Odovtos-International Journal of Dental Sciences (Odovtos-Int. J. Dent. Sc.), Online First, 2026. ISSN: 2215-3411

https://doi.org/10.15517/w6yvxb19

https://revistas.ucr.ac.cr/index.php/rOdontos

CASE REPORT:

Application of 3D-Printed Patient-Specific Titanium Plate in Mandibular Cyst Surgery:

A Case-Based Approach

Aplicación de una placa de titanio específica para el paciente impresa en 3D en la cirugía de quistes mandibulares: Un enfoque basado en un caso clínico

Hasan Aktaş DDS, MSc1 https://orcid.org/0000-0003-2523-0315

Ömer Uranbey DDS, PhD1 https://orcid.org/0000-0003-0628-2419

Burcu Gürsoytrak DDS, PhD1 https://orcid.org/0000-0002-9893-0649

1Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Aydın Adnan Menderes University, Aydın, Turkey.

Correspondence to: Ömer Uranbey DDS, PhD - eomeruranbey@gmail.com

Received: 15-X-2025 Accepted: 2-V-2026

ABSTRACT: Pathological lesions such as cysts and tumors can significantly weaken the mandible, increasing the risk of pathological fractures during or after surgical removal. Preventive osteosynthesis using patient-specific plates (PSPs) has emerged as a reliable method to enhance mandibular stability in such cases. The intraoperative use of these plates may be considered in patients at elevated fracture risk, as demonstrated in the present case. A 67-year-old woman was detected with a well-defined unilocular radiolucent lesion in the right posterior mandible during a routine dental examination. Cone-beam computed tomography revealed a lesion measuring 24.0 × 11.6 × 24.6 mm, extending to the base of the mandible. Enucleation of the lesion was planned, with a preoperative decision to use a patient-specific titanium plate due to the high fracture risk. Virtual surgical planning (VSP) was performed using CBCT data, and a customized plate was fabricated using 3D printing technologies. During surgery under general anesthesia, the cyst was enucleated, and the PSP was fixed at the planned location. The patient was followed up during the first week, second week, first month, and eighth month. Postoperative healing was uneventful, with resolution of transient hypoesthesia and confirmed plate positioning on follow-up imaging.This case suggests that the application of a patient-specific plate, guided by virtual planning and three-dimensional modeling, may help reduce the risk of pathological fracture during mandibular surgery, while allowing for more precise plate adaptation and stable postoperative outcomes.

KEYWORDS: Patient-specific plate; Mandibular cyst enucleation; Virtual surgical planning; Pathological fracture prevention.

RESUMEN: Las lesiones patológicas, como los quistes y tumores, pueden debilitar significativamente la mandíbula, aumentando el riesgo de fracturas patológicas durante o después de su extirpación quirúrgica. La osteosíntesis preventiva mediante placas específicas para el paciente ha surgido como un método fiable para mejorar la estabilidad mandibular en estos casos. El uso intraoperatorio de estas placas puede considerarse en pacientes con un riesgo elevado de fractura, como se demuestra en el presente caso. Se detectó una lesión radiolúcida unilocular bien delimitada en la región posterior derecha de la mandíbula en una mujer de 67 años durante un examen odontológico de rutina. La tomografía computarizada de haz cónico reveló una lesión de 24,0 × 11,6 × 24,6 mm, que se extendía hasta la base mandibular. Se planificó la enucleación de la lesión y, debido al alto riesgo de fractura, se decidió preoperatoriamente utilizar una placa de titanio específica para el paciente. La planificación quirúrgica virtual se realizó utilizando los datos de la tomografía computarizada de haz cónico, y se fabricó una placa personalizada mediante tecnologías de impresión 3D. Durante la cirugía bajo anestesia general, se enucleó el quiste y la placa específica para el paciente se fijó en la localización planificada. La paciente fue controlada durante la primera semana, la segunda semana, el primer mes y el octavo mes postoperatorio. La cicatrización postoperatoria transcurrió sin complicaciones, con resolución de la hipoestesia transitoria y confirmación de la correcta posición de la placa en las imágenes de seguimiento. Este caso sugiere que la aplicación de una placa específica para el paciente, guiada por planificación virtual y modelado tridimensional, puede ayudar a reducir el riesgo de fractura patológica durante la cirugía mandibular, al tiempo que permite una adaptación más precisa de la placa y resultados postoperatorios estables.

PALABRAS CLAVE: Placa específica para el paciente; Enucleación de quiste mandibular; Planificación quirúrgica virtual; Prevención de fractura patológica.

Introduction

Mandibular fractures are one of the most common types of fracture, accounting for 36-70% of fractures of the facial skeleton (1). Mandibular fractures can be caused by various factors, including motor vehicle accidents, assault, domestic violence, falls, sports injuries, work-related accidents and ballistic injuries, as well as pathological fractures (2). Pathological mandibular fractures account for less than 2% of all mandibular fractures (3).

Pathological fractures typically occur following surgical intervention in the region due to underlying pathology. These fractures are possible in areas affected by osteoradionecrosis, osteomyelitis, MRONJ, cysts or tumours. They may occur during or after tooth extraction, implant placement, or the removal of cysts or neoplasms in these areas (4). Studies in the literature have shown that large odontogenic cysts, though uncommon, can cause pathological fractures of the mandible (5).

Intraoperative plate-screw fixation is used to prevent pathological fractures following surgery, similarly to its use in fracture treatment. For this purpose, conventional plate systems are employed for open reduction and internal fixation (6).

The miniplates used in the traditional Michelet-Champy technique offer several advantages, including ease of use, intraoral application, a reduced risk of nerve damage, and the elimination of the need for maxillomandibular fixation. Disadvantages include the need for precise adaptation at the plate-bone interface, the requirement for a second plate to counteract tensile forces, and the potential suppression of cortical blood supply (7).

In recent years, virtual surgical planning (VSP) and patient-specific customized plates (PSP) have been increasingly utilized in the management of mandibular fractures (8,9). PSP systems present several clinical advantages compared to conventional plating methods. Their anatomical design facilitates surgical access while providing superior stability at the fracture site. Unlike conventional systems, PSP reduce the demand for meticulous intraoperative adaptation and minimize bone displacement or occlusal changes during screw fixation. Additionally, their pre-contoured structure streamlines the procedure, significantly shortening operative time (10). Studies suggest that PSP are preferred in the treatment of mandibular fractures because they provide greater stability, higher bite forces and shorter operating times than conventional plates (11).

PSP enable oral and maxillofacial surgery to be personalised. While this technique has been well-established in temporomandibular joint (TMJ) total joint reconstruction, its application remains relatively novel in maxillofacial reconstruction and orthognathic surgical procedures. Reduced costs and the development of CAD/CAM technology will improve the accuracy, efficiency, and overall results of studies in these areas (12).

This case report describes the digital design and surgical planning of a PSP aimed at minimizing the risk of pathological fracture following enucleation of a large mandibular cyst. The report was prepared in accordance with the CARE reporting guidelines (Supplementary Material).

Case Presentation & Diagnosis

A 67-year-old woman with no systemic diseases presented to the clinic for a routine dental examination. No symptoms were observed on intraoral examination. Orthopantomograph (OPG) imaging revealed a unilocular, radiolucent, well-demarcated, and radiopaque cystic lesion in the posterior region of the right mandible (Figure 1.A). The patient reported occasional mild pain in the affected area.

For Dental Volumetric Tomography (CBCT) imaging, the Planmeca ProMax 3D Mid (Planmeca, Helsinki, Finland) device available at our hospital was utilized. The imaging parameters were as follows: field of view (FOV) of 16.0 × 6.2 cm, voxel size of 400 µm, image matrix of 400 × 400, and 155 slices. The exposure settings were 90 kVp and 8 mA. CBCT imaging of the patient revealed a lesion extending from the anterior ramus of the right mandible to the distal aspect of tooth number 47, perforating both the buccal and lingual bones and reaching the mandibular basis (Figure 1.B-C). Tomographic evaluation revealed that the lesion measured approximately 24.0 × 11.6 × 24.6 millimeter (mm). The remaining bone thickness averaged 1.21 mm at the base, 1.0 mm on the buccal side, and was largely perforated in the crestal and lingual areas. Based on the radiologic features of the cyst, Odontogenic Keratocyst, Lateral Periodontal Cyst, Residual Cyst were considered in the preliminary diagnosis. Due to the risk of pathologic fracture following enucleation of the cyst with wide margins, a preoperative decision was made to stabilize the defect using a PSP.

Plate Design and Manufacturing

DICOM files obtained from the patient’s CBCT scans were converted into ".stl" format using RadiAnt DICOM Viewer (Medixant, Poland) for 3D modeling. The STL files were visualized with Formlabs Form 2 software (Figure 2.A), while segmentation was performed in OsiriX MD (Pixmeo SARL, Switzerland). Design processes were carried out using Geomagic software (Hexagon, Stockholm, Sweden). Surgical planning, including the definition of dimensions, structural support, and printing parameters of the patient-specific plate (PSP), was conducted collaboratively by physicians and technicians (Biotechnica Engineering Co. Ltd., Türkiye). The model was then optimized for accurate 3D printing, and both a physical mandible model and a titanium plate prototype were produced with the Formlabs Form 2 printer (Figure 2.B).

The prototype’s contour and fit were evaluated on the model and intraorally, particularly in relation to the marginal gingiva. Chairside adjustments were made accordingly. Based on these evaluations, incision planning and management of hard and soft tissues post-enucleation were refined. Following final approval, the surgical model was printed using an EOS P Series SLS printer, and the titanium plate was fabricated with an EOS M Series DMLS system (EOS, Krailling, Munich). The plate was sterilized by autoclaving and prepared for surgical use.

Figure 1. Coincidentally detected large radiolucent lesion in the mandible A.OPG image, B.Axial CBCT section, C.Coronal CBCT section.

Figure 2. Mandible model and plate design created using the Formlabs Form 2 software. A.design, B.Printed.

Surgical Procedure and Follow-up

The patient underwent surgery under general anesthesia due to the need for precise lesion localization, procedural ease, and the risk of intraoperative fracture. An intraoral mucoperiosteal full-thickness flap was used to expose the area from the anterior aspect of the ramus to the anterior region of the mental foramen. One advantage of preoperative virtual surgical planning is the ability to predetermine the incision line. In this way, a modified incision line was created to extend the flap to the posterior and lingual regions, reducing the potential risk of plaque exposure in the postoperative period.

Similarly, during the model surgery conducted on the preoperative 3D model, the operators rehearsed procedures involving hard tissues, including bone reduction, undercut correction, and cyst perforation. This preoperative simulation facilitated a more controlled and predictable surgical intervention. Simultaneously, the cyst was enucleated using a guided approach, minimizing bone loss (Figure 3.A-B). 2.0-mm-diameter miniscrews (KLS Martin, Tuttlingen, Germany), which were compatible with the designed PSP, were fixed to the bone (Figure 3.C). Hemostasis within the cystic cavity was achieved. The mucoperiosteal flap was then mobilized and adapted to ensure complete coverage of the surgical site and the fixation plate. Closure was performed in two layers muscle and mucosa using 3-0 Vicryl sutures (Figure 3.D).

Postoperative follow-up was conducted at one week, two weeks, and one month. The patient was prescribed oral amoxicillin twice daily for the first postoperative week and was instructed to maintain a liquid diet for two weeks after surgery. Intermaxillary fixation was not applied. The patient was advised to rest, and follow-up care was continued. Initial hypoesthesia in the mental nerve distribution, presumed to be secondary to postoperative edema, resolved completely within the first month. Early postoperative symptoms were primarily limited to expected pain and swelling. Postoperative CBCT imaging confirmed that the PSP was in the correct position (Figure 4.A-B).

Histopathological examination revealed that the cyst wall was lined by hyperplastic stratified squamous epithelium. The connective tissue showed inflammatory cell infiltration, cholesterol clefts, multinucleated giant cells, and erythrocytes. Based on the radiological and histopathological findings, the lesion was diagnosed as a residual cyst (Figure 5.A-B). During the postoperative follow-up period, Tooth #47 demonstrated loss of vitality. The patient was referred for endodontic consultation, and root canal treatment was subsequently performed. At the 8-month follow-up, a panoramic radiograph was obtained to evaluate postoperative healing (Figure 6). The patient remains under clinical and radiographic observation. The clinical course and management steps are summarized in Table 1.

Figure 3. A.Flap margins and cyst excision, B.The cyst obtained, C.Intraoperative view of PSP, D.The flap was sutured.

Figure 4. A.Postoperative CBCT reconstruction of mandible, coronal view, B.Lateral view.

Figure 5. A-B: Histopathology showing cyst wall lined by hyperplastic stratified squamous epithelium with inflammatory infiltration, cholesterol clefts, giant cells, and erythrocytes, consistent with a residual cyst.

Figure 6. Panoramic radiograph obtained at the 8-month follow-up demonstrating satisfactory postoperative healing.

Table 1. Chronological summary of presentation, imaging, digital planning, surgery, and follow-up visits (1 week, 2 weeks, 1 month, and 8 months) with key outcomes.

Time Point	Clinical Stage	Key Findings / Interventions	Outcomes
Initial Presentation	Routine dental examination	67-year-old woman; asymptomatic intraoral exam; mild occasional pain reported	Unilocular radiolucent lesion detected on panoramic radiograph
Diagnostic Imaging	CBCT evaluation	Lesion measuring 24.0 × 11.6 × 24.6 mm; extension to mandibular base; buccal and lingual cortical perforation; reduced residual bone thickness	High risk of pathological fracture identified
Preoperative Planning	Virtual surgical planning (VSP) and PSP design	DICOM data converted to STL; segmentation and plate design performed; 3D-printed mandibular model and titanium PSP fabricated	Surgical simulation completed; plate adaptation confirmed
Surgery (Day 0)	Cyst enucleation + preventive osteosynthesis	Intraoral approach under general anesthesia; enucleation of lesion; fixation of patient-specific titanium plate with 2.0-mm miniscrews	No intraoperative complications; stable fixation achieved
Postoperative Week 1	Clinical follow-up	Mild pain and swelling; hypoesthesia in mental nerve distribution	Healing within expected limits
Postoperative Week 2	Clinical follow-up	Reduction in edema; no signs of infection or wound dehiscence	Continued uneventful healing
Postoperative Month 1	Clinical + radiological follow-up	Resolution of hypoesthesia; CBCT confirmed correct plate positioning	Stable postoperative course
Postoperative Month 8	Long-term follow-up	Panoramic radiograph obtained; Tooth #47 received endodontic treatment due to loss of vitality	No pathological fracture; satisfactory bone healing; patient asymptomatic

Discussion

Pathological formations such as cysts or tumors, although benign, can cause severe resorption of surrounding structures (13). Mandibular weakening may result in pathological fractures during or after the pathology. When such a scenario is predicted or has occurred, various treatment strategies can be developed through a comprehensive evaluation of both local and systemic conditions (14).

For this purpose, conventional treatment methods such as marsupialization and decompression can be applied to various regions of the jaw, either alone or in combination with other approaches (15). This method protects surrounding vital structures and reduces the risk of pathological fractures, particularly in large cysts. However, the literature has reported disadvantages such as prolonged marsupialization and chronic irritation, which reduce the suitability of the treatment for some patients (16,17). In our case, patient-related factors such as age and the distance of residence from our hospital precluded the feasibility of prolonged marsupialization.

Enucleation is a method in which the entire lesion is removed (18).The aim is to completely remove the cyst epithelium from the bone to achieve primary closure after the operation and interrupt the intraoral relationship with the cyst cavity. It enables a histopathological examination of all the excised material. Removal of large cysts using this method carries the risk of damaging adjacent anatomical structures, potentially leading to hypoesthesia from nerve injury or even mandibular fracture (19,20). In our patient, given the cyst’s location in the mandible, we determined that completing the procedure with enucleation alone would carry a high risk of mandibular fracture.

To our knowledge, three studies have reported on the use of intraoperative plate fixation to prevent pathological fractures (21,22,23). Castellani (22) and Bazin (23) used custom-made plates in their studies. Castellani et al. (22) treated a recurrent mandibular odontogenic keratocyst with conservative enucleation, preceded by the preoperative placement of a customized load-bearing titanium plate to prevent pathological fracture. Similarly, Bazin et al. (23) reported two cases of mandibular cysts managed with cyst enucleation and preventive osteosynthesis using customized titanium plates to mitigate intra- and postoperative fracture risks. In contrast, Pippi et al. (21), who shared the first literature on the use of non-customized titanium miniplates, a 45-year-old man underwent surgery for impacted molars, with titanium miniplate placement for stabilization, followed by successful healing and plate removal after two years. Uncomplicated healing in the 3 cases mentioned. Also in our case where a custom plate has been used, there have been no sequelae in terms of postoperative healing and the patient is in follow-up.

Fixation procedures can be performed using standard miniplates or custom-designed plates. These have various advantages or disadvantages compared to each other. Among the authors who have compared these systems in the treatment of fractures, Malhotra, Sadhwani, and Taalab concluded that PSP’s are more resistant and stable, easier to apply, and associated with fewer complications than conventional miniplates (7,9,11). Mishra et al. further noted that, from a clinical perspective, there are no significant differences between the two systems (24). The rationale for selecting custom plates in our patient included reducing operative time, minimizing potential alignment issues associated with conventional mini-plates, achieving improved anatomical conformity to the surgical site, and enabling preoperative determination of appropriate screw lengths through three-dimensional planning.

In the present case, the primary disadvantages of the process included the preparation of jaw and plate models, the time required for chairside evaluation, the necessity for close coordination with the technician, and the overall cost. Similarly, Bazin et al. (23) have identified the additional procedural steps and associated expenses as the most significant current limitations of PSP’s.

The advantages of our case were that the jaw's condition after pathology removal could be predicted using models, the operation could be explained to patients more easily, and the plate could be fitted to the jaw exactly during surgery. Additionally, the overall operation time was reduced. Similarly, Taalab et al. (11) reported that the superior fit of PSP’s helps prevent bone resorption by reducing the stress exerted by screw heads on the plate. As three-dimensional systems become more widespread and integrated into routine clinical practice, the reported disadvantages and limitations are expected to gradually disappear. In this context, personalized treatment approaches, which are advancing rapidly, are emerging as a viable alternative to conventional methods. In addition to clinical and radiological findings, patient-reported outcomes are important to assess overall success. Our patient reported only mild postoperative pain and swelling, with transient hypoesthesia resolving within one month, and no functional or aesthetic complaints thereafter.

This report is limited by its single-case design, the absence of long-term follow-up, and the inability to evaluate the approach under comparable conditions across multiple patients. Future studies involving larger case series and longer observation periods are needed to better assess the reproducibility and clinical benefits of this approach.

AUTHOR CONTRIBUTION STATEMENT: Conceptualization, surgical procedure and manuscript drafting, O.U.; Literature review, figure preparation, and manuscript editing, H.A.; Virtual surgical planning, 3D modeling, and critical revision of the manuscript, B.G. All authors read and approved the final manuscript.

Funding: Not funded.

Ethical Approval and Consent to Participate: Ethical approval was not required for this case report. The patient provided written informed consent to participate.

Consent for Publication: Written informed consent was obtained from the patient for publication of the case details and images.

Competing interests: The authors declare no competing interests.

Clinical trial number: Not applicable.

Acknowledgements: We would like to thank Biotechnica Engineering for their support with digital planning and 3D printing services.

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