Mandibular reconstruction in the "In-House" era: the 3D Slicer alternative

Mandibular reconstruction following tumour resection remains a complex surgical challenge, requiring precise restoration of facial symmetry and function. While virtual surgical planning (VSP) has transformed practices, its adoption remains hindered by the prohibitive costs of commercial platforms and proprietary cutting guides. This pilot study explores the viability of a simplified in-house workflow, using 3D Slicer — a free open-source software — for free fibula flap reconstruction, without the use of industrial cutting guides.

The specific objective of this study was to evaluate the operative outcomes and the cost-effectiveness of this protocol in a series of four patients (n=4). The authors tested the hypothesis that "in-house" planning — including thresholding segmentation and PLA 3D printing — could optimise surgical efficiency while removing financial barriers. The reported results are compelling: a 70.4% reduction in ischaemia time (mean of 51.0 minutes) and a 99% decrease in modelling costs, with printing costs limited to 3-7 USD, paving the way for the democratisation of high technology in oral surgery.

Methodology: an "in-house" digital workflow

This case series, designed as a proof of concept, included four consecutive patients (3 males and 1 female) aged 28 to 58 years (mean: 39.0 years; SD: 13.1), operated on between July and December 2024. Clinical indications included three ameloblastomas and one squamous cell carcinoma.

The experimental protocol followed the following virtual planning steps:

• Data processing: use of 3D Slicer version 5.6.2, an open-source software platform.
• Segmentation: generation of 3D mandibular models by thresholding from preoperative CT scan data.
• Surgical planning: reconstruction using a symmetry technique (mirroring) to restore the mandibular anatomy.
• Manufacturing: 3D printing of physical models in polylactic acid (PLA).

The approach is characterised by the complete absence of commercial fibular cutting guides. Surgical performance was quantified via ischaemia time and total operative time (means and 95% CI). The economic analysis compared the cost of in-house printed models (50,000 to 100,000 IDR, or approximately 3 to 7 USD) to the prices of standard commercial solutions.

Results: Operative efficiency and economic impact

This case series evaluated four consecutive patients (3 males, 1 female) with a mean age of 39.0 years (SD 13.1; range 28-58 years). Diagnoses included three ameloblastomas and one squamous cell carcinoma. The implementation of the 3D Slicer workflow for mandibular reconstruction generated significant clinical and financial data.

Analysis of the results highlights two major points for surgical practice:

• Time optimisation: The mean ischaemia time of 51.0 minutes represents a 70.4% reduction compared to conventional approaches documented in the literature. This efficiency was achieved without the use of proprietary fibular cutting guides.
• Financial accessibility: The production cost of the anatomical models made of polylactic acid (PLA) ranged between 50,000 and 100,000 IDR (approximately 3 to 7 USD), representing a drastic 99% reduction compared to the rates of commercial virtual planning platforms.

Clinically, the authors report a flap survival rate of 100%. No postoperative complications were observed in the four patients. The digital mirroring technique via 3D Slicer enabled precise restoration of facial symmetry, validating the viability of this simplified "in-house" protocol for free fibula flap reconstruction.

Analysis of the reduction in ischaemia time and costs

This case series demonstrates that an "in-house" virtual surgical planning (VSP), utilising the open-source 3D Slicer software, radically optimises mandibular reconstruction. The most significant outcome is the reduction of the mean ischaemia time to 51 minutes, representing a 70.4% decrease compared to the cited conventional approaches. This efficiency is due to preparation on 3D models printed in polylactic acid (PLA), allowing for precise pre-bending of the plates even before the surgical phase.

An economical alternative to proprietary platforms

The major obstacle to the adoption of VSP remains its often prohibitive cost. Here, the authors report negligible printing costs (approximately 3 to 7 USD), representing a 99% saving compared to commercial guides. Despite the absence of fibular cutting guides, the sole use of printed mirror mandibular models made it possible to secure facial symmetry and ensure 100% flap survival in the four patients of the cohort (three ameloblastomas, one squamous cell carcinoma).

Limitations and scope of the study

The weakness lies in the very limited sample size (n=4) and the preliminary nature of this proof-of-concept. Furthermore, the absence of physical cutting guides requires increased manual precision from the surgeon. However, these data prove that access to advanced reconstructive technology can be democratised without relying on massive industrial budgets.

Digital optimisation of mandibular reconstruction

This case series (n=4) demonstrates that an in-house protocol using the open-source software 3D Slicer reduces the mean ischaemia time to 51 minutes, representing a 70.4% decrease compared to conventional approaches. The use of PLA anatomical models printed at a negligible cost of 3 to 7 USD achieves 100% survival of free fibula flaps, without resorting to expensive commercial cutting guides.

In practical terms, for the practitioner:

• Reduce your fixed costs: replace proprietary platforms with open-source tools (3D Slicer) to save up to 99% on the digital preparation of your reconstructions.
• Gain efficiency in the operating theatre: use in-house 3D printing and the mirroring technique to pre-bend your plates, reducing the ischaemia time below the critical 60-minute mark.
• Democratise virtual planning: the absence of proprietary physical cutting guides does not compromise surgical success if the digital preparation by thresholding and segmentation is rigorous beforehand.

Technical glossary of the study

3D Slicer: Free open-source software platform used in this study for medical image processing and virtual surgical planning (VSP) from CT scan data.

Thresholding segmentation: Digital process enabling the isolation of mandibular bone structures from computed tomography data to generate accurate three-dimensional models.

Mirror technique (Mirroring): Virtual reconstruction method using the anatomical symmetry of the patient's healthy hemimandible to model the part affected by the tumour.

Ischaemia time: Duration during which the free flap is deprived of vascularisation; the study highlights a significant reduction in this time (average of 51 minutes) due to preoperative planning.

Polylactic acid (PLA): Polymer used for 3D printing of mandibular anatomical models, allowing the pre-forming of reconstruction plates at an extremely reduced cost (approximately 3-7 USD).

Free fibula flap: Reconstructive technique involving the transfer of a vascularised bone segment from the fibula to the mandible, requiring extreme precision to restore function and facial symmetry.

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