling guides and customized plates should be considered. It is important to consider that virtual surgical planning and the 3D printing workflow require a learning curve for digital planning and a 3D laboratory workstation with specialized staff, equipment, and software. Further prospective studies comparing VSP and conventional intraoperative plate bending are needed to assess differences in surgical time, costs, and clinical outcomes. Declarations The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. Author Contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Ylenia Gugliotta, Federica Sobrero and Andrea Novaresio. The first draft of the manuscript was written by Ylenia Gugliotta and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. This is an observational study. The Intercompany Territorial Ethics Committee (CET), A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy has confirmed that no ethical approval is required. Informed consent was obtained from all individual participants included in the study. This study was performed in line with the principles of the Declaration of Helsinki. The authors affirm that human research participants provided informed consent for publication of the images in Figure(s) 1, 2, 3 and 4. 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Cite Share Download PDF Status: Published Journal Publication published 27 Oct, 2025 Read the published version in Oral and Maxillofacial Surgery → Version 1 posted Editorial decision: Revision requested 29 Sep, 2025 Reviews received at journal 20 Sep, 2025 Reviewers agreed at journal 20 Sep, 2025 Reviewers invited by journal 29 Aug, 2025 Editor assigned by journal 15 Aug, 2025 Submission checks completed at journal 15 Aug, 2025 First submitted to journal 12 Aug, 2025 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 Advisory Board 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-7358734","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":507412259,"identity":"be39ffd0-ce4c-49d3-bfc4-7d1fe45272e2","order_by":0,"name":"Ylenia Gugliotta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIie3PMUvDQBQH8BcC6XI06wXE+hGeBDrF5qu8ENClOmdwuCLUTdesfoOA0PnCQV0CWW+si5NDXEoHEa9VKkLPrA73h+Me3P3evQNwcfmPGZhFu8oXcruFZm0LZiX+nniGEEIkDDGGWY2/rzxz1xCUPc+g8per1TVMqvZhJt8276NYX9aqK+AotZLgAmkJeaWfRV0Sni70FUnZ2AdDxcacAshR10IxQm+hpyjr+V8kXHP6+CHpY9lLWMCzOUywne1IVvEeEqlgzLM7TpH2zF/O47xsXlE2DWdMHibDp5uXaLNO0mGrVNclx2f3t9O4K4okHYjD5OSrFc8Ep18H3DIWwOi7VQqhZQ4XFxcXl0+wtGOpO7VrNQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Turin","correspondingAuthor":true,"prefix":"","firstName":"Ylenia","middleName":"","lastName":"Gugliotta","suffix":""},{"id":507412264,"identity":"ecf97e66-3c91-4ff2-b7d9-27b26620819d","order_by":1,"name":"Fabio Roccia","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Fabio","middleName":"","lastName":"Roccia","suffix":""},{"id":507412266,"identity":"9c00e5ad-f133-472d-a715-180590540f45","order_by":2,"name":"Andrea Novaresio","email":"","orcid":"","institution":"Polytechnic University of Torino","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Novaresio","suffix":""},{"id":507412269,"identity":"cd42bbf0-77ab-4336-9475-dc390522fd08","order_by":3,"name":"Pompeo Cassano","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Pompeo","middleName":"","lastName":"Cassano","suffix":""},{"id":507412270,"identity":"5ecbfd62-02df-4c46-b1a8-7290f9e86792","order_by":4,"name":"Federica Sobrero","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Federica","middleName":"","lastName":"Sobrero","suffix":""},{"id":507412271,"identity":"c11f0259-8bad-49cf-9754-b3d5e0259627","order_by":5,"name":"Guglielmo Ramieri","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Guglielmo","middleName":"","lastName":"Ramieri","suffix":""},{"id":507412272,"identity":"f6099dfa-c1e9-4604-a668-1c327e1fac5f","order_by":6,"name":"Emanuele Zavattero","email":"","orcid":"","institution":"University of Turin","correspondingAuthor":false,"prefix":"","firstName":"Emanuele","middleName":"","lastName":"Zavattero","suffix":""}],"badges":[],"createdAt":"2025-08-12 19:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7358734/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7358734/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10006-025-01484-7","type":"published","date":"2025-10-27T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90898243,"identity":"8ee95ed2-0f24-46f3-9382-3456061931e7","added_by":"auto","created_at":"2025-09-09 11:53:35","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15628,"visible":true,"origin":"","legend":"\u003cp\u003ePatient n°1. Atrophic mandible fracture segmented into individual fracture segments. This patient presented a quadruple mandible fracture; three fractures were non-displaced and therefore were segmented as a unique fracture segment\u003c/p\u003e","description":"","filename":"image1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7358734/v1/97a85d785f1fc7710d1a5701.jpg"},{"id":90898199,"identity":"2e8466c0-6190-410c-9a35-5efe32ae00f4","added_by":"auto","created_at":"2025-09-09 11:53:32","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":14541,"visible":true,"origin":"","legend":"\u003cp\u003ePatient n°1. a. Anatomic model of the mandible after virtual fracture reduction. b. Obtained mandible model printed with FormLabs® resin 3D printer and used to preoperatively pre-bend a stock load-bearing plate\u003c/p\u003e","description":"","filename":"image2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7358734/v1/b5e9e7c064e7e1cdd01ab082.jpg"},{"id":90898224,"identity":"b4e76e1f-ca54-45fd-9fcb-6c4f02de1f28","added_by":"auto","created_at":"2025-09-09 11:53:34","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":54789,"visible":true,"origin":"","legend":"\u003cp\u003ePatient n°1. Open reduction and internal fixation (ORIF) via cervical approach. a. Fracture simplification and temporary fixation with 1.0 mm thick miniplate with monocortical screws. b. Pre-bent 2.0 mm thick angle to angle plate placed and fixed with locking screws. c. Final result after removing the miniplates\u003c/p\u003e","description":"","filename":"image3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7358734/v1/0f381acf70340c9db2c865a8.jpg"},{"id":90898225,"identity":"52d8e25d-37e1-4524-b427-481fd372fb84","added_by":"auto","created_at":"2025-09-09 11:53:34","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":36500,"visible":true,"origin":"","legend":"\u003cp\u003ePatient n°1. Postoperative panoramic radiograph showing good reduction of the mandibular fractures\u003c/p\u003e","description":"","filename":"image4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7358734/v1/1ce38603ddcd16b12e79a382.jpg"},{"id":95040416,"identity":"757c798b-7c0b-4e04-b88b-bbf3ec029986","added_by":"auto","created_at":"2025-11-03 16:08:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":635629,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7358734/v1/f0f8b4ef-1067-401c-9734-d9241ec46249.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Virtual reduction and 3D printing in the management of edentulous atrophic mandibular fractures: case series and literature review","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe increase in life expectancy across Europe and developing countries, together with the adoption of more active lifestyles and the consequent increase in injuries among the elderly, is bringing a rise in the incidence of maxillofacial fractures in patients over 60 years of age [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This trend, combined with the growing prevalence of age-related conditions such as edentulism and mandibular atrophy, is sustaining a rise in the incidence of atrophic mandibular fractures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to AO principles and literature, the recommended treatment for severe atrophic mandibular fractures is open reduction and internal rigid fixation with load-bearing plate and locking screws [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis technique necessitates extensive exposure to achieve full visualization of the bone fragments and allows the placement and adaptation of a long reconstruction plate and its fixation on adequate bone. Therefore, an extraoral approach is often recommended, leading to prolonged surgery time in elderly patients that often present medical comorbidities [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSince the 1980s, the application of computer-aided design and manufacturing (CAD/CAM) in healthcare has revolutionized diagnostic and interventional medicine [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Virtual surgical planning (VSP) initially found application in maxillofacial reconstructive and orthognathic surgery, and its advantages in efficiency and accuracy, as well as morphological and functional outcomes, are well documented in the literature [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the past decade, several authors have highlighted the potential of these technologies in cranio-maxillofacial trauma surgery, particularly for reducing surgical time, guiding fracture reduction, and predicting reconstruction outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Notably, midface and orbital trauma have benefited the most from these advancements, due to the complex surgical access required, the proximity to vital structures, and the high demands for both functional and aesthetic outcomes related to the eye [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFew authors have proposed the use of VSP and CAD/CAM in the treatment mandible fractures. The design of bone fragment repositioning guides [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] or occlusal splints based on an ideal occlusion achieved after virtual fracture reduction [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] is reported in literature, but both these techniques rely on dental occlusion, and therefore are not applicable to edentulous patients.\u003c/p\u003e\u003cp\u003eThe management of edentulous atrophic mandibular fractures utilizing VSP applications is documented only in few case reports [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] or small case series [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary objective of this study was to present the outcomes of VSP combined with CAD/CAM and 3D printing techniques in the surgical management of eight cases of atrophic mandibular fractures. Additionally, a review of the current literature is presented to contextualize these findings and highlight advancements in this evolving field.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003eBetween January 1st, 2022, and December 31st, 2024, eight patients with edentulous atrophic mandible fractures were treated at the Division of Maxillofacial Surgery, AOU Citt\u0026agrave; della Salute e della Scienza, University of Turin, Italy.\u003c/p\u003e\u003cp\u003ePatients with pathological fractures, as defined by Ezsias and Sugar [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], or who had been treated with bisphosphonates or other drugs that might have had an adverse effect on bone remodeling were excluded.\u003c/p\u003e\u003cp\u003eCollected data included age, gender, cause of mandibular fracture, degree of atrophy according to Luhr's classification [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], site and type of the fracture (non-displaced; mild, moderate, or severe displacement according to Ellis and Price [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] \u0026mdash; the most displaced fracture per patient was considered), number of osteosynthesis plates, mean virtual planning time, 3D printing time, operative time, hospital stay length, adequacy of reduction according to Ramanathan et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and complications. The minimum follow-up time was 3 months.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Pre-operative VSP\u003c/h2\u003e\u003cp\u003eVSP was conducted as follows:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eVirtual model: DICOM (Digital Imaging and Communications in Medicine) data of preoperative CT-scan of each patient were transferred to Mimics Innovation Suite\u0026reg; 24.0 (Materialise, Belgium) segmentation software. The thresholding and segmentation of the skull were conducted. The mandible was further segmented into individual fracture segments and their 3D stereolithography files (STL) were extracted. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThen, virtual reduction was performed by manipulating the fracture segments in order to achieve optimal anatomical alignment using ProPlan CMFTM software (Materialise, Belgium) and an anatomic mandible STL model was obtained. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea).\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e3D manufacturing: to transfer the plan information to the operating theatre the obtained anatomic mandible STL model was printed in our in-hospital 3D laboratory using FormLabs\u0026reg; resin 3D printer. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eModel surgery: A stock load-bearing device (MODUS\u0026reg; TRILOCK, Medartis, Switzerland) was preoperatively pre-bent on the obtained stereolithographic model. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Surgical Technique\u003c/h2\u003e\u003cp\u003eAll surgeries were performed by the same senior surgeon, with assistance from two residents. Open reduction and internal fixation (ORIF) using an external approach were performed. Dissection was carried out in a subperiosteal plane to expose the mandibular fracture site, with careful preservation of the marginal mandibular branch of the facial nerve. Preservation of the superior and lingual attachments of the periosteum was ensured to maintain vascular supply. Each fracture reduction was achieved through temporary fixation using one 1.0 mm thick miniplate with monocortical screws (MODUS\u0026reg; TRAUMA 2.0, Medartis, Switzerland), positioned along the inferior border of the mandible, to maximize bone surface contact (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). After reduction of all the fractures the pre-bent 2.0 mm thick plate was placed from symphysis to mandibular angle with at least three locking screws on each side of each fracture. In cases of bilateral fractures, an angle-to-angle plate was placed. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). Then, miniplates were removed. (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec).\u003c/p\u003e\u003cp\u003eThe adequacy of reduction was evaluated intraoperatively as the degree of separation between the fracture fragments after osteosynthesis according to Ramanathan et al [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] .\u003c/p\u003e\u003cp\u003eAll patients underwent a postoperative panoramic radiograph and clinical examinations at one week, one month and at three months after surgery to assess the clinical outcomes. (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Informed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to its retrospective nature, the study was exempt from formal IRB review (Intercompany Territorial Ethics Committee (CET), A.O.U. Citt\u0026agrave; della Salute e della Scienza di Torino, Turin, Italy). Informed consent was obtained from all individual participants included in the study. All procedures performed were in accordance with the 2002 Helsinki declaration. The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eSeven out of eight patients were female. The mean age was 82.6 years (range 80\u0026ndash;92). The etiology of trauma was a fall caused by slipping or tripping in all cases. Six patients were classified as having class III atrophy, and two as class II.\u003c/p\u003e\n\u003cp\u003eAll patients had multiple mandibular fractures, for a total of 19 fractures. The most common fracture site was the mandibular body, which was involved in at least one fracture in every patient. Mild displacement was observed in three patients, moderate displacement in two, and severe in three. Virtual surgical planning and plate pre-bending took on average 90.5 \u0026plusmn; 10.5 minutes, but the time decreased from the first to the last patient (Table 1). Mean resin 3D printing time was 208 \u0026plusmn; 3.4 minutes.\u003c/p\u003e\n\u003cp\u003eIntraoperatively, the pre-bent plate demonstrated a good anatomical fit in all patients following proper reduction, with no need for further plate adaptation. The adequacy of reduction was judged intraoperatively as \u0026ldquo;very good\u0026rdquo; in five patients and \u0026ldquo;good\u0026rdquo; in three.\u003c/p\u003e\n\u003cp\u003eThe mean operative time was 135.3 minutes. Postoperative panoramic radiographs showed adequate reduction in all patients. The average post-surgery hospital stay was 2 days, contributing to an overall hospitalization duration of 4.6 days. All patients experienced postoperative edema and pain, which resolved within one week after surgery. None exhibited delayed wound healing, wound dehiscence, seroma, hematoma, or infection. At 3 months post-surgery, no patient presented injury to the marginal mandibular branch of the facial nerve. Mean follow-up was 16 months.\u003c/p\u003e\n\u003cp\u003eTable 1. Characteristics of patients and fractures presented.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003eN.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eAge (y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;N\u0026deg; of F.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eF. site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eF. Side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eAtrophy degree\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eDisplacement\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eAdequacy of reduction\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003ePlanning time\u003c/p\u003e\n \u003cp\u003e(m)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBody, Symphysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBody\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eVery good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBody, Condyle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eRight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBody\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eVery good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBody, Parasymphysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eVery good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBody\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eVery good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBody\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eSevere\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eVery good\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 36px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBody\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eF: fracture; y: years; m: minutes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003e\u003c/em\u003eAccording to Luhr, 1996 [25]\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u0026nbsp;\u003c/sup\u003eAccording \u0026nbsp;to Ellis and Price, 2008 [3]\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u0026nbsp;\u003c/sup\u003eAccording to Ramanathan et al, 2020 [16]\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eEdentulous mandibles fractures account for less than 5% of all mandibular fractures; however, they present unique clinical challenges [26]. The progressive alveolar bone resorption associated with edentulism results in reduced and sclerotic bone volume, poor vascularization, and the absence of stable anatomical landmarks [27]. Additionally, the lack of occlusal support eliminates a critical reference point for proper alignment of fracture segments and restoration of vertical dimension and the atrophic bone structure complicates the placement of rigid reconstruction plates and increases the risk of injury to the inferior alveolar nerve (IAN). These anatomical and biomechanical limitations make accurate anatomical reduction more difficult and raise the risk of local complications.\u003c/p\u003e\n\u003cp\u003eMoreover, edentulous patients with mandibular atrophy are often elderly and frequently present with multiple comorbidities, which heighten both surgical and anesthetic risks [19, 21\u0026ndash;23].\u003c/p\u003e\n\u003cp\u003eIn light of these complexities, the use of virtual surgical planning (VSP) and computer-aided design/computer-aided manufacturing (CAD/CAM) technologies has emerged as a promising strategy to enhance the management of atrophic mandibular fractures [28, 29].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs early as 2010, Van Sickels and Cunningham reported favourable outcomes in mandibular fracture management using preoperatively bent plates on standard plastic mandibular models, which were subsequently adjusted intraoperatively to match patient-specific anatomy [30]. Although VSP was not employed in their study, the authors noted a reduction in operative time when plates were pre-contoured before surgery.\u003c/p\u003e\n\u003cp\u003eIn recent years, with the progressive development of new technologies, several authors have advocated the application of VSP and CAD/CAM-assisted approaches in the treatment of fractures of the atrophic edentulous mandible (Table 2) [18, 23].\u003c/p\u003e\n\u003cp\u003eTable 2. Literature review\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003ePatient\u003c/p\u003e\n \u003cp\u003e(N, gender)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eFractures (N, site)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eAtrophy degree\u003cstrong\u003e\u003cem\u003e\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eSurgical technique\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eOutcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eOliveira Brito et al, 2016 [19]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1, M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e1, body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003en.r.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eEO approach, LBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eSatisfactory reduction\u003cem\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eAbbate et al, 2023 [20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e4, 50% F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003en.r.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003en.r.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eEO approach, LBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eAccuracy: 100%\u003cem\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 141px;\"\u003e\n \u003cp\u003eCaruso et al, 2024 [23]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 76px;\"\u003e\n \u003cp\u003e5, 66% F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e2, body + symphysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 66px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEO approach, LBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 133px;\"\u003e\n \u003cp\u003eAccuracy: 88.2%\u003cem\u003e\u003csup\u003ed\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e1, body\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e3, bil body, symphysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e1, body\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e2, body + symphysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003eFa\u0026ccedil;anha de Carvalho et al, 2020 [18]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e1, F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e2, bil body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eEO approach, LBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eGood reduction\u003cem\u003e\u003csup\u003ee\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 141px;\"\u003e\n \u003cp\u003eMaloney et al, 2019 [22]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2, F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e2, bil body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEO approach, LBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eGood reduction\u003cem\u003e\u003csup\u003ee\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e1, body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 133px;\"\u003e\n \u003cp\u003eAdequate reduction\u003cem\u003e\u003csup\u003ee\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 141px;\"\u003e\n \u003cp\u003eCastro-N\u0026uacute;\u0026ntilde;ez et al, 2018 [21]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2, 50% F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e1, body\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003en.r.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp\u003eEO approach, LBO + temporary miniplates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 133px;\"\u003e\n \u003cp\u003en.r.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 141px;\"\u003e\n \u003cp\u003e1, body\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eM: male; F: female; bil: bilateral; n.r.: not reported; EO: extra-oral; LBO: load bearing osteosynthesis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003e\u003c/em\u003eAccording to Luhr, 1996 [25]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/em\u003e Evaluated\u003csup\u003e\u0026nbsp;\u003c/sup\u003eon postoperative CT.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/em\u003e Reported as percentage of cases with discrepancies between predicted and postoperative bone segments position \u0026lt;1.5mm.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003ed\u003c/sup\u003e\u003c/em\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eReported as percentage of cases with discrepancies between predicted and postoperative bone segments position \u0026lt;2mm.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003csup\u003ee\u003c/sup\u003e\u003c/em\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eEvaluated\u003csup\u003e\u0026nbsp;\u003c/sup\u003eon postoperative panoramic radiograph.\u003c/p\u003e\n\u003cp\u003eA review of the literature confirms that these fractures occur more frequently in females and are most commonly located in the mandibular body. In all reported cases, the fractures were approached via an extraoral route and treated using load-bearing osteosynthesis. Virtual surgical planning (VSP) was consistently employed preoperatively to achieve virtual reduction of the fracture segments and to generate an STL model of the reconstructed mandible. This model was then 3D printed and used to pre-bend a load-bearing plate prior to surgery, with the exception of five cases reported by Caruso et al. [23].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this case series, the digital mandibular model was utilized to design patient-specific titanium plates and drilling guides with notably high precision, achieving fragment positioning errors of less than 2 mm in 88.2% of cases. The authors also reported that the use of patient-specific implants (PSIs) facilitated accurate condylar seating and provided high predictability in screw placement, thereby reducing the risk of injury to the inferior alveolar nerve (IAN). Moreover, these custom plates were described as thinner than standard stock plates while maintaining sufficient mechanical strength, thus minimizing interference with future dental rehabilitation. The authors emphasized that this technique is particularly beneficial in cases of severe atrophy, comminuted fractures, or when bone grafting is required to bridge fracture gaps, as observed in several cases within the series [23]. However, the production of titanium PSIs remains both costly and time-consuming. Additionally, the design of accurate and unambiguous drilling guides can be particularly challenging in the absence of dental reference points.\u003c/p\u003e\n\u003cp\u003eOn the other hand, Fa\u0026ccedil;anha de Carvalho et al described the use of a pre-bent plate together with fragments repositioning guides [18]. However, in cases of non-comminuted fractures and without bony gaps, we believe that the fracture can be anatomically reduced using the pre-bent plate as a reference for proper positioning. Moreover, the repositioning guide described does not incorporate drilling references, therefore its primary advantage is stabilizing the fracture prior to placing the load-bearing plate; this can be achieved more efficiently and cost-effectively with the use of miniplates.\u003c/p\u003e\n\u003cp\u003eIn our study the use of a stock plate bent preoperatively on mandible model obtained from the virtual anatomic reduction of the fractures allowed for good reduction in all cases. Moreover, the in-house printing of the models enabled maintaining low costs, and the planning times were relatively short, didn\u0026rsquo;t depend on the number of fractures and decreased with the learning curve and training of dedicated personnel. Additionally, this process eliminated the lengthy intraoperative bending of thick plates. Although this study does not include an accuracy analysis, the same protocol demonstrated a very high accuracy in the case series by Abbate et al., where all the cases showed discrepancies of less than 1.5 mm between the\u0026nbsp;virtual planning and postoperative CT [20].\u003c/p\u003e\n\u003cp\u003eOn the other hand, in cases of comminuted fractures or those requiring bone grafts, when anatomic reduction is impossible, the use of drilling guides and custom plates as described by Caruso et al [23] could offer greater advantages, justifying the higher costs and production times of the PSIs.\u003c/p\u003e\n\u003cp\u003eThe integration of new technologies in the management of atrophic mandibular fractures offers a tailored approach that addresses many challenges associated with these complex injuries, with a potential reduction in operative times in a vulnerable population and a potential improvement in the clinical outcomes.\u003c/p\u003e\n\u003cp\u003eThe progressive availability of specific in-house tools for virtual surgical planning and 3D printing have allowed a simpler, quicker, and more cost-effective utilization of these technologies. Furthermore, with a short learning curve, the in-hospital 3D laboratory could also be considered a valuable tool for learning, as the virtual model allows the junior surgeons to simulate the operation and share the decision making with the senior surgeons. The implementation of preoperative planning enhances the accessibility of the procedure for less experienced surgeons, enabling them to perform it safely and achieve favorable outcomes even in their early cases. This is especially advantageous given the condition\u0026apos;s low epidemiological prevalence, which limits the opportunities for younger surgeons to gain practical experience [4,18,21,22].\u003c/p\u003e\n\u003cp\u003eDespite the numerous advantages, the higher costs compared to conventional techniques are a significant consideration. Furthermore, the planning and fabrication process requires preparation time that can delay surgery by several days or weeks. However, for atrophic edentulous fractures, there is rarely an indication for immediate emergency treatment, making a brief delay usually not clinically significant.\u003c/p\u003e\n\u003cp\u003eDespite the limited number of patients, this case series represents the largest cohort of edentulous atrophic multiple mandibular fracture patients treated with the aid of VSP.\u0026nbsp;\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn conclusion, we believe that the use of a plate preoperatively bent on a stereolithographic model of the patient\u0026apos;s mandible, obtained through virtual reduction of the fractures, should become part of the standard treatment protocol for atrophic mandibular fractures\u0026mdash; especially when in-house 3D printing is possible. In cases of comminuted fractures or with significant bone continuity deficits, the use of drilling guides and customized plates should be considered.\u003c/p\u003e\n\u003cp\u003eIt is important to consider that virtual surgical planning and the 3D printing workflow require a learning curve for digital planning and a 3D laboratory workstation with specialized staff, equipment, and software. Further prospective studies comparing VSP and conventional intraoperative plate bending \u0026nbsp; are needed to assess differences in surgical time, costs, and clinical outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Ylenia Gugliotta, Federica Sobrero and Andrea Novaresio. The first draft of the manuscript was written by Ylenia Gugliotta and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eThis is an observational study. The\u0026nbsp;Intercompany Territorial Ethics Committee (CET), A.O.U.\u0026nbsp;Citt\u0026agrave;\u0026nbsp;della\u0026nbsp;Salute\u0026nbsp;e\u0026nbsp;della\u0026nbsp;Scienza\u0026nbsp;di\u0026nbsp;Torino, Turin, Italy\u0026nbsp;has confirmed that no ethical approval is required.\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors affirm that human research participants provided informed consent for publication of the images in Figure(s) 1, 2, 3 and 4.\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the article. Any further data is available from the corresponding author, YG, upon reasonable request.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBojino A, Roccia F, Carlaw K, Aquilina P, Rae E, Laverick S, Romeo I, Iocca O, Copelli C, Sobrero F, Segura-Paller\u0026egrave;s I, Ganasouli D, Zanakis SN, de Oliveira Gorla LF, Pereira-Filho VA, Gallafassi D, Perez Faverani L, Alalawy H, Kamel M, Samieirad S, Jaisani MR, Rahman SA, Rahman T, Aladelusi T, Hassanein AG, Duran-Valles F, Bescos C, Goetzinger M, Bottini GB (2022) A multicentric prospective analysis of maxillofacial trauma in the elderly population. Dent Traumatol 38(3):185-195. doi: 10.1111/edt.12736\u003c/li\u003e\n\u003cli\u003eGugliotta Y, Roccia F, Sobrero F, Ramieri G, Volpe F (2024) Changing trends in maxillofacial injuries among paediatric, adult and elderly populations: A 22-year statistical analysis of 3424 patients in a tertiary care centre in Northwest Italy. Dent Traumatol 40(2):187-194. doi: 10.1111/edt.12904 \u003c/li\u003e\n\u003cli\u003eEllis E 3rd, Price C. Treatment protocol for fractures of the atrophic mandible (2008) J Oral Maxillofac Surg 66(3):421-35. doi: 10.1016/j.joms.2007.08.042\u003c/li\u003e\n\u003cli\u003eGerbino G, Cocis S, Roccia F, Novelli G, Canzi G, Sozzi D. Management of atrophic mandibular fractures: An Italian multicentric retrospective study (2018) J Craniomaxillofac Surg 46(12):2176-2181. doi: 10.1016/j.jcms.2018.09.020. \u003c/li\u003e\n\u003cli\u003eEhrenfeld M, Manson PN, Prein J. Principles of Internal Fixation of the Craniomaxillofacial Skeleton, Trauma and Orthognathic Surgery (2012) Munich, Germany\u003c/li\u003e\n\u003cli\u003eFranciosi E, Mazzaro E, Larranaga J, Rios A, Picco P, Figari M. Treatment of edentulous mandibular fractures with rigid internal fixation: case series and literature review (2014) Craniomaxillofac Trauma Reconstr 7(1):35-42. doi: 10.1055/s-0033-1364195\u003c/li\u003e\n\u003cli\u003eDoi K. Computer-aided diagnosis in medical imaging: historical review, current status and future potential (2007) Comput Med Imaging Graph 31(4-5):198-211. doi: 10.1016/j.compmedimag.2007.02.002\u003c/li\u003e\n\u003cli\u003eZhang N, Liu S, Hu Z, et al. Accuracy of virtual surgical planning in two-jaw orthognathic surgery: comparison of planned and actual results (2016) Oral Surg Oral Med Oral Pathol Oral Radiol 122(2): 143\u0026ndash;51. 11. doi: 10.1016/j.oooo.2016.03.004\u003c/li\u003e\n\u003cli\u003eVan den Bempt M, Liebregts J, Maal T, et al. Toward a higher accuracy in orthognathic surgery by using intraoperative computer navigation, 3D surgical guides, and/or customized osteosynthesis plates: a systematic review (2018) J Craniomaxillofac Surg 46(12):2108\u0026ndash;19. doi: 10.1016/j.jcms.2018.10.012\u003c/li\u003e\n\u003cli\u003eResnick CM, Inverso G, Wrzosek M, et al. Is there a difference in cost between standard and virtual surgical planning for orthognathic surgery? (2016) J Oral Maxillofac Surg 74(9):1827\u0026ndash;33. doi: 10.1016/j.joms.2016.03.035\u003c/li\u003e\n\u003cli\u003eTarsitano A, Ricotta F, Baldino G, et al. Navigation guided resection of maxillary tumours: the accuracy of computer-assisted surgery in terms of control of resection margins - a feasibility study (2017) J Craniomaxillofac Surg;45(12):2109\u0026ndash;14. doi: 10.1016/j.jcms.2017.09.023\u003c/li\u003e\n\u003cli\u003eRicotta F, Cercenelli L, Battaglia S, et al. Navigation guided resection of maxillary tumors: can a new volumetric virtual planning method improve outcomes in terms of control of resection margins? (2018) J Craniomaxillofac Surg 46(12):2240\u0026ndash;7. doi: 10.1016/j.jcms.2018.09.034\u003c/li\u003e\n\u003cli\u003eBernstein JM, Daly MJ, Chan H, et al. Accuracy and reproducibility of virtual cutting guides and 3D-navigation for osteotomies of the mandible and maxilla (2017) PLoS ONE 12(3). doi: 10.1371/journal.pone.0173111\u003c/li\u003e\n\u003cli\u003eJansen J, Schreurs R, Dubois L, Maal TJJ, Gooris PJJ, Becking AG. The advantages of advanced computer-assisted diagnostics and three-dimensional preoperative planning on implant position in orbital reconstruction (2018) J Craniomaxillofac Surg 46(4):715-721. doi: 10.1016/j.jcms.2018.02.010\u003c/li\u003e\n\u003cli\u003eEl-Gengehi M, Seif SA. Evaluation of the Accuracy of Computer-Guided Mandibular Fracture Reduction (2015) J Craniofac Surg 26(5):1587-91. doi: 10.1097/SCS.0000000000001773\u003c/li\u003e\n\u003cli\u003eRamanathan M, Panneerselvam E, Krishna Kumar Raja VB. 3D planning in mandibular fractures using CAD/CAM surgical splints - A prospective randomized controlled clinical trial (2020) J Craniomaxillofac Surg 48(4):405-412. doi: 10.1016/j.jcms.2020.02.004\u003c/li\u003e\n\u003cli\u003eKoenig ZA, Lokant BT, Weaver S, Brooke SM, Uygur HS. Surgical Guide Splint Fabrication via Virtual Surgical Planning for Complex Mandible Fractures in the Trauma Setting (2023) J Craniofac Surg 16. doi: 10.1097/SCS.0000000000009898\u003c/li\u003e\n\u003cli\u003eFa\u0026ccedil;anha de Carvalho E, Alkmin Paiva GL, Yonezaki F, Machado GG. Computer-Aided Surgical Simulation in Severe Atrophic Mandibular Fractures: A New Method for Guided Reduction and Temporary Stabilization Before Fixation (2021) J Oral Maxillofac Surg 79(4):892.e1-892.e7. doi: 10.1016/j.joms.2020.11.011\u003c/li\u003e\n\u003cli\u003eBrito NM, Soares RS, Monteiro EL, Martins SC, Cavalcante JR, Grempel RG, Neto JA. Additive Manufacturing for Surgical Planning of Mandibular Fracture (2016) Acta Stomatol Croat 50(4):348-353. doi: 10.15644/asc50/4/8\u003c/li\u003e\n\u003cli\u003eAbbate, V.; Committeri, U.; Troise, S.; Bonavolont\u0026agrave;, P.; Vaira, L.A.; Gabriele, G.; Biglioli, F.; Tarabbia, F.; Califano, L.; Dell\u0026rsquo;Aversana Orabona, G. Virtual Surgical Reduction in Atrophic Edentulous Mandible Fractures: A Novel Approach Based on \u0026ldquo;in House\u0026rdquo; Digital Work-Flow (2023) Appl. 13: 1474. doi:10.3390/app13031474\u003c/li\u003e\n\u003cli\u003eCastro-N\u0026uacute;\u0026ntilde;ez J, Shelton JM, Snyder S, Sickels JV. Virtual Surgical Planning for the Management of Severe Atrophic Mandible Fractures (2018) Craniomaxillofac Trauma Reconstr Jun;11(2):150-156. doi: 10.1055/s-0037-1601865\u003c/li\u003e\n\u003cli\u003eMaloney KD, Rutner T. Virtual Surgical Planning and Hardware Fabrication Prior to Open Reduction and Internal Fixation of Atrophic Edentulous Mandible Fractures (2019) Craniomaxillofac Trauma Reconstr 12(2):156-162. doi: 10.1055/s-0039-1677723\u003c/li\u003e\n\u003cli\u003eCaruso DP, Aquino VM, Hajibandeh JT. Management of Atrophic Edentulous Mandible Fractures Utilizing Virtual Surgical Planning and Patient-Specific Implants (2024) Craniomaxillofac Trauma Reconstr 17(4):NP138-NP145. doi: 10.1177/19433875241259808\u003c/li\u003e\n\u003cli\u003eEzsi\u0026aacute;s A, Sugar AW. Pathological fractures of the mandible: a diagnostic and treatment dilemma (1994) Br J Oral Maxillofac Surg 32(5):303-6. doi: 10.1016/0266-4356(94)90051-5\u003c/li\u003e\n\u003cli\u003eLuhr HG, Reidick T, Merten HA. Results of treatment of fractures of the atrophic edentulous mandible by compression plating: a retrospective evaluation of 84 consecutive cases (1996) J Oral Maxillofac Surg 54(3):250-4; discussion 254-5. doi: 10.1016/s0278-2391(96)90733-8\u003c/li\u003e\n\u003cli\u003eBera RN, Tiwari P. Current Evidence for the Management of Edentulous Atrophic Mandible Fractures: A PRISMA-SWiM Guided Review (2023) Craniomaxillofac Trauma Reconstr 16(4):317-332. doi: 10.1177/19433875221115585\u003c/li\u003e\n\u003cli\u003eKumar L. Biomechanics and clinical implications of complete edentulous state (2014) J Clin Gerontol Geriatr 5(4):101-104. doi:10.1016/j.jcgg.2014.03.001\u003c/li\u003e\n\u003cli\u003eSalinas CA, Morris JM, Sharaf BA. Craniomaxillofacial Trauma: The Past, Present and the Future (2023) J Craniofac Surg 34(5):1427-1430. doi: 10.1097/SCS.0000000000009334\u003c/li\u003e\n\u003cli\u003eZavattero E, Fasolis M, Novaresio A, Gerbino G, Borbon C, Ramieri G. The Shape of Things to Come: In-Hospital Three-Dimensional Printing for Mandibular Reconstruction Using Fibula Free Flap (2020) Laryngoscope 130(12):E811-E816. doi: 10.1002/lary.28650\u003c/li\u003e\n\u003cli\u003eVan Sickels JE, Cunningham LL. Management of atrophic mandible fractures: are bone grafts necessary? (2010) J Oral Maxillofac Surg 68(6):1392-5. doi: 10.1016/j.joms.2009.08.020\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":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Mandibular fracture, CAD/CAM technologies, Virtual surgical planning, Computer-guided surgery, Edentulous mandible fracture, Atrophic mandible fracture","lastPublishedDoi":"10.21203/rs.3.rs-7358734/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7358734/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e. The management of atrophic mandible fractures poses challenges due to the lack of stable occlusion and the inadequate bone volume. In this case series, we introduce a technique based on virtual surgical planning and in-house computer-aided design and manufacturing for surgical treatment of severe atrophic mandibular fractures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e. Between January 1sts 2022 and December 31st, 2024, eight patients with edentulous mandibular fractures were treated. Collected data included age, gender, cause of mandibular fracture, degree of atrophy according to Luhr's classification, site and type of fracture according to Ellis and Price, mean virtual planning and operative time, number of osteosynthesis plates, hospital stay length, adequacy of reduction according to Ramanathan and clinical outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e. Seven females and one male (mean age 82.6 years; range 80–92) were included. Six patients were classified as having class III atrophy, two as class II. The most frequent site of fracture was the body of the mandible. Mild, moderate, and severe displacement were observed respectively in three, two and three patients. Postoperative panoramic radiography showed good and very good reduction respectively in three and five patients. Virtual surgical planning and plate pre-bending took on average 90.5 minutes. Mean operative time was 135.3 minutes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e. Virtual fracture reduction and plate pre-bending on stereolithographic models stands out as a valuable tool for managing severe atrophic mandibular fractures. The authors believe this approach has potential to improve surgical time and accuracy in such complex cases with good cost-effectiveness and time efficiency.\u003c/p\u003e","manuscriptTitle":"Virtual reduction and 3D printing in the management of edentulous atrophic mandibular fractures: case series and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 11:53:19","doi":"10.21203/rs.3.rs-7358734/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-29T12:04:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-20T19:12:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14766874132015306060919279960482088466","date":"2025-09-20T08:02:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-29T11:01:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-15T08:59:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-15T08:58:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"Oral and Maxillofacial Surgery","date":"2025-08-12T19:14:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"aaafd754-3529-4e07-98ed-c2d135d88c31","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T16:04:12+00:00","versionOfRecord":{"articleIdentity":"rs-7358734","link":"https://doi.org/10.1007/s10006-025-01484-7","journal":{"identity":"oral-and-maxillofacial-surgery","isVorOnly":false,"title":"Oral and Maxillofacial Surgery"},"publishedOn":"2025-10-27 15:57:30","publishedOnDateReadable":"October 27th, 2025"},"versionCreatedAt":"2025-09-09 11:53:19","video":"","vorDoi":"10.1007/s10006-025-01484-7","vorDoiUrl":"https://doi.org/10.1007/s10006-025-01484-7","workflowStages":[]},"version":"v1","identity":"rs-7358734","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7358734","identity":"rs-7358734","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}