Accuracy and Clinical Outcomes of Mandibular Reconstruction Using Fibula Free Flaps and Open-Source Virtual Surgical Planning

Mandibular reconstruction using fibula free flaps (FFF) remains the gold standard, although achieving precise anatomic restoration with conventional freehand techniques can be challenging. This study evaluates the surgical accuracy and clinical outcomes of mandibular reconstruction assisted by open-source virtual surgical planning (VSP) and 3-dimensional (3D)-printed models without the use of cutting guides. Twenty-five patients underwent FFF reconstruction between January 2021 and March 2025. Preoperative planning was performed using open-source software (3D Slicer and Blender), and 3D-printed models were used intraoperatively as reference guides, while osteotomies were performed freehand. Surgical accuracy was assessed by comparing preoperative virtual plans with postoperative CT measurements, including intercondylar, intergonial, and anteroposterior distances, gonial angle, and fibula segment length. Linear deviations ranged from 1.53 to 3.05 mm and remained clinically acceptable. Small but statistically significant differences were observed in intercondylar distance, intergonial distance, and fibula segment length (P<0.05), whereas anteroposterior distance and gonial angle showed no significant differences, indicating high concordance between planned and actual outcomes. All flaps survived (100%), with stable occlusion, satisfactory facial symmetry, and good mandibular function observed in all patients. One minor complication (postoperative bleeding) was reported, with no cases of infection or hardware failure. These findings demonstrate that open-source VSP combined with 3D printing enables accurate, reliable, and cost-effective mandibular reconstruction, even without cutting guides, and represents a feasible approach, particularly in resource-limited settings.