Computer-aided design and manufacturing technology in oral and maxillofacial reconstruction: a narrative review

Introduction

Background

Over the past two decades, advances in medical digital technology have improved diagnostic accuracy and surgical outcomes in the field of oral and maxillofacial surgery (1). As a component of computer-assisted surgery (CAS), modern three-dimensional (3D) imaging allows clinicians to visualize skeletal deformities, soft tissue pathologies, and spatial anatomical relationships with precision. When combined with interactive software, these imaging tools enable surgeons to perform virtual surgical planning (VSP) and design patient-specific surgical guides or templates to achieve more accurate drilling, resection, and implant placement (2,3).

A complete CAS workflow typically includes: (I) preoperative VSP; (II) intraoperative navigation; and (III) intraoperative and/or postoperative imaging for accuracy validation (2). Preoperative VSP begins with acquiring high-resolution imaging data from computed tomography (CT), cone beam computed tomography (CBCT), magnetic resonance imaging (MRI), or ultrasound, and is saved as Digital Imaging and Communications in Medicine (DICOM) format, which stores volumetric data for 3D reconstruction and can be manipulated on planning software (3,4). Surface anatomy, including dentition and gingiva, can be captured with intraoral or optical scanners, generating a stereolithography (STL) format that can be superimposed onto DICOM datasets to create an anatomically precise virtual model for simulation (3,5) (Figure 1). Numerous VSP software platforms are now available, allowing clinicians to visualize anatomical regions from multiple perspectives, perform linear and/or volumetric measurements, segment and mirror structures, and design prostheses or patient-specific devices (6,7).

Figure 1 Data acquisition in the VSP phase. The DICOM data from diagnostic CT or CBCT images can be merged with STL data gathered from an intraoral scanner or 3D scanner in the VSP software. Note that before the image merging, there was scatter on the surface of the crowns. 3D, three-dimensional; CBCT, cone beam computed tomography; CT, computed tomography; DICOM, Digital Imaging and Communications in Medicine; STL, stereolithography; VSP, virtual surgical planning.

After virtual planning, the digital plan may be transferred to the operating room either through surgical navigation or by fabricating computer-aided design and manufacturing (CAD-CAM) surgical guides, occlusal splints, or patient-specific implants (PSIs). Surgical navigation involves importing the digital files from VSP software into a surgical navigation system, which is used to map the surgical point correlating to the image point in real-time. The other and more common options are patient-specific plates, surgical guides, and occlusal splints designed in VSP software, which can be post-processed and exported to manufacturing systems for fabrication (8). Although CAD-CAM workflows require longer preoperative preparation (9), several studies have shown reduced operative time and fewer intraoperative complications compared with conventional freehand surgery (10,11). Additionally, postoperative accuracy in these workflows is generally assessed by superimposing CT or CBCT scans onto the virtual plan and reporting mean linear deviation, angular error, or spatial distance between planned and achieved positions (1,12,13).

Rationale and knowledge gap

Although numerous reviews have examined VSP workflows or, separately, biomaterials and additive manufacturing (AM) for patient-specific reconstruction, these topics are rarely discussed as a unified continuum (3,7,8). Existing literature tends to focus either on digital planning or on biomaterials, but rarely examines them together as a single continuum of technological development (1). This gap limits a comprehensive understanding of how VSP, CAD-CAM, and emerging materials collectively influence modern maxillofacial reconstruction.

Objective

This narrative review aims to summarize the evolution of VSP and CAD-CAM in craniomaxillofacial surgery, with specific emphasis on biomaterials and fabrication technologies that have expanded their clinical applications. The review integrates current evidence to: (I) outline contemporary practices; (II) evaluate their clinical impact; and (III) identify future directions for innovation in craniomaxillofacial reconstruction. We present this article in accordance with the Narrative Review reporting checklist (available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-8/rc).

Methods

Study selection and data sources

This narrative review evaluates the recent advancements and applications of CAD-CAM and AM in oral and maxillofacial reconstruction. With the transformative impact of these technologies on clinical practices, the focus was placed on surgical guides, PSIs, and the integration of these tools in preoperative planning and intraoperative procedures.

Literature search was conducted using PubMed, ScienceDirect databases for articles published between 1995 and 2025. The search keywords included “CAD-CAM”, “maxillofacial”, “3D printing”, “additive manufacturing”, “stereolithography”, “patient-specific implants”, and “surgical guides” (Table 1).

Priority was given to studies offering significant clinical advancements, robust data, or influential reviews. Landmark contributions were included to provide context and illustrate pivotal developments in the field. As a narrative review, this article does not include quantitative synthesis; therefore, publication bias and heterogeneity were not assessed statistically. However, this methodological choice allows inclusion of landmark works and broader technological developments despite varying levels of clinical evidence.

Selection criteria

Studies were included based on their relevance to CAD-CAM and AM technologies, focusing on:

• Technological application: articles describing Subtractive manufacturing and AM processes like selective laser sintering (SLS), stereolithography (SLA), or 3D printing in fabricating implants or surgical guides.
• Clinical relevance: studies demonstrating PSIs in reconstructions of the mandible, maxilla, or orbit.
• Innovation: research highlighting material advancements, such as titanium and polymer composites, and the enhancement of surgical outcomes.
• Outcome measures: evidence-based reports and clinical outcomes, including operative time, implant fit and accuracy, complications, functional outcomes, aesthetic results, and long-term durability of the reconstructed area. Studies reporting recovery metrics such as time to full rehabilitation, reduced surgery time, and reduced postoperative complications were also prioritized.
• Studies focused on in vitro research, animal models, or non-surgical uses were excluded.

Data extraction and study selection rationale

This narrative review emphasizes works showcasing technological evolution. We deliberately selected studies illustrating the role of CAD-CAM in oral and maxillofacial surgery by targeting seminal contributions and the most recent advancements that showcase the evolving nature of these technologies. Recent contributions reflect the shift towards more individualized approaches in reconstructive surgery. Foundational and pioneering studies in the 1990s were also included to provide historical context for the evolution of CAD-CAM technology, from its early applications in conceptual designs to its modern use in fabricating PSIs. Given the large volume of available studies, the selected articles provided clear, clinically relevant outcomes and/or new technological advancements. While some foundational works from earlier decades were included for context, newer studies that address current trends and efficacy were favored to ensure relevance to modern clinical practices.

CAD-CAM

CAD-CAM technology makes rapid, automatic manufacturing possible. As computers and manufacturing machines become more affordable, CAD-CAM is moving away from one-size-fits-all to custom-made solutions in medicine and dentistry.

CAD-CAM technology was first introduced to dentistry in the 1970s by four important figures: Dr. Bruce Altschuler, Dr. Francois Duret, Dr. Werner Mormann, and Marco Brandestini (14,15). They began with the optical impression of tooth abutment, design of the restoration, and then fabricated dental crowns using by milling device. The milling method, also known as “machining”, “subtractive manufacturing”, and “subtractive fabrication”, is a process in which a block of material is cut into a desired shape by power-driven cutting instruments such as saws, lathes, or drills (16,17). This subtractive computer-aided manufacturing (CAM) technology is applied for many dental applications in the fields of prosthodontics and restorative dentistry, as well as orthodontics, such as the fabrication of orthodontic retainers (14). The other CAM technology is AM, also known as “additive fabrication” and the most used kind of “rapid prototyping (RP)”. This additive CAM technology builds 3D objects through processing and slicing the computer-aided design (CAD) data into equal-thickness layers. Then the sliced data is imported to the CAM machine, which prints the material layer-by-layer or point-to-point. These layers of material are cumulated vertically and finally fused to fabricate the 3D objects (18).

The use of the kind of CAD-CAM techniques in clinical dentistry or maxillofacial surgery can be quite different. Compared to subtractive manufacturing, AM allows the creation of very complex geometries or objects with internal complexity, therefore it is thought be have greater flexibility and fewer restrictions (19). Craniomaxillofacial surgeons and orthopedic surgeons use AM technology as the mainstream fabricating method in their practice (20). The subtractive method, which currently can provide more precise and delicate objects than additive fabrication, is used more commonly in fabricating dental crowns, inlays, onlays, veneers, copings, denture frameworks, etc. (21) (Figure 2).

Figure 2 3D objects created by CAD-CAM technology. (A) Surgical guide made by additive method. (B) Dental bridges and crowns made by subtractive method. 3D, three-dimensional; CAD-CAM, computer-aided design and manufacturing.

Current AM technology

The concept of AM has been put forward since the late 1980s. It was originally used to create parts and scale models for the automotive industry. Then, the concept and technologies were developed, and now there are many different types of AM processes available in the medical and dental fields (22,23).

VAT photopolymerization—SLA, digital light projection (DLP). SLA was the very first method of additive fabrication method developed by Charles W. Hull of UVP company in the USA. This method works by using photochemical processes, in which layers of photosensitive monomers are cross-linked and solidified by ultraviolet (UV) light to form 3D polymers. Therefore, photosensitive resin is the most often used material in the SLA method (24).

Sheet lamination—laminated object manufacturing (LOM). LOM works by adhering layers of papers, resins, or metals that are already cut or contoured by laser beams or other methods (8).

Powder bed fusion—SLS, direct metal laser sintering (DMLS), selective laser melting (SLM). These manufacturing methods use thermal energy, such as a carbon dioxide (CO₂) laser, to fuse regions of the powder bed. Both plastics and metals are used widely in this type of method (25).

Material extrusion and material jetting—fused deposition modeling (FDM), fused filament fabrication (FFF). In this technique, materials are heated to a melting state or liquid droplets of material are dispersed through feeding nozzles. Once the parts are placed and cooled down, they solidify. Resins, metals, and ceramics are all choices of material (25,26).

Binder jetting—3D printing, color jet printing (CJP). Liquid bonding agglomerate is selectively sprayed on the area where powder is already deposited. The powder is added layer-by-layer, compacted, and sprayed with a liquid bonding agent, and a binder is added. Finally, the overlaying materials form a 3D geometry object that is solidified by singing off the binding agent (27).

Direct energy deposition (DED)—laser-engineered net shaping (LENS), electron beam melting (EBM), direct metal deposition. DED consists of a nozzle mounted on a multi-axis arm which can move in multiple directions. The material, mostly metals, is deposited and soon melted and fused with a laser or electron beam (28).

Besides artificial grafts that are implanted into the human body to replace or restore the defect, all kinds of materials can be selected for additive fabrication. To fabricate 3D anatomical models, surgical guides/templates, or occlusal splints, various kinds of resins and metals can be processed by the above AM methods. As for the prosthetic implants made of biocompatible materials, they still require a series of studies to collect safety and effectiveness data approved by an International Review Board (IRB) or Food & Drug Administration (FDA) to be used.

CAD-CAM application in maxillofacial bone reconstruction

In maxillofacial reconstructive surgeries, bones that serve as tissue scaffolds are the most important parts to build up to support soft tissue elements. Conventional jawbone reconstruction involves composite microvascular free flap tissue transfer with or without a reconstruction plate to provide mechanical support, form, and function. The introduction of CAD-CAM technology provides different ways to aid in the reconstruction of the maxillomandibular bone complex. Current applications of CAD-CAM in maxillofacial reconstruction include but are not limited to: (I) generating custom anatomical models to facilitate bone plate or mesh bending; (II) fabricating surgical guides and splints to provide precise cutting, drilling, and alignment of bones; (III) biocompatible implants or analogs to replace hard tissue; (IV) customized titanium mesh as scaffold for grafting (29).

CAD-CAM contour jawbone models

In cases with oral malignancy or jawbone tumors, generating 3D contour replicas of patients helps in physically interacting with models and planning resection margins of tumors. If we need models or replicas to serve as a template for making surgical guides or splints manually, new 3D contour models established by the mirror-image function in CAD-CAM software can be rendered. These newly established 3D models with ideal shapes of maxillofacial bones also allow for the preoperative bending of reconstruction plates or bars, which can easily be adapted to the bones intraoperatively. All the above ideas can be applied in a reconstruction plan when the VSP software is not powerful enough to design a guide, or no navigation systems are available.

The early clinical reports using computer technology to render 3D models for craniofacial reconstructions could be traced back to the early 90s (30-33). In those cases, the models were fabricated by CAD-CAM and served as templates for the fabrication of a custom implant (Figure 3).

Figure 3 A patient’s mandible model was fabricated by CAD-CAM and served as a template for plate pre-bending. CAD-CAM, computer-aided design and manufacturing.

In 2006, Hannan published a technical note with two cases of recreating the original contour in tumor-deformed mandibles for plate adaptation (34). He described that the idea was coming from Coward et al., who fabricated a 3D printing of a mirror-image wax ear to reconstruct the lost contralateral side of the ear (35). Cohen et al. presented 3 cases with mandibular ameloblastoma to demonstrate the use of CAD-CAM models to facilitate accurate contouring of plates and planning bone graft harvest geometry before surgery (4). Both of the case reports have concluded usage of a pre-bending plate helped to make surgical procedures easier, shorten surgical time, and decrease blood loss and optical contour of the mandible. Later, Azuma et al. presented a case-control trial with 28 patients with malignant oral tumors who underwent unilateral segmental mandibulectomy and simultaneous mandible reconstruction. Twelve out of 28 patients were treated with a reconstruction plate pre-bent based on CAD-CAM models, while the other 16 patients received conventional plate reconstruction. They compared esthetic outcomes in the two groups by panoramic image analysis and found more symmetrical contour of the mandible was achieved with CAD-CAM technology (36).

Some modifications of 3D images in the designing phase of CAD-CAM have been made, especially when bone plates as well as long bone grafts were considered for reconstruction. Hallermann et al. provided an idea of adding cylinder geometry bars as fibular graft models in their VSP software. After virtual planning the cutting point of the mandible, they could set the cylinder bars to an appropriate alignment. Afterward, they fabricated CAM models, and the simulated surgery could be transferred to actual surgery by bending the reconstruction plate according to the models (37).

The CAD-CAM model technique described above has some limitations and drawbacks during clinical practice. The main problem is to accurately fit the pre-bent reconstruction plate to the mandibular segments during the surgery, for the segments can move freely in all spatial directions. It is also hard to contour the fibula graft or flap based on the template. If the osteotomy of fibular bone is still performed arbitrarily, it is difficult to get good bone-to-bone contact between fibular segments.

CAD-CAM custom surgical guides and positioning splints

More advanced CAD technology helps simulate osteotomies around the lesions, segmentation, movement of bones, design and construct surgical guides/templates, or position the splints. The surgical guide refers to the negative replica of certain segments of bone to guide precise cutting or drilling, while positioning splints refer to the negative replica of virtual final postoperative positions of patient structures, hence, to guide precise alignment of bones (30). Currently, surgical guides and splints are the most popular medical applications of CAD-CAM, which can optimize the shape of reconstructed jawbones. CAD-CAM surgical guides and splints can facilitate segmentation, contouring, plate fixation of fibular shafts, and finally bring an intimate fit of bone margins of the donor anatomy to the recipient site.

The concept of this technique was initially reported by Lee et al. in 2004, with clinical data of 22 patients who underwent segmental mandibulectomy and vascularized fibular flap reconstruction. They fabricated custom mandibular replicas of patients, but the surgical templates were hand-made directly with cured resin, not by CAD-CAM (38).

Thanks to more functional modules available in the VSP software, Leiggener et al. (39) and Hirsh et al. (40) in 2009 both described a protocol to plan the osteotomies and design the cutting guides on the computer. The protocol involves acquiring the patient’s angiographic CT of the lower extremities as well as the maxillofacial region. The DICOM data of the mandible and fibula, along with vessels, were imported to the software so they could perform virtual bone cutting, segmentation, and repositioning. This way, an ideal connection between fibula and mandibular segments can be achieved virtually. Once the virtual surgical simulation is done, surgical templates or cutting jigs are designed by reverse engineering technique to fit the specific locations of bones and printed for actual surgery use. Later, Coppen et al. (41), Zavattero et al. (42), Lee et al. (43), Bosc et al. (44), and Ren et al. (45) all reported their successful clinical results using virtual planning and CAD-CAM surgical templates in the reconstruction of the mandible with free fibular bone graft. Now, the use of this CAD-CAM technique for mandibular reconstruction has become essential and viable (46-48) (Figure 4).

Figure 4 After virtual surgical planning, surgical templates and guides can be fabricated by CAD-CAM. (A) A fibula flap was virtually designed to reconstruct the defect, and cutting guides were prepared using virtual surgical planning. (B) After virtual surgical planning, CAD-CAM was used to fabricate stereolithographic models, mandibular and fibular cutting guides, and a pre-bent osteosynthesis plate. [Reproduced with permission and adapted from the following article: Virtual surgical planning in fibula flap mandibular reconstruction. Frontiers of Oral and Maxillofacial Medicine 2020;2:12 (48)]. CAD-CAM, computer-aided design and manufacturing.

A similar method was used in harvesting and shaping the iliac crest for mandible reconstruction with the aid of VSP and CAD-CAM surgical templates. Modabber et al. reported 20 cases utilizing vascularized iliac crest bone grafts for mandibular reconstruction (49). They further compared time efficiency, functional and esthetic outcomes of using the CAS to the conventional reconstructive surgery and proved that the help of virtual planning and CAD-CAM of surgical templates help to reduce the surgical time (also transplant ischemic time), decrease donor site defect, and result in a more accurate position of the condyle position (50). Zhang et al. also evaluated 45 patients with mandibular tumors who underwent mandibulectomy and vascularized iliac crest flap reconstruction. They also made CAD-CAM models for bending the reconstruction plate and surgical templates for the aid of cutting and positioning the bone segments. Their study results showed the computer-assisted group had better mandibular contour and condyle position compared to the conventional surgery group (51).

Midface reconstruction cases using CAD-CAM technology have been reported by Hanasono et al. (52) and Lethaus et al. in 2010 (53). The two groups of surgeons both used fibular free flaps to reconstruct total maxillectomy and partial maxillectomy cases. Similar cases were also reported by other surgeons afterwards (54-56).

CAD-CAM custom implants

Implants are individualized prostheses used to repair or replace hard or soft tissue defects. CAD-CAM implants can mimic the appearance and structural features of anatomical aspects more accurately (57). For maxillofacial bone reconstruction, the material of choice should, first of all, have high biocompatibility, and additional advantages if it also has proper mechanical properties, fracture resistance, and lighter weight. Currently available materials that have been CAD-CAMed and reported in the previous literature include, but are not limited to, pure titanium, Grade 5 titanium (Ti6Al4V), zirconia-alumina composite ceramic (Al₂O₃-ZrO₂), cobalt-chromium-molybdenum alloy, polyether ether ketone (PEEK) plastic, calcium and phosphate compound ceramics, etc. (58-61)

The earliest report of the usage of custom implants for jawbone reconstructions dates back to 1997. Eufinger et al. reported four cases with oral malignancies undergoing jaw resection with CAD-CAM templates for cutting and drilling, and reconstruction of jawbones was performed with CAD-CAM implants. They fabricated titanium prostheses and templates on a milling machine, and the prosthesis parts in contact with bone were coated with hydroxyapatite or titanium plasma spray after CAM. The prototypes of their custom implants had excellent short-term esthetic and functional outcomes; unfortunately, wound complications and difficulties in covering these large and heavy prostheses with soft tissue flaps in the long term were reported (62). In 1999, Peckitt et al. fabricated CAD-CAM physical models of patients and customized titanium jawbone implants for orofacial reconstruction. In their case report, oral cancer resection margins on the maxillae and mandible were planned on the models. Custom maxillary and hemi-mandibular implants were constructed from titanium alloy, and the abutments for overdenture were welded into the implants. On the day of surgery, the surgeons were able to stabilize the custom implants to the patient’s resected maxilla and mandible with mini screw fixation and reconstruction plate system, and they also managed to deliver the overdentures before the patients were discharged from the hospital. The author treated eight patients with this technique and concluded with successful restoration results of patients’ facial form and jaw function (63).

Then, many other case reports have been published with the usage of different CAM technologies in making customized reconstruction plates or mesh for maxillary and mandibular reconstruction (64-72). Case series and cohort studies also have shown good predictability and better results from using customized prosthetic implants for reconstructions. Shan et al. reported two cases using CAD-CAM custom titanium mesh to reconstruct maxillary and mandibular defects. They evaluated surgical outcomes by comparing pre-and postoperative 3D data and found the rate of concordance was 81 and 94% within 3 mm for the mandibular and maxillary reconstructions, respectively (73). Tarsitano et al. reported four cases who underwent maxillary reconstruction with CAD-CAM titanium mesh after tumor resection. They superimposed pre- and post-operative CT data and found less than 1 mm of deviation between planning and results in most regions, with the orbital floor and alveolus being the most frequent sites of deviation (74). Mascha et al. developed CAD-CAM patient-specific mandibular plate (PSMP) for single plate reconstruction with or without the combination of vascularized osseous graft. The study consisted of 18 mandibular reconstruction cases with the PSMP method and showed satisfactory results with a median deviation of 1.13 mm (75). A short-term outcome from a single custom mandibular prosthesis for reconstruction was reported by Bedogni et al. They treated 18 consecutive patients with a CAD-CAM titanium mandibular replica who were not candidates for vascularized osseous grafts. Upon one-year follow-up, no signs of implant fracture or displacement and screw loosening were detected (76).

In cases where mandibular reconstruction is administered with CAD-CAM prostheses combined with free flaps. Tarsitano et al. presented 9 cases that had CAD-CAM mandibular implants, including a condyle combined with a free fibular flap for reconstruction. They showed a 2 to 72-month outcome with an average of 3.8 mm (1.3–6.7 mm) postoperative deviation of the condyle. No plate exposure, no plate loosening, nor complaint of joint pain from patients had been reported (77). Another larger retrospective cohort by Lee et al. included 126 patients who underwent mandibular reconstruction with virtually planned free fibular flaps. Among them, seventy-one patients had traditionally bent non-customized plates, and 55 patients had a CAD-CAM customized plate. The study found reconstruction with custom plates had significantly shorter total operative times, fewer overall complications, and shorter lengths of hospital stay (78).

For the reconstruction of complex midface, orbital, and cranio-orbital defects, CAD-CAM PSIs provide a highly effective solution by aligning precisely with the unique anatomical features of each patient. These implants not only restore the appearance of the face but also deliver the structural support needed for functional rehabilitation (79,80). One of the key advancements in this area has been the use of 3D-printed PEEK implants, which have demonstrated excellent precision in reconstructing damaged facial structures. In a study by Chepurnyi et al., 28 patients underwent post-traumatic orbital reconstruction using PEEK implants, with results showing a significant clinical advantage over traditional pre-bent plates. These PEEK implants were particularly effective in restoring the volume and shape of the damaged orbit, with the mean volume difference between the reconstructed and intact orbits being minimal, at just 0.74±0.6 cm³ (81). This precise volumetric restoration is essential for both functional recovery and cosmetic appearance, particularly in sensitive areas like the orbit. Similarly, Cárdenas-Serres et al. presented a series of 15 patients who had undergone resective surgeries for benign or malignant lesions, followed by reconstruction with pre-fabricated PEEK implants. Although temporary post-operative edema caused some facial asymmetry in the early stages of recovery, patients reported that the final aesthetic outcomes were highly satisfying. The restoration of their facial appearance had a positive impact on their overall quality of life, further emphasizing the importance of CAD-CAM in not only achieving functional outcomes but also enhancing the emotional and psychological well-being of patients. These findings highlight the growing utility of PEEK implants in complex craniofacial reconstructions, where precision and biocompatibility are paramount (82).

Beyond functional reconstructions, CAD-CAM technology also allows for the creation of custom aesthetic implants, such as chin, cheek, and jaw implants, tailored to meet specific cosmetic goals. These implants are designed with the utmost precision to align with the patient’s natural facial structure or facilitate the outcomes of orthognathic surgeries, ensuring a harmonious and proportionate result that enhances facial symmetry. By creating implants that are customized to each patient’s unique anatomy, CAD-CAM technology provides a level of personalization that traditional methods cannot match (83,84). Whether the goal is to restore lost volume, correct asymmetry, or improve facial balance, these custom facial implants offer a significant improvement in overall appearance, giving patients a more youthful and aesthetically pleasing facial profile (85).

CAD-CAM customized titanium mesh as a scaffold for grafting

The application of CAD-CAM customized titanium mesh as scaffolding for grafting represents a significant advancement in oral & maxillofacial reconstruction. These patient-specific meshes, fabricated using 3D imaging data and modeling techniques, provide a robust and biocompatible framework for bone grafting in complex anatomical defects (86). Titanium’s superior mechanical properties—lightweight, high strength, and excellent biocompatibility—allow for optimal integration with surrounding tissues, promoting both structural integrity and enhanced surgical outcomes.

Customized meshes are particularly beneficial in cases requiring delicate and precise design, such as dentoalveolar reconstruction, where alveolar bone regeneration due to teeth loss is needed to facilitate future dental implant placement (87); or extensive bone regeneration, such as after tumor resection or trauma, where traditional grafting methods may be insufficient. By tailoring the mesh to the patient’s unique anatomy, surgeons can achieve improved contour accuracy and a closer fit, leading to enhanced outcomes in both aesthetics and functionality (88).

In 2015, Sumida et al. conducted a pivotal study comparing laser-sintered titanium meshes with conventional methods, involving 13 participants in each group. Results demonstrated significant benefits of CAD-CAM technology, with a reduction in mean operative time from 111.9±18.5 to 75.4±11.6 minutes. However, the number of fixation screws decreased from 3.23±0.73 to 1.31±0.48, showing that the alveolar ridge defect size is another important factor that obscured the impact (89). As studies highlighted that titanium mesh enabled greater bone gain, Chiapasco et al. reported a retrospective analysis of 41 patients with 53 atrophic sites treated using customized CAD-CAM titanium meshes. After seven months, the mean vertical bone gain was 4.78±1.88 mm, while horizontal bone gain averaged 6.35±2.10 mm, demonstrating the reliability of this technique for severe atrophic ridge defects.

The porous structure of the mesh further enhances vascularization and osteogenesis, crucial for graft stability and healing (90). Despite some challenges, such as increased difficulty in mesh removal during post-regeneration re-entry, the precision and predictability afforded by CAD-CAM technology have established titanium meshes as a preferred option for guided bone regeneration, minimizing intraoperative adjustments and reducing operative time.

CAD-CAM temporomandibular joint (TMJ) prosthesis

Turning to the field of TMJ replacement, CAD-CAM technology has made significant strides in improving the precision and outcomes of TMJ prostheses. In traditional TMJ reconstruction, the use of stock prosthetics often results in suboptimal fit and function, leading to complications such as pain, restricted mobility, and facial nerve weakness (91). However, CAD-CAM technology enables the creation of personalized prosthetic joints that are tailored to replicate the patient’s original joint geometry. This level of customization not only improves joint mobility but also reduces pain and enhances long-term functionality, offering a more effective solution for patients with severe TMJ degeneration or dysfunction. The customization of TMJ prostheses helps to minimize complications related to ill-fitting implants, which are common in traditional methods, and ensures that the prosthesis integrates more effectively with the patient’s anatomy (92).

In 1995, Mercuri et al. presented a multicenter study involving 215 patients who received custom CAD-CAM TMJ prostheses from Techmedica. The results showed significant improvements in multiple parameters, including pain, function, and diet. Patients also reported an objective increase in maximal interincisal opening, indicating a marked improvement in jaw mobility post-surgery. These findings demonstrate the clinical efficacy of custom CAD-CAM TMJ prostheses in enhancing the quality of life for patients suffering from TMJ disorders (93). Similarly, a comparative study by Siegmund et al. examined 28 patients who were treated with either stock TMJ prostheses or CAD-CAM prostheses between 2015 and 2017. The study found that, after six months, there were no significant differences between the two groups in terms of mouth opening, pain relief, or diet. This suggests that CAD-CAM prostheses are at least comparable to traditional systems in terms of clinical outcomes, but with the added benefit of better anatomical alignment and reduced risk of complications (94).

Despite these promising results, there remain areas for improvement in the application of CAD-CAM technology for TMJ reconstruction. One of the primary challenges is the biocompatibility and wear resistance of the materials currently used in these prostheses. Over time, the materials must withstand the high levels of stress and strain exerted by the jaw during normal function, and there is ongoing research aimed at developing more durable materials (95). Advances in surface modification techniques, such as coating prostheses with biocompatible materials, are also being explored to enhance the longevity and functionality of these implants (96). Furthermore, the potential for integrating tissue engineering strategies into TMJ reconstruction offers exciting possibilities for creating more natural, long-lasting joint replacements. Continued research in these areas is crucial for refining the use of CAD-CAM technology in TMJ replacement and ensuring the long-term success of these personalized implants.

CAD-CAM customized bone block for alveolar ridge augmentation

Adequate alveolar ridge form and size are essential for the appropriate 3D positioning of dental implants. In areas where atrophy of the alveolar ridge exists because of the loss of teeth, a ridge augmentation procedure is required to rebuild the area. Although particulate bone grafting combining different types of membranes or titanium meshes is currently mainstream for ridge augmentation, block bone grafting might hold some advantages in large alveolar bone defects (97). The primary drawback of block bone graft is that its geometry is fixed and cannot be 100% adapted to the form of the ridge. Even if the voids between the bone block and the ridge can be filled with particulate bone, it might still compromise bone regeneration. One way to overcome the problem is to fabricate a 3D model of the ridge and to pre-shape the bone block manually on the model (98). With the advancement of CAD-CAM technology, customized bone blocks fabricated by automatic milling or additive methods should be an alternative and smarter way in the future.

In 2013, Schlee and Rothamel treated two patients with 3 areas of combined horizontal and vertical defects on the mandible. They took allogenic bone grafts and processed them following Tutoplast-protocol and low-dose gamma irradiation. Then the bone graft was milled based on the CAD design for the ideal shape of bone to put on the ridge. Those bone grafts were fixed using osteosynthesis screws. After 6 months, a biopsy was taken during implant bed preparation at 6 implant sites. Dental implants were placed and stable up to 12 months after crown restoration, and the histological exam revealed new bone formation in all augmented areas (98). This report represents a proof of concept for CAD-CAM allograft bone block in alveola ridge augmentation. The same year, Figliuzzi et al. presented a similar case report with a histological examination of CAD-CAM bone graft for ridge augmentation on the posterior mandible. They fabricated custom alloplast (commercial coralline hydroxyapatite block) by milling method. After 6 months, a newly formed and well-integrated bone was observed, and dental implants were placed with good primary stability. The custom bone block was easier to handle during the surgery, which helped to reduce surgical time (99).

Later in 2014, Mangano et al. did a 1-year prospective study consisting of 10 patients who received maxillary ridge augmentation with CAD-CAM milling custom hydroxyapatite blocks. After the healing period, well-integrated new bone was observed in all patients, and dental implants were placed with good stability (100). Excellent clinical results were also presented by two different authors in their case reports (101,102).

Limitations of the study

This review has several limitations that should be acknowledged. As a narrative review, it provides descriptive synthesis rather than systematic inclusion and quality assessment of evidence. The literature search was performed primarily through PubMed and ScienceDirect, which may have excluded relevant studies from other databases or unpublished sources. The broad publication window means that older studies may not reflect current standards of VSP or CAD-CAM technology, while rapid technological advances may limit the immediacy of more recent findings. Many of the included studies were retrospective in design, and only a minority offered extended follow-up, limiting the ability to evaluate long-term conclusions. Additionally, this review didn’t include an independent topic about acute maxillofacial trauma, although many of the discussed principles are transferrable to trauma workflows.

Meanwhile, accuracy in CAS workflows is commonly evaluated by superimposing pre- and post-operative 3D imaging to measure deviations between planned and achieved results. Because validation protocols and anatomical sites vary significantly across studies, this review focuses on broader clinical outcomes rather than detailed accuracy metrics.

Finally, clinical application of CAS and CAD-CAM is influenced by cost barriers, steep learning curves for software and design, and potential errors from segmentation or 3D printing that propagate through the workflow (103). These factors may introduce selection bias, as high-resource centers adopt these technologies earlier and publish more frequently (104). Further studies should balance clinical benefits with cost-effectiveness and training feasibility.

Future possibilities

CAS has rapidly adapted by surgeons around the world. Among the three applications of CAD-CAM in maxillofacial reconstruction, both CAD-CAM contour models and CAD-CAM surgical guides or positioning splints help to execute surgical procedures in an easier way and shorter time. However, the development of optimal 3D implants or scaffolds for hard tissue repair or regeneration still has a long way to go. To be able to regain and restore the function and shape of bone structure, the implants or scaffolds should have proper biocompatibility, osteoconductivity or osteoinductivity, and mechanical strength. These features are dependent on the characteristics of materials, geometric design, and microstructure of the implants. We are not there yet, but a good collaboration between material scientists, engineers, and clinicians will be the key to making this bone tissue engineering happen.

Conclusions

In summary, there is an increasing number of articles published every year pertaining to all different applications of CAS in the field of surgery. We cannot include all but only provide a concise overview of the usage of CAD-CAM technology in oral and maxillofacial bone reconstruction. Based on the current limited review, some of the applications are already very mature, while some are still in their early stage of development. As for the evidence level of articles, many of them are still limited to case reports and case series, and only a few of them are cohort studies and have analytical data. Even so, it is undoubted that the current CAD-CAM workflow is valid and will be more maneuverable. As the hardware becomes “economically” more accessible to surgeons and technicians, the standard of care using this technology will be anticipated in the future.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-8/rc

Peer Review File: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-8/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://fomm.amegroups.com/article/view/10.21037/fomm-25-8/coif). S.K.C. serves as an unpaid editorial board member of Frontiers of Oral and Maxillofacial Medicine from July 2024 to June 2026. S.K.C. is the employee of Brockton Oral and Maxillofacial Surgery Inc. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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