Mandibular fractures are among the most frequently encountered injuries of the facial skeleton. Their clinical importance extends beyond bony continuity because the mandible is central to occlusion, mastication, speech, facial width, and lower facial symmetry. Road traffic trauma, interpersonal violence, falls, and occupational injuries remain common causes, while fracture pattern is influenced by impact direction, dentition, bone quality, and anatomic weak points [1-4]. The operative objective is therefore not simply to bridge a fracture line. It is to restore the three-dimensional form of the mandible while re-establishing stable occlusion and permitting early function. Conventional open reduction and internal fixation depends on preoperative radiographic interpretation, intraoperative exposure, manual reduction, temporary maxillomandibular fixation, and plate adaptation. In straightforward fractures this approach is reliable. Difficulty increases when there is marked displacement, bilateral injury, loss of intuitive anatomic landmarks, pre-existing asymmetry, or a complex curvature that must be reproduced accurately. Repeated plate bending and iterative reduction can add operating time and may introduce small errors in mandibular width, projection, condylar relationship, or hardware position. Three-dimensional virtual surgical planning has changed the way complex craniomaxillofacial procedures are planned. CT or cone-beam CT data can be segmented into virtual skeletal models, individual fragments can be manipulated in three dimensions, and the anticipated postoperative anatomy can be inspected before incision. The planned anatomy can then be transferred to surgery through printed models, occlusal splints, drilling guides, cutting guides, or patient-specific hardware [5-12]. Although much of the accuracy literature arose from orthognathic surgery and reconstruction, these workflows provide a conceptual basis for trauma care because they separate the intellectual work of reduction from the time pressure of the operating room. Reports specific to mandibular trauma describe virtual reduction, plate pre-bending, customized hardware, and computer-assisted modeling in complex or atrophic fractures [13-22]. These studies generally suggest improved predictability and easier intraoperative transfer, but many are case reports, technical series, or small cohorts. A second evidence gap concerns outcomes that matter directly to patients. Pain, chewing restriction, social function, and oral health-related quality of life can remain impaired after radiographically satisfactory fracture repair. Instruments such as the 14-item Oral Health Impact Profile (OHIP-14) make it possible to quantify this recovery from the patient perspective [23-25]. The present study was therefore designed to compare VSP-assisted and conventional planning in mandibular fracture management using three complementary domains: geometric surgical accuracy, operative efficiency, and patient-reported recovery. The working hypothesis was that VSP would reduce the discrepancy between planned and achieved mandibular anatomy, shorten operative time, and improve early postoperative patient-reported outcomes.

2.1 Study design and setting This manuscript was structured as a prospective comparative clinical study conducted in the Department of Dentistry, Surabhi Institute of Medical Sciences, Mittapally Village, Siddipet Mdl & District, Telangana, India, from January 2024 to December 2024. Consecutive adults requiring open reduction and internal fixation (ORIF) for a displaced mandibular fracture were screened. Patients were treated through either a VSP-assisted pathway or a conventional planning pathway. Recruitment continued until 30 evaluable participants were available in each group. Because the source dataset and institutional approval record were not supplied for the present manuscript-development exercise, the numerical dataset reported below is synthesized and the final ethics approval number, approval date, and consent documentation must be inserted from institutional records before submission. 2.2 Eligibility criteria Adults aged 18 to 60 years were considered eligible when they had a recent traumatic fracture involving the symphysis, parasymphysis, body, or angle of the mandible, clinically evident displacement or malocclusion requiring ORIF, adequate preoperative CT imaging, and sufficient dentition to assess occlusion. Patients were excluded for isolated condylar fractures managed without open fixation, pathological fractures, severely atrophic edentulous mandibles, active osteomyelitis, panfacial trauma in which mandibular operative time could not be separated reliably, previous major mandibular reconstructive surgery, a requirement for immediate bone graft reconstruction, or a medical condition that precluded standard fracture surgery. 2.3 Planning pathways and group definition In the VSP group, thin-slice CT data were exported in Digital Imaging and Communications in Medicine (DICOM) format and segmented to generate a three-dimensional mandibular model. Fracture segments were separated and virtually reduced by using dental occlusion, continuity of the inferior border, contralateral symmetry, ramal orientation, and condylar position as reference points. The reduced mandible was exported as a stereolithography file. A three-dimensional model was produced for preoperative inspection, and standard titanium plates were pre-contoured on the planned anatomy. Where the fracture pattern permitted, a simple positioning or drilling guide was used to assist transfer of the virtual plan. The aim of the digital workflow was to minimize intraoperative trial-and-error reduction rather than to mandate a patient-specific implant in every case. 2.4 Conventional planning Patients in the conventional group underwent standard clinical evaluation with multiplanar CT review and three-dimensional CT visualization where available. Fracture reduction was planned from occlusion and radiographic anatomy, but no virtual fragment manipulation, printed reduction model, or preoperative plate adaptation was performed. Plates were selected and contoured during the operation after exposure and provisional fracture reduction. 2.5 Operative technique All procedures were performed under general anesthesia using a standardized ORIF protocol. Dental occlusion was re-established with temporary maxillomandibular fixation when required. Fracture sites were exposed through intraoral or extraoral approaches according to location and soft-tissue conditions. Fixation used titanium miniplates along functional osteosynthesis lines or a load-bearing reconstruction plate when fracture morphology required greater rigidity. Wounds were irrigated and closed in layers. Perioperative antibiotic prophylaxis, analgesia, oral hygiene instructions, and postoperative diet progression were standardized across groups. 2.6 Assessment of surgical accuracy Postoperative CT was obtained according to the institutional trauma follow-up protocol and compared with the preoperative target anatomy. For the VSP group, the postoperative mandible was surface-registered to the planned reduced model. For the conventional group, a target reduction model was reconstructed retrospectively from the preoperative CT by applying the same anatomic reduction rules, allowing a comparable planned-versus-achieved analysis. Hardware and dental artifact regions were excluded from surface calculations. The principal accuracy measure was mean absolute surface deviation in millimeters. Secondary geometric measures included maximum surface deviation, absolute intergonial width error, absolute intercondylar distance error, and plate-position deviation. Lower values indicated closer reproduction of the target anatomy. 2.7 Operative efficiency outcomes Total operative time was recorded from incision to completion of wound closure. Reduction-and-fixation time was defined from first exposure of the fracture to completion of definitive osteosynthesis. Plate-contouring time included bending, checking, removal, and re-bending of plates before definitive fixation. The need for any clinically meaningful intraoperative re-bending after initial plate placement was recorded as a binary outcome. Estimated blood loss was abstracted from the anesthesia and operative records. 2.8 Patient-reported and clinical outcomes Oral health-related quality of life was assessed with OHIP-14, in which 14 items are scored from 0 to 4 and summed to a total of 0 to 56, with higher scores indicating greater adverse impact [23]. Questionnaires were administered preoperatively and at 1 week, 6 weeks, and 3 months. Pain intensity was scored on a 0 to 10 visual analogue scale on postoperative day 1 and day 7. At 3 months, patients rated overall treatment satisfaction on a five-point scale. Time to resumption of a normal or near-normal diet was recorded in days. Clinical follow-up also included maximal interincisal opening, occlusal disturbance, wound infection, persistent or clinically relevant neurosensory symptoms, hardware-related problems, and reoperation. 2.9 Sample size The sample size was based on detecting a 20-minute difference in operative time between groups, assuming a standard deviation of 25 minutes, a two-sided alpha of 0.05, and 80% power. This required approximately 26 patients per group. Allowing for incomplete imaging or follow-up, a target of 30 patients per group was used, giving a total analytical sample of 60. 2.10 Statistical analysis Continuous variables were summarized as mean ± standard deviation. Between-group comparisons used independent-samples t tests, with Welch correction where variances differed. Categorical variables were compared using Pearson chi-square tests; Fisher exact tests were used when expected cell counts were small. Fracture-location distributions were evaluated using an overall chi-square test. OHIP-14 was compared between groups at each scheduled assessment, and change over time was interpreted alongside the serial trajectory. Effect estimates are presented as mean differences with 95% confidence intervals where informative. All tests were two-sided and p<0.05 was considered statistically significant. Statistical calculations were designed to be reproducible in SPSS version 28.0 or equivalent software.

3.1 Study flow and baseline profile Sixty patients were included in the analytical cohort, 30 in each planning pathway. The study groups were closely matched for age, sex, mechanism of injury, dominant fracture location, frequency of multiple mandibular fracture lines, and the proportion with displacement greater than 5 mm. No baseline variable showed a statistically significant between-group difference (Table 1). The flow of the synthesized cohort is shown in Figure 1. Figure 1: Flow of patients through the comparative study Table 1: Baseline demographic and fracture characteristics Characteristic VSP (n=30) Conventional (n=30) Statistic p value Age, years 32.7 ± 10.4 33.9 ± 9.8 t = -0.46 0.647 Male sex, n (%) 24 (80.0) 23 (76.7) χ² = 0.10 0.754 Road traffic injury, n (%) 21 (70.0) 20 (66.7) χ² = 0.08 0.781 Multiple mandibular fracture lines, n (%) 12 (40.0) 13 (43.3) χ² = 0.07 0.793 Displacement >5 mm, n (%) 18 (60.0) 17 (56.7) χ² = 0.07 0.793 Dominant site: parasymphysis, n (%) 11 (36.7) 10 (33.3) Dominant site: angle, n (%) 9 (30.0) 10 (33.3) χ² = 0.10* 0.992* Dominant site: body, n (%) 6 (20.0) 6 (20.0) Dominant site: symphysis, n (%) 4 (13.3) 4 (13.3) Values are mean ± SD or n (%). Continuous age comparison used an independent-samples t test. Categorical comparisons used Pearson chi-square tests. *Overall 2 × 4 chi-square test for dominant fracture location. VSP, virtual surgical planning 3.2 Postoperative geometric accuracy VSP produced a closer geometric match to the intended mandibular anatomy across every prespecified accuracy measure (Table 2 and Figure 2). Mean absolute surface deviation was 1.18 ± 0.39 mm in the VSP group compared with 2.31 ± 0.68 mm after conventional planning, a mean difference of -1.13 mm (95% CI -1.42 to -0.84; p<0.001). Errors in mandibular width, condylar separation, and plate position showed the same direction and magnitude of effect. The consistency across independent geometric measures suggests that the observed difference was not driven by a single landmark or registration method. Table 2: Accuracy of achieved mandibular reduction relative to target anatomy Accuracy measure VSP Conventional Mean difference (95% CI) Statistic p value Mean absolute surface deviation, mm 1.18 ± 0.39 2.31 ± 0.68 -1.13 (-1.42 to -0.84) t = -7.90 <0.001 Maximum surface deviation, mm 2.84 ± 0.76 4.62 ± 1.11 -1.78 (-2.27 to -1.29) t = -7.25 <0.001 Intergonial width error, mm 1.09 ± 0.48 2.16 ± 0.81 -1.07 (-1.42 to -0.72) t = -6.22 <0.001 Intercondylar distance error, mm 1.24 ± 0.52 2.42 ± 0.88 -1.18 (-1.56 to -0.80) t = -6.32 <0.001 Plate-position deviation, mm 1.36 ± 0.44 2.57 ± 0.73 -1.21 (-1.52 to -0.90) t = -7.78 <0.001 Values are mean ± SD. Negative mean differences favor VSP because lower deviation indicates greater accuracy. Welch independent-samples t tests were used. CI, confidence interval; VSP, virtual surgical planning. Figure 2: Postoperative geometric accuracy. Bars show mean ± SD. Lower values indicate closer reproduction of the target anatomy. 3.3 Operative efficiency Total operative time was reduced by 26.7 minutes with VSP, from 106.3 ± 23.1 minutes to 79.6 ± 17.8 minutes (95% CI for the difference -37.37 to -16.03; p<0.001). The largest proportional saving occurred during plate contouring, which averaged 6.8 minutes after preoperative model-based adaptation compared with 19.7 minutes in the conventional group. Intraoperative plate re-bending was required in 4 of 30 VSP cases and 19 of 30 conventional cases (χ²=15.86, p<0.001). Estimated blood loss was also lower by 27 mL on average (p=0.013), although blood loss was not a primary endpoint (Table 3 and Figure 3). Table 3: Operative efficiency outcomes Outcome VSP Conventional Difference (95% CI) Statistic p value Total operative time, min 79.6 ± 17.8 106.3 ± 23.1 -26.7 (-37.37 to -16.03) t = -5.01 <0.001 Reduction and fixation time, min 44.3 ± 11.2 68.9 ± 15.4 -24.6 (-31.57 to -17.63) t = -7.08 <0.001 Plate-contouring time, min 6.8 ± 4.2 19.7 ± 7.8 -12.9 (-16.16 to -9.64) t = -7.98 <0.001 Plate re-bending required, n (%) 4 (13.3) 19 (63.3) Not applicable χ² = 15.86 <0.001 Estimated blood loss, mL 91 ± 35 118 ± 46 -27 (-48.16 to -5.84) t = -2.56 0.013 Continuous outcomes used Welch independent-samples t tests. Plate re-bending was compared by Pearson chi-square test. Negative continuous differences favor VSP. VSP, virtual surgical planning. Figure 3: Operative time by planning pathway. Bars show mean ± SD 3.4 Patient-reported recovery Preoperative OHIP-14 scores were nearly identical between groups, indicating a comparable patient-reported burden before fixation. After treatment, OHIP-14 scores declined in both groups, but the reduction was faster after VSP-assisted surgery. The between-group difference was 4.3 points at 1 week (p=0.011), remained 4.3 points at 6 weeks (p<0.001), and narrowed to 1.9 points at 3 months (p=0.038). This pattern is consistent with an early recovery advantage rather than a large persistent difference after healing (Table 4 and Figure 4). Pain scores were similar on postoperative day 1 but lower in the VSP group by day 7. Patients in the VSP pathway resumed a normal or near-normal diet approximately 5.6 days earlier on average and reported higher three-month satisfaction. Maximal mouth opening at three months showed a small numerical advantage for VSP, but the between-group comparison was at the conventional threshold of statistical significance (p=0.050). Table 4: Patient-reported and functional recovery Outcome VSP Conventional Mean difference (95% CI) p value OHIP-14 preoperative 33.1 ± 7.8 32.6 ± 8.1 0.5 (-3.61 to 4.61) 0.808 OHIP-14 at 1 week 19.2 ± 6.0 23.5 ± 6.7 -4.3 (-7.59 to -1.01) 0.011 OHIP-14 at 6 weeks 8.4 ± 4.1 12.7 ± 5.2 -4.3 (-6.72 to -1.88) <0.001 OHIP-14 at 3 months 4.8 ± 3.1 6.7 ± 3.8 -1.9 (-3.69 to -0.11) 0.038 VAS pain, postoperative day 1 5.0 ± 1.2 5.3 ± 1.3 -0.3 (-0.95 to 0.35) 0.357 VAS pain, postoperative day 7 2.0 ± 1.0 2.8 ± 1.2 -0.8 (-1.37 to -0.23) 0.007 Time to normal/near-normal diet, days 17.2 ± 5.6 22.8 ± 7.4 -5.6 (-9.00 to -2.20) 0.002 Treatment satisfaction at 3 months, 1-5 4.6 ± 0.5 4.2 ± 0.7 0.4 (0.08 to 0.72) 0.014 Maximum mouth opening at 3 months, mm 40.8 ± 4.2 38.5 ± 4.7 2.3 (0.00 to 4.60) 0.050 Values are mean ± SD. Between-group comparisons used Welch independent-samples t tests. Lower OHIP-14 and VAS scores indicate better outcomes, whereas higher satisfaction and mouth opening indicate better outcomes. OHIP-14, 14-item Oral Health Impact Profile; VAS, visual analogue scale; VSP, virtual surgical planning. Figure 4: OHIP-14 trajectory from preoperative assessment to three months. Points show mean ± SD; lower scores indicate less oral health-related impact. 3.5 Complications and secondary safety outcomes Complications were uncommon in both groups. Any recorded complication occurred in 3 patients (10.0%) after VSP and 9 patients (30.0%) after conventional planning. The difference did not reach statistical significance by Fisher exact testing (p=0.104). Individual events, including infection, transient or persistent neurosensory symptoms, occlusal disturbance, and reoperation, were also not significantly different. The study was not powered for low-frequency safety outcomes, so the absence of statistical significance should not be interpreted as equivalence (Table 5). Table 5: Postoperative complications through three months Outcome VSP, n (%) Conventional, n (%) Test p value Postoperative occlusal disturbance 1 (3.3) 5 (16.7) Fisher exact 0.195 Surgical-site infection 1 (3.3) 3 (10.0) Fisher exact 0.612 Clinically relevant neurosensory symptom 3 (10.0) 5 (16.7) Fisher exact 0.706 Reoperation 0 (0) 2 (6.7) Fisher exact 0.492 Any recorded complication 3 (10.0) 9 (30.0) Fisher exact 0.104 Fisher exact tests were used because of small expected cell counts. Patients could contribute to more than one individual complication category; the “any complication” row counts unique patients. VSP, virtual surgical planning.

4.1 Principal findings Three findings emerged from this comparative model. First, the VSP pathway reproduced the intended mandibular anatomy more closely than conventional planning, with an approximately 1.1 mm reduction in mean surface error. Second, digital planning shifted a meaningful portion of the reduction and plate-adaptation work out of the operating room, producing a 26.7-minute reduction in total operative time and a marked reduction in intraoperative plate re-bending. Third, the technical gains were accompanied by better early patient-reported recovery. OHIP-14 scores separated at one and six weeks and then converged as fracture healing progressed. This is clinically coherent: a more efficient and less iterative operation is more likely to affect early pain, swelling, mastication, and confidence than to create a large quality-of-life difference once both groups have healed. 4.2 Surgical accuracy and transfer of the virtual plan The accuracy advantage is consistent with the broader evolution of computer-assisted craniomaxillofacial surgery. Bell described computer planning and navigation as particularly useful when anatomy is complex or reconstruction must be performed in three dimensions [5]. Virtual treatment planning studies in orthognathic surgery established a workflow in which preoperative manipulation, splint or guide fabrication, and postoperative verification can convert an intended skeletal movement into a measurable result [6-10]. Those principles translate naturally to trauma: the surgeon can assess fragment rotation, mandibular width, lower-border continuity, and condylar relationship before being constrained by swelling, bleeding, soft-tissue tension, or limited exposure. Trauma-specific publications are smaller but point in the same direction. Thor used virtual osteotomies and a patient-specific reconstruction plate to correct a displaced bilateral mandibular body fracture after failed fixation [13]. Rizzi and colleagues showed that a computer algorithm could generate fracture reduction and hardware appearances judged highly similar to postoperative images [14]. Castro-Núñez and colleagues used VSP in severe atrophic fractures and emphasized predictable reduction with manageable treatment time [16]. Kokosis et al. applied CAD/CAM in acute traumatic mandibular reconstruction and documented restoration of occlusion using a digitally planned construct [17]. The present synthesized effect size is therefore plausible, but it should be validated against the actual postoperative CT dataset rather than assumed from the literature. 4.3 Operative time and plate manipulation The time savings observed here were concentrated in reduction, fixation, and plate contouring. This is the part of the procedure where VSP should have its strongest mechanistic effect. Three-dimensional analysis allows the surgeon to decide the intended fragment relationship and plate shape before incision, while the printed model provides a stable surface for pre-bending. In contrast, conventional adaptation requires repeated placement, visual inspection, removal, bending, and re-placement. The difference in plate re-bending, 13.3% versus 63.3%, is therefore more informative than total time alone because it identifies the operative step most directly altered by the intervention. Rubio-Palau et al. noted that three-dimensional planning can reduce surgical time while increasing preoperative preparation [12]. The RSNA 3D-printing guidance similarly emphasizes that clinical value depends on the entire chain from image acquisition and segmentation to fabrication and quality control [18]. Nilsson et al. reported that an in-house haptic-assisted system could achieve sub-2-mm virtual reduction accuracy with a relatively short planning process [20]. More recently, Voss et al. highlighted the feasibility of virtual planning and plate pre-bending even in the acute trauma setting [21]. These observations are important because a shorter operation is not a free benefit if digital preparation delays definitive fracture care. A practical VSP service must therefore be designed around rapid segmentation, standardized protocols, local printing or dependable manufacturing, and clear thresholds for selecting cases that will benefit most. 4.4 Patient-reported outcomes Radiographic alignment alone does not capture the burden of mandibular trauma. Patients experience pain, diet restriction, difficulty chewing, sleep disturbance, social embarrassment, time away from work, and anxiety about occlusion and facial appearance. Slade developed OHIP-14 as a concise measure of oral health-related functional and psychosocial impact [23]. In mandibular fracture populations, Omeje and colleagues demonstrated that quality of life changes substantially during recovery and that different treatment approaches can affect pain, psychosocial, and physical domains differently [24]. Amran et al. also used OHIP-14 after mandibular fracture surgery and reinforced the relevance of patient-centered assessment alongside clinical outcomes [25]. In the current model, VSP did not produce a meaningful preoperative difference, which supports baseline comparability of patient-perceived injury burden. The postoperative separation was largest during the first six weeks and became smaller by three months. This temporal pattern is preferable to an implausibly large late difference because fracture healing, restoration of diet, and neuromuscular adaptation should allow many conventionally planned cases to catch up. The lower day-7 pain score and earlier return to a normal diet provide converging evidence that the OHIP-14 difference reflects a broader recovery signal rather than questionnaire noise alone. 4.5 Clinical implications The results support a selective rather than indiscriminate role for VSP. A straightforward, minimally displaced single fracture in an experienced trauma unit may not justify a full digital workflow. The potential value increases when reduction is difficult to visualize, when two or more fragments determine mandibular width and projection, when plate contouring is expected to be demanding, or when pre-existing anatomic asymmetry makes intuitive reduction unreliable. VSP may also be valuable for teaching because it forces the operating team to articulate the intended reduction before surgery and provides a common three-dimensional reference for surgeons, residents, radiologists, and engineers. The economic question remains unresolved. Digital planning incurs software, personnel, printer, sterilization, and quality-assurance costs. Those expenses may be offset partly by reduced operating-room occupancy, fewer repeated plate manipulations, and possibly fewer secondary corrections. A formal cost-effectiveness analysis should therefore include both preoperative digital labor and intraoperative resource use rather than treating shorter operative time as the only economic endpoint. 4.6 Strengths and limitations A strength of the study design is the simultaneous assessment of geometry, time, and patient experience. These domains answer different questions: whether the reduction was accurate, whether the operation was efficient, and whether the patient recovered well. The use of quantitative three-dimensional deviation also avoids relying only on subjective statements such as “good reduction.” Serial OHIP-14 assessment adds a patient-centered dimension that is missing from many digital-trauma reports. Several limitations require emphasis. The numerical dataset in this manuscript is synthesized because source patient records were not provided, so the values cannot be represented as actual findings until verified. Even if the proposed study is implemented prospectively, non-random treatment allocation can introduce selection bias, particularly if VSP is preferentially used for complex cases or when digital resources are available. The single-center sample is modest and is underpowered for infrequent complications. Postoperative CT-based accuracy depends on segmentation, registration, threshold selection, and artifact exclusion. The study also does not quantify preoperative planning time, direct digital-workflow cost, radiation exposure, surgeon learning curve, or longer-term hardware removal. These variables should be incorporated into a definitive trial.

Within this synthesized comparative dataset, virtual surgical planning was associated with more accurate reproduction of mandibular anatomy, substantially less intraoperative plate manipulation, and shorter operative time than conventional planning. Patient-reported oral health impact also improved more rapidly during the early postoperative period, while complication rates were too low for a reliable between-group conclusion. These findings support the clinical rationale for VSP in displaced or technically demanding mandibular fractures, but they should be interpreted as a manuscript-development model until the numerical values are replaced or confirmed using the actual study database. A prospective study with verified imaging measurements, documented ethics approval, prespecified case-selection criteria, and a formal cost analysis would provide stronger evidence for routine implementation.

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