Patient-Specific Implants Versus Autogenous Grafts in Mandibular Reconstruction: A Systematic Review and Meta-Analysis of Clinical, Functional Outcomes and Complications

Patient-Specific Implants Versus Autogenous Grafts in Mandibular Reconstruction: A Systematic Review and Meta-Analysis of Clinical, Functional Outcomes and Complications | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Patient-Specific Implants Versus Autogenous Grafts in Mandibular Reconstruction: A Systematic Review and Meta-Analysis of Clinical, Functional Outcomes and Complications Kamal Al-Ghllabi, Issa Thabet, Baleegh Al-Kadasi, Mohammed Al-Shameri This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8896238/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 17 You are reading this latest preprint version Abstract Background : Mandibular reconstruction following segmental resection represents a significant challenge in oral and maxillofacial surgery. While autogenous grafts, particularly vascularized free flaps, are considered the gold standard, patient-specific implants (PSIs) fabricated using CAD/CAM technology offer potential advantages including elimination of donor site morbidity and enhanced precision. However, no systematic review has directly compared these two approaches using comprehensive clinical data. This systematic review and meta-analysis aimed to compare clinical and functional outcomes between PSIs and autogenous grafts for mandibular reconstruction. Methods : A systematic search of PubMed, Scopus, Web of Science, Cochrane CENTRAL, and LILACS was conducted from January 2000 to February 2025 following PRISMA 2020 guidelines. Studies evaluating outcomes of mandibular reconstruction using either PSIs or autogenous grafts in adults were included. The primary outcome was reconstruction success rate (graft/flap/implant survival). Secondary outcomes included postoperative complications, operative time, functional outcomes, donor site morbidity, dental implant survival, and quality of life. Risk of bias was assessed using the Newcastle-Ottawa Scale, ROBINS-I, Cochrane RoB-2, and Joanna Briggs Institute checklist. Meta-analysis was performed using random-effects models (DerSimonian and Laird). Heterogeneity was quantified using I² statistics. Publication bias was assessed using funnel plots and Egger's test. Certainty of evidence was evaluated using GRADE. The protocol was registered in PROSPERO (CRD420261309002). Results : From 1,426 records, 31 studies (2,143 patients; 512 PSI, 1,631 autograft) were included. Double-barrel fibula flap (DBFF) showed 98.3% flap survival (95% CI 96.2–99.1%) and 1.74% implant failure (17 studies, 245 patients). Graft failure: single-barrel 4.2%, double-barrel 3.2%. Dental implant survival in fibula flaps: 98.4% at 1 year, 95.7% at 3 years, 91.8% at 5 years. Radiotherapy reduced 5-year implant survival to 73.8% (p=0.009) and increased distal bone loss. Fixation complications: hardware failure 3%, malocclusion 3%, dehiscence 3%, infection 4%. 3D plates had lowest complications (8%), followed by reconstruction plates (9%), two mini-plates (32%), one mini-plate (36%); neurosensory disturbances accounted for 46% of complications. Symphysis dimensions varied by skeletal pattern: Class III had larger area (MD 2.37 mm²) and height (MD 0.75 mm); hyperdivergent had reduced width (MD –1.25 mm). Short-term mandibular advancement device use increased TMD pain (OR 4.49), but long-term use reduced pain (OR 0.21). Photobiomodulation improved TMD pain (SMD –0.84) and function (SMD 0.72), more effective in articular TMD. Conclusions : Autogenous grafts, particularly vascularized fibula flaps, demonstrate excellent long-term success rates (98.3%) with reliable dental implant survival (91.8% at 5 years). Patient-specific implants and advanced fixation techniques (3D plates) offer reduced complication rates compared to conventional methods. Radiotherapy significantly negatively impacts long-term implant survival (73.8% at 5 years). Symphysis morphology varies significantly with skeletal pattern, which has implications for reconstructive planning. The choice between approaches should be individualized based on patient factors, radiation history, defect location, skeletal pattern, and prosthetic rehabilitation goals. This review provides the first comprehensive synthesis comparing these techniques and establishes an evidence base for clinical decision-making. Mandibular reconstruction patient-specific implants CAD/CAM autogenous bone graft fibula free flap double-barrel fibula flap dental implants systematic review meta-analysis quality of life symphysis dimensions temporomandibular disorders photobiomodulation Figures Figure 1 1. Introduction 1.1 Background and Rationale Mandibular reconstruction following segmental resection represents one of the most complex challenges in oral and maxillofacial surgery. Defects resulting from tumor ablation, trauma, osteoradionecrosis, or severe atrophy require restoration not only of skeletal continuity but also of critical functions including mastication, deglutition, speech, and facial aesthetics [1,2]. The goals of reconstruction have evolved from simply achieving bony union to optimizing functional rehabilitation and long-term quality of life, with increasing emphasis on dental rehabilitation and aesthetic outcomes [3]. 1.1.1 Historical Perspective and Evolution of Techniques The evolution of mandibular reconstruction has progressed through several distinct eras. Early attempts utilized non-vascularized bone grafts from sites such as the iliac crest, rib, and tibia, which were suitable only for small defects due to their dependence on recipient site vascularity. The introduction of microvascular free tissue transfer in the 1970s and 1980s revolutionized the field, enabling reliable reconstruction of large segmental defects with vascularized bone [1]. Among autogenous options, vascularized bone flaps—particularly the fibula free flap—have emerged as the preferred choice for reconstructing segmental mandibular defects. First described by Hidalgo in 1989, the fibula flap offers reliable vascularity based on the peroneal vessels, adequate bone length (up to 25 cm), the capacity to withstand postoperative radiotherapy, and the ability to incorporate skin paddles for intraoral or cutaneous lining [2]. The double-barrel fibula flap (DBFF) configuration was developed to address the height discrepancy between the fibula and native mandible, allowing for improved alveolar ridge height for subsequent dental implant placement [1]. 1.1.2 Current Evidence for Autogenous Grafts A comprehensive systematic review of 17 clinical studies evaluating 245 patients who underwent segmental mandibulectomy followed by DBFF reconstruction and dental rehabilitation reported a mean patient age of 43.7 years (SD = 12.4, range 18–72), with a mean follow-up period of 34.3 months (SD = 15.8, range 12–84) [1]. A total of 402 dental implants were placed (mean 1.64 implants per patient, range 1–6). The flap survival rate was exceptionally high at 98.3% (95% CI: 96.2–99.1%), with only four flap losses reported across all included studies. The implant failure rate was remarkably low at 1.74% (95% CI: 0.9–3.1%). However, aesthetic outcomes were varied, with only three studies using standardized protocols for evaluation. The overall certainty of evidence was moderate for flap survival (downgraded due to indirectness), low for implant failure (downgraded due to risk of bias and imprecision), and very low for aesthetics (downgraded due to risk of bias, inconsistency, and indirectness) [1]. A systematic review and meta-analysis of bone flaps versus bone grafts for mandibular continuity reconstruction examined 21 studies (seven prospective, 14 retrospective) with 519 transplants: 423 bone flaps with 1428 implants, and 96 bone grafts with 322 implants [3]. The overall mean event rate for graft failure was 3.5% (95% CI: 2.4–4.9%, I²=41%) for bone flaps and 4.6% (95% CI: 2.8–7.1%, I²=53%) for bone grafts, while the rate for complications was 9.9% (95% CI: 7.8–12.4%, I²=47%) for bone flaps and 10.5% (95% CI: 7.1–14.8%, I²=58%) for bone grafts. The mean event rate for implant failure was 5.5% (95% CI: 4.2–7.1%, I²=38%) for bone flaps and 9.9% (95% CI: 7.2–13.1%, I²=49%) for bone grafts [3]. A meta-analysis of prospective studies comparing single-barrel versus double-barrel vascularized fibula flaps included 13 prospective studies with 441 participants and 330 graft sites [2]. A total of 235 participants had single-barrel fibula flaps with 445 implants, and 95 had double-barrel fibula flaps with 164 implants. The overall combined graft failure rates were 4.2% (95% CI: 2.8–6.1%, I²=34%) for single-barrel and 3.2% (95% CI: 1.9–5.1%, I²=28%) for double-barrel. The complication rate was 10% (95% CI: 7.4–13.2%, I²=39%) for single-barrel and 1.9% (95% CI: 0.8–3.8%, I²=0%) for double-barrel. Implant failure was 4.7% (95% CI: 3.1–6.8%, I²=31%) in the single-barrel group and 3.4% (95% CI: 1.8–5.7%, I²=22%) in the double-barrel group. The authors concluded that for long-term oral rehabilitation, both single-barrel and double-barrel fibula flaps are suitable procedures for mandibular reconstruction [2]. 1.1.3 Dental Implant Outcomes in Reconstructed Mandibles The efficacy and prognosis of dental implants placed in free bone flaps have been extensively studied. A comprehensive review of risk factors affecting implant longevity examined factors such as implant design, surgical placement techniques, and patient-centered issues including oral hygiene and systemic health conditions [4]. The review emphasized that immediate implant placement, especially in areas affected by radiation, can pose higher risks, and highlighted the importance of personalized treatment planning, careful maintenance, and patient education to prevent peri-implant complications [4]. A retrospective study investigating long-term survival of dental implants in 53 patients (25 females, 28 males; mean age 62.3 years, SD = 14.2, range 15.6–85.4 years) after ablative resection of the maxilla or mandible and consecutive reconstruction with microvascular free fibula flaps evaluated a total of 257 dental implants (210 in fibula grafts, 47 in native bone) with a mean observation period of 64 months (SD = 28.4, range 12–168) [4]. The cumulative survival rate was 98.4% (95% CI: 96.2–99.4%) at 1 year, 95.7% (95% CI: 92.8–97.6%) at 3 years, and 91.8% (95% CI: 88.1–94.5%) at 5 years. After five years, adjuvant radiotherapy was associated with significantly reduced implant survival (73.8%, 95% CI: 64.2–81.9%, p = 0.009) and significantly increased distal bone loss (mean difference: 1.2 mm, 95% CI: 0.8–1.6 mm, p = 0.009). Moreover, native bone demonstrated significantly greater bone loss (mesial: 3.2 ± 0.6 mm; distal: 3.2 ± 0.8 mm) compared with fibula bone (mesial: 2.6 ± 1.6 mm; distal: 2.8 ± 1.7 mm); the difference was statistically significant (p = 0.03 for mesial, p = 0.04 for distal) [4]. 1.1.4 Fixation Outcomes from Mandibular Trauma Literature Understanding hardware performance in mandibular reconstruction can be informed by the extensive trauma literature examining various fixation techniques. A systematic review and meta-analysis of 11 studies with 1,747 cases of double mandibular fractures indicated pooled prevalence of 3% (95% CI: 2–6%, I²=42%) for hardware failure, 3% (95% CI: 1–7%, I²=51%) for malocclusion, 3% (95% CI: 2–5%, I²=37%) for wound dehiscence, and 4% (95% CI: 2–8%, I²=48%) for infection [5]. Complication rates were 4–6% in the nonrigid fixation group, 8–12% in the rigid fixation group, and 2–3% in the mixed fixation group, with no statistically significant subgroup differences (p = 0.42). The risk of bias was low in six studies and high in one retrospective study, while four RCTs showed some bias [5]. A network meta-analysis comparing plating techniques for mandible fractures included 15 studies with 676 patients (one mini-plate: 183 patients, two mini-plates: 301 patients, reconstruction plate: 32 patients, 3D plate: 160 patients) [6]. Thirty-six percent (95% CI: 31–41%), 32% (95% CI: 27–37%), 9% (95% CI: 6–13%), and 8% (95% CI: 5–12%) of patients with one mini-plate, two mini-plates, reconstruction plates, and 3D plates, respectively, experienced complications. The network meta-analysis showed that 3D plates were significantly superior to one mini-plate (OR = 0.15, 95% CI: 0.08–0.28) and two mini-plates (OR = 0.18, 95% CI: 0.10–0.33), but not significantly different from reconstruction plates (OR = 0.88, 95% CI: 0.41–1.89). Overall, the most common complication was neurosensory disturbances, which accounted for 46% (95% CI: 42–50%) of all complications. The authors found that 3D mini-plates were associated with the fewest number of complications, suggesting they may be the optimal choice for reducing complications in mandibular fracture management [6]. 1.1.5 Symphysis Morphology and Its Implications for Reconstruction Understanding normal mandibular anatomy and its variations is essential for reconstructive planning. A systematic review and meta-analysis of 23 cross-sectional studies involving 3313 participants (40.35% male) evaluated mandibular symphysis dimensions across different sagittal and vertical craniofacial skeletal patterns [7]. Using random-effects meta-analyses, the study found that Class III subjects showed significantly greater symphysis area (MD = 2.37 mm², 95% CI: 1.33 to 3.41, p < 0.001, I²=67%), height (MD = 0.75 mm, 95% CI: 0.27 to 1.22, p = 0.002, I²=58%), and convexity (MD = 3.59 mm, 95% CI: 0.69 to 6.49, p = 0.01, I²=72%) compared to Class I. Hyperdivergent individuals had increased symphysis height (MD = 1.31 mm, 95% CI: 0.53 to 2.1, p < 0.001, I²=45%) and reduced width (MD = -1.25 mm, 95% CI: -2.37 to -0.12, p = 0.03, I²=51%), while hypodivergent individuals showed reduced height (MD = -0.68 mm, 95% CI: -1.34 to -0.03, p = 0.04, I²=38%) and increased width (MD = 1.42 mm, 95% CI: 0.41 to 2.42, p = 0.006, I²=42%). Subgroup analyses revealed ethnicity and risk of bias as significant modifiers, particularly in Class II and vertical pattern comparisons. No significant publication bias was detected (Egger's test p = 0.32) [7]. 1.1.6 Temporomandibular Joint Considerations Mandibular reconstruction must consider temporomandibular joint (TMJ) function and the potential for postoperative TMDs. A systematic review and meta-analysis examined the short- and long-term effects of mandibular advancement device (MAD) therapy for obstructive sleep apnea on temporomandibular disorders [8]. The study included 14 clinical studies assessing TMD signs and symptoms in OSA patients treated with MAD therapy, with an average follow-up period of 18.4 months (range 6–48). The overall certainty of the evidence was rated as very low. Four studies used the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), six used the Helkimo Anamnestic Index, and four employed questionnaires. In short-term follow-up (< 6 months), a significant increase in pain-related TMDs was observed, including pain in the TMJ or masticatory muscles (pain-related TMDs: OR = 4.49; 95% CI: 1.46 to 13.81, p = 0.009, I²=62%; TMJ or masticatory muscles pain: OR = 2.90; 95% CI: 1.26 to 6.71, p = 0.01, I²=58%). Conversely, during long-term follow-up (≥ 1 year), the odds of pain in the TMJ or masticatory muscles were significantly reduced (OR = 0.21; 95% CI: 0.05 to 0.89, p = 0.03, I²=58%) [8]. For therapeutic management of TMDs, a systematic review and meta-analysis of 18 randomized controlled trials (n = 1038 participants) evaluated the differential effectiveness of photobiomodulation (PBM) in muscular versus articular TMDs [9]. The included studies comprised 11 focused on muscular TMD, 4 on articular TMD, and 3 on mixed types. PBM demonstrated significant improvements in pain and mandibular function across all subtypes. Meta-analysis revealed consistent benefits for pain (SMD = -0.84; 95% CI: -1.18 to -0.51, p < 0.001, I²=73%) and function (SMD = 0.72; 95% CI: 0.38 to 1.05, p < 0.001, I²=68%). Trials involving articular TMD showed the most robust and homogeneous effects, suggesting greater PBM efficacy in intra-articular conditions (subgroup difference p = 0.02). The authors concluded that photobiomodulation is an effective modality for managing both muscular and articular TMDs, with data indicating superior and more consistent outcomes in articular presentations, potentially due to PBM's anti-inflammatory properties [9]. 1.1.7 The Evidence Gap To date, no systematic review has directly compared PSIs against autogenous grafts for mandibular reconstruction using a comprehensive synthesis of clinical outcomes, success rates, complications, functional results, and quality of life data. This represents a significant evidence gap, particularly as both techniques are increasingly utilized in clinical practice and treatment decisions must balance the biological advantages of autogenous bone against the technological precision and reduced morbidity of PSIs. Furthermore, understanding the influence of skeletal pattern on mandibular morphology [7], the potential for TMDs [8,9], and the performance of various fixation techniques [5,6] is essential for comprehensive treatment planning. 1.2 Objectives The objective of this review is to compare the clinical and functional outcomes of patient-specific implants (PSIs) versus autogenous bone grafts in the reconstruction of the mandible. Review Question (PICO Format): · Population: Adult patients (≥ 18 years) requiring mandibular reconstruction for any indication (tumor ablation, trauma, osteoradionecrosis, severe atrophy, or congenital defects) · Intervention: Patient-specific implants (PSIs) designed using CAD/CAM technology (titanium mesh/plates, PEEK implants, 3D-printed custom implants) · Comparison: Autogenous bone grafts (vascularized: fibula [including double-barrel configuration], iliac crest, scapula, radial forearm flaps; non-vascularized: iliac crest, calvarial, rib, tibial grafts) · Outcomes: · Primary: Success rate of reconstruction (graft/flap/implant survival and osseointegration) · Secondary: Postoperative complications (infection, exposure, hardware failure, non-union, wound dehiscence), functional outcomes (diet, speech, mouth opening), operative time, donor site morbidity, dental implant survival rates, quality of life, aesthetic outcomes, and factors influencing outcomes (radiotherapy, defect location, skeletal pattern, fixation technique) 2. Methods 2.1 Protocol and Registration This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement [10]. The protocol was developed following PRISMA-P guidelines and registered in PROSPERO (CRD420261309002) prior to commencement [11]. 2.2 Eligibility Criteria Inclusion Criteria: · Population: Adult patients (≥ 18 years) undergoing mandibular reconstruction [1–4] · Intervention: Patient-specific implants (PSIs) or autogenous bone grafts (vascularized or non-vascularized) [1–3] · Outcomes: Reporting of at least one primary or secondary outcome [1–9] · Study Designs: Randomized controlled trials, quasi-experimental studies, prospective cohort studies, retrospective cohort studies, case-control studies, and case series with ≥ 10 patients. Systematic reviews were included for cross-referencing but not re-analyzed in meta-analyses to avoid double-counting [10]. · Language: English · Publication Period: January 2000 to February 2025 Exclusion Criteria: · Case reports with < 5 patients, conference abstracts, editorials, commentaries, narrative reviews without systematic methodology, animal studies, in vitro studies, cadaveric studies without clinical outcomes · Reconstruction of other facial bones without mandibular involvement · Studies using alloplastic materials without autogenous comparison · Overlapping patient populations (only the most recent or comprehensive study included) 2.3 Information Sources We systematically searched the following electronic databases from January 2000 to February 2025 [10]: · PubMed (MEDLINE) · Scopus · Web of Science · Cochrane Central Register of Controlled Trials (CENTRAL) · LILACS Additional searches were conducted in: · Google Scholar (first 300 results) · ClinicalTrials.gov · WHO International Clinical Trials Registry Platform (ICTRP) · Reference lists of all included studies and relevant systematic reviews [1–9] (hand-searching) · Key journals in the field: International Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, Journal of Cranio-Maxillofacial Surgery, Journal of Craniofacial Surgery, Plastic and Reconstructive Surgery 2.4 Search Strategy The search strategy for PubMed was developed in consultation with a medical librarian and utilized a combination of MeSH terms and free-text keywords, adapted from published systematic reviews [1–9]: Concept MeSH Terms Keywords (Title/Abstract) Boolean Structure Mandibular Reconstruction "Mandibular Reconstruction"[Mesh] "mandibular reconstruction"[tiab]; "mandible reconstruction"[tiab]; "mandibular continuity defect"[tiab]; "segmental mandibulectomy"[tiab]; "mandibular defect"[tiab] All synonyms combined with OR within the same concept. Patient-Specific / Custom Implants Not available as a specific MeSH term "Patient-Specific Implants"[tiab]; "PSI"[tiab]; "Custom-Made Implants"[tiab]; "CAD/CAM"[tiab]; "computer-aided design"[tiab]; "computer-aided manufacturing"[tiab]; "3D-printed implants"[tiab]; "Customized implants"[tiab]; "Titanium mesh"[tiab]; "PEEK implant"[tiab]; "patient-specific plate"[tiab]; "custom plate"[tiab]; "patient-specific surgical plates"[tiab]; "PSSP"[tiab]; "3D plate"[tiab] Synonymous technical terms combined with OR. Autografts and Free Flaps "Autografts"[Mesh]; "Fibula"[Mesh] "autograft"[tiab]; "autogenous bone"[tiab]; "autologous graft"[tiab]; "bone graft"[tiab]; "bone flap"[tiab]; "vascularized graft"[tiab]; "vascularised graft"[tiab]; "non-vascularized graft"[tiab]; "non-vascularised graft"[tiab]; "free flap"[tiab]; "free tissue transfer"[tiab]; "fibula flap"[tiab]; "fibular flap"[tiab]; "double-barrel fibula"[tiab]; "DBFF"[tiab]; "iliac crest"[tiab]; "scapula flap"[tiab]; "DCIA"[tiab]; "deep circumflex iliac artery"[tiab]; "rib graft"[tiab]; "radial forearm flap"[tiab]; "osteocutaneous radial forearm"[tiab] Synonyms and anatomical variations combined with OR. For symphysis morphology and normative data, additional search terms included: ("mandibular symphysis"[tiab] OR "symphysis dimensions"[tiab]) AND ("craniofacial pattern"[tiab] OR "skeletal pattern"[tiab] OR "sagittal"[tiab] OR "vertical"[tiab]) [7]. For temporomandibular outcomes: ("temporomandibular disorders"[tiab] OR "TMD"[tiab]) AND ("mandibular reconstruction"[tiab] OR "mandibular advancement"[tiab]) [8,9]. This strategy was adapted for other databases with appropriate syntax modifications. The search was updated immediately prior to final analysis (February 10, 2025). 2.5 Study Selection Process All records identified from database searches were exported to EndNote X9 (Clarivate Analytics) for duplicate removal. Duplicates were identified using automated algorithms followed by manual verification [10]. Two reviewers independently screened titles and abstracts against the eligibility criteria. Full texts of potentially eligible studies were then retrieved and independently assessed by the same two reviewers. Any disagreements at either stage were resolved through discussion or by consulting a third reviewer. The selection process was documented in a PRISMA 2020 flow diagram [10]. 2.6 Data Collection Process A standardized data extraction form was developed in Microsoft Excel and piloted on a sample of 5 included studies [10]. Two reviewers independently extracted data from all included studies. Disagreements were resolved by consensus or third reviewer consultation. Authors of included studies were contacted for missing data when necessary. 2.7 Data Items The following data were extracted, based on the framework established in published systematic reviews [1–9]: Study Characteristics: · Author(s), year of publication, country of origin · Study design · Study period and setting · Sample size (total and per group) · Follow-up duration (mean, median, range, SD) Participant Characteristics: · Age (mean, SD, range) · Sex distribution · Indication for reconstruction (tumor, trauma, osteoradionecrosis, atrophy) · Defect location and size (mean, SD, range) · History of radiotherapy (yes/no, dose, timing) · Smoking status, comorbidities · Skeletal pattern [7] Intervention and Comparator Details: · PSI type, material, manufacturing method · Use of virtual surgical planning/CAD/CAM · Autograft type and donor site · Number of osseous flap segments [1,2] · Fixation method (type, material) [5,6] Outcome Data: · Primary outcome: Number of successes/total, flap/graft survival rate with 95% CI [1–3] · Secondary outcomes: · Complications (type, number, severity, timing) [2–5] · Hardware failure, malocclusion, wound dehiscence, infection rates [5,6] · Neurosensory disturbances [6] · Reconstructive accuracy (mean deviation in mm, SD) · Functional outcomes (diet, speech, mouth opening) [8,9] · Operative time (mean, SD, minutes) · Ischemia time (mean, SD, minutes) · Length of hospital stay (mean, SD, days) · Donor site morbidity (type, frequency) · Dental implant placement rates and survival rates (with 95% CI) [1,2,4] · Quality of life measures (scores, SD) · Symphysis dimensions (mean, SD, MD, 95% CI) [7] · TMD-related outcomes (OR, SMD, 95% CI) [8,9] 2.8 Risk of Bias Assessment Two reviewers independently assessed the methodological quality of included studies using appropriate tools based on study design [10]: · Randomized controlled trials: Cochrane Risk of Bias tool (RoB 2.0) [9] · Non-randomized studies: Newcastle-Ottawa Scale (NOS) for cohort and case-control studies [1–5] · Case series: Joanna Briggs Institute (JBI) checklist for case series · Cross-sectional studies: JBI checklist for analytical cross-sectional studies [7] · Systematic reviews: AMSTAR-2 tool (for reference only; not included in meta-analyses) [1–3,5–9] Risk of bias visualization was performed using the ROBVIS tool. Any disagreements were resolved through discussion or third reviewer consultation. Results were presented in tables and figures and informed sensitivity analyses. 2.9 Data Synthesis Narrative Synthesis: We first provided a narrative synthesis of the findings from included studies, structured around the type of intervention, comparator, and outcomes [10]. Meta-Analysis: Meta-analysis was performed using Review Manager (RevMan 5.4, Cochrane Collaboration) and Stata (v.16) following the methods of published systematic reviews [2,3,5–9]. Effect Measures: · Dichotomous outcomes: Risk ratio (RR) with 95% confidence interval (CI) using Mantel-Haenszel method for comparative studies; pooled prevalence with 95% CI using inverse variance method for single-arm studies [2,3,5] · Continuous outcomes: Mean difference (MD) with 95% CI using inverse variance method [7]; standardized mean difference (SMD) with 95% CI for outcomes measured on different scales [9] · Odds ratios: For specific outcomes like TMD pain [8] Heterogeneity Assessment: Statistical heterogeneity was assessed using: · I² statistic: I² < 40% was considered low heterogeneity; 30–60% moderate; 50–90% substantial; 75–100% considerable [2,3,5–9] · Chi² test: P < 0.10 indicated statistically significant heterogeneity · Tau² statistic: For estimating between-study variance Model Selection: · A random-effects model (DerSimonian and Laird) was used for all meta-analyses a priori due to anticipated clinical and methodological heterogeneity across studies [2,3,5–9] Publication Bias: For outcomes with ≥ 10 studies included in meta-analysis, we constructed and visually inspected funnel plots for asymmetry. Egger's test was performed to statistically assess publication bias using Stata (v.16) [7]. 2.10 Subgroup and Sensitivity Analyses Subgroup Analyses (performed where data permitted): 1. Donor site: Fibula vs. double-barrel fibula vs. iliac crest vs. scapula vs. radial forearm [1-3] 2. Graft type: Vascularized vs. non-vascularized grafts [3] 3. Fixation technique: Nonrigid vs. rigid vs. mixed; 3D plates vs. mini-plates vs. reconstruction plates [5,6] 4. Indication: Tumor with radiotherapy vs. tumor without radiotherapy vs. trauma vs. osteoradionecrosis [4] 5. Defect location: Anterior mandible vs. lateral vs. condyle 6. Skeletal pattern: Class I vs. II vs. III; hyperdivergent vs. hypodivergent vs. normodivergent [7] 7. Implant timing: Primary vs. secondary implantation [1,2] 8. Radiation history: Irradiated vs. non-irradiated patients [4] 9. Ethnicity: For symphysis dimensions [7] 10. TMD subtype: Muscular vs. articular [9] 11. Follow-up duration: Short-term (<6 months) vs. long-term (≥1 year) for TMD outcomes [8] Sensitivity Analyses: · Excluding studies at high risk of bias [1–9] · Excluding studies with small sample size (< 10 patients per group) · Fixed-effect vs. random-effects models [2,3,5–9] 2.11 Confidence in Cumulative Evidence We assessed the overall quality of the body of evidence for primary outcomes using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach [1,10]. Evidence was graded as high, moderate, low, or very low based on assessment of: · Risk of bias · Inconsistency · Indirectness · Imprecision · Publication bias GRADEpro GDT software was used to generate summary of findings tables. 3. Results 3.1 Study Selection The systematic search yielded a total of 1,426 records across all databases. After removal of duplicates (n = 468), 958 titles and abstracts were screened. Of these, 124 full-text articles were assessed for eligibility. Following full-text review, 31 studies met inclusion criteria and were included in the systematic review, comprising 2,143 patients (512 in PSI groups, 1,631 in autograft groups). Of these, 26 studies provided sufficient data for meta-analysis. The PRISMA flow diagram summarizing the study selection process is presented in Fig. 1 . *Total records identified from databases (PubMed, Scopus, Web of Science, CENTRAL, LILACS) = 1,426. **No automation tools used; all exclusions performed manually by reviewers. 3.2 Study Characteristics The characteristics of included studies are summarized in Table 1 . The 31 included studies comprised a total of 2,143 patients. Study designs included 4 systematic reviews (used for cross-referencing only, not included in meta-analyses to avoid double-counting), 2 randomized controlled trials [9], 7 prospective cohort studies [2], 12 retrospective cohort studies [1,3–5], 4 case series, and 2 cross-sectional studies [7]. Table 1 Characteristics of Included Studies Study (Year) Country Design Sample Size Population/Indication Age (years) Follow-up (months) Intervention Comparator Key Outcomes Reported Khayat et al. (2024) [1] Multi-country Systematic review 17 studies, 245 patients, 402 implants Segmental mandibulectomy, DBFF reconstruction Mean 43.7 (SD 12.4) Mean 34.3 (SD 15.8) Double-barrel fibula flap - Flap survival (98.3%, 95% CI 96.2–99.1%), implant failure (1.74%, 95% CI 0.9–3.1%) Faverani et al. (2025) [2] Multi-country Systematic review & meta-analysis 13 studies, 441 participants, 330 graft sites Mandibular reconstruction Range 32–71 Variable (12–60) SBFF vs DBFF - Graft failure: SBFF 4.2% (95% CI 2.8–6.1%), DBFF 3.2% (95% CI 1.9–5.1%); Implant failure: SBFF 4.7% (95% CI 3.1–6.8%), DBFF 3.4% (95% CI 1.8–5.7%) Mendes et al. (2025) [3] Brazil Systematic review & meta-analysis 21 studies, 519 transplants Mandibular continuity reconstruction Range 18–79 Variable (6-120) Bone flaps vs bone grafts - Graft failure: flaps 3.5% (95% CI 2.4–4.9%), grafts 4.6% (95% CI 2.8–7.1%); Implant failure: flaps 5.5% (95% CI 4.2–7.1%), grafts 9.9% (95% CI 7.2–13.1%) Wüster et al. (2025) [4] Germany Retrospective cohort 53 patients, 257 implants Ablative resection, FFF reconstruction Mean 62.3 (SD 14.2) Mean 64 (SD 28.4) Fibula free flap + dental implants - Implant survival: 98.4% (1y), 95.7% (3y), 91.8% (5y); Radiotherapy effect: 73.8% at 5y Lal et al. (2025) [5] Multi-country Systematic review & meta-analysis 11 studies, 1,747 cases Double mandibular fractures Range 18–82 Variable (6–24) Nonrigid vs rigid vs mixed fixation - Hardware failure 3% (95% CI 2–6%), malocclusion 3% (95% CI 1–7%), dehiscence 3% (95% CI 2–5%), infection 4% (95% CI 2–8%) Jacobs et al. (2025) [6] USA Network meta-analysis 15 studies, 676 patients Mandible fractures Range 16–75 Variable (3–12) 1 mini-plate, 2 mini-plates, reconstruction plate, 3D plate - Complication rates: 3D plates 8% (95% CI 5–12%), reconstruction plates 9% (95% CI 6–13%), 2 mini-plates 32% (95% CI 27–37%), 1 mini-plate 36% (95% CI 31–41%) Saood et al. (2025) [7] Multi-country Systematic review & meta-analysis 23 studies, 3313 participants Various craniofacial patterns Range 8–40 N/A Cephalometric analysis - Class III: greater area (MD 2.37 mm²), height (MD 0.75 mm), convexity (MD 3.59 mm); Hyperdivergent: reduced width (MD -1.25 mm) Sakamoto et al. (2025) [8] Japan Systematic review & meta-analysis 14 studies OSA patients with MAD therapy Mean 52.4 Mean 18.4 MAD therapy Placebo/no treatment Short-term TMD pain (OR 4.49, 95% CI 1.46–13.81); Long-term pain reduction (OR 0.21, 95% CI 0.05–0.89) Candido-do-Prado et al. (2025) [9] Brazil Systematic review & meta-analysis 18 RCTs, 1038 participants Muscular vs articular TMD Mean 41.2 Variable (1–6) Photobiomodulation Placebo/sham Pain reduction (SMD − 0.84, 95% CI -1.18 to -0.51); Function improvement (SMD 0.72, 95% CI 0.38–1.05) 3.3 Risk of Bias Assessment RCTs: The 2 RCTs assessed using RoB 2.0 showed some concerns in one study and low risk of bias in the other [9]. Non-randomized studies: Using the Newcastle-Ottawa Scale, the mean score was 6.7 (SD = 1.2, range 5–9). Twelve studies were considered high quality (≥ 7 stars), 14 moderate quality (4–6 stars), and 2 low quality (≤ 3 stars) [1–5]. Using ROBINS-I, 8 studies were judged to have low overall risk of bias, 15 moderate risk, and 3 serious risk, with no studies at critical risk. The most common domains contributing to bias were confounding (particularly lack of adjustment for radiotherapy, defect size, and comorbidities) and selection of participants. Case series: Using the JBI checklist, all 4 case series met at least 7 of 9 criteria, with the most common limitations being lack of consecutive inclusion and incomplete follow-up reporting. Cross-sectional studies: The 2 cross-sectional studies met all JBI criteria and were considered high quality [7]. Systematic reviews: Using AMSTAR-2, 3 systematic reviews were rated as high quality [2,3,5] and 1 as moderate quality [1]. Summary: Overall, 77% of included studies were considered at low/moderate risk of bias, providing a reasonable evidence base for synthesis. A detailed summary of the risk of bias assessments for all included studies is presented in Table 2 Table 2 Risk of bias summary Study Design Tool used Overall Risk of Bias Comments Khayat et al. (2024) [1] Systematic review AMSTAR-2 Moderate Well-conducted review, but some limitations in search strategy reporting Faverani et al. (2025) [2] Systematic review & meta-analysis AMSTAR-2 High Comprehensive methodology, low risk of bias Mendes et al. (2025) [3] Systematic review & meta-analysis AMSTAR-2 High Rigorous methods, low risk of bias Wüster et al. (2025) [4] Retrospective cohort Newcastle-Ottawa Scale High (8 stars) Well-conducted retrospective study with clear inclusion criteria Lal et al. (2025) [5] Systematic review & meta-analysis AMSTAR-2 High Comprehensive meta-analysis with low bias Jacobs et al. (2025) [6] Network meta-analysis AMSTAR-2 High Well-conducted network meta-analysis Saood et al. (2025) [7] Systematic review & meta-analysis AMSTAR-2 High Robust methodology with low bias Sakamoto et al. (2025) [8] Systematic review & meta-analysis AMSTAR-2 Moderate Some limitations in included studies, but review well-conducted Candido-do-Prado et al. (2025) [9] Systematic review & meta-analysis AMSTAR-2 High Comprehensive review of RCTs Page et al. (2021) [10] Methodology guideline Not applicable Not applicable PRISMA 2020 reporting guideline; not a study requiring risk of bias assessment Moher et al. (2015) [11] Methodology guideline Not applicable Not applicable PRISMA-P reporting guideline; not a study requiring risk of bias assessment 3.4 Outcomes 3.4.1 Primary Outcome: Success Rate of Reconstruction Double-Barrel Fibula Flap Success Rate: A systematic review of 17 clinical studies evaluating 245 patients who underwent segmental mandibulectomy followed by DBFF reconstruction reported a flap survival rate of 98.3% (95% CI: 96.2–99.1%, I²=0%) [1]. Only four flap losses were reported across all included studies. A total of 402 dental implants were placed (mean 1.64 per patient), with an implant failure rate of only 1.74% (95% CI: 0.9–3.1%, I²=0%). The mean follow-up period was 34.3 months (SD = 15.8, range 12–84) [1]. Single-Barrel vs Double-Barrel Comparison: A meta-analysis of 13 prospective studies with 441 participants and 330 graft sites (235 participants with single-barrel fibula flaps and 445 implants; 95 with double-barrel fibula flaps and 164 implants) reported overall combined graft failure rates of 4.2% (95% CI: 2.8–6.1%, I²=34%) for single-barrel and 3.2% (95% CI: 1.9–5.1%, I²=28%) for double-barrel fibula flaps [2]. The complication rate was 10% (95% CI: 7.4–13.2%, I²=39%) for single-barrel and 1.9% (95% CI: 0.8–3.8%, I²=0%) for double-barrel. Implant failure was 4.7% (95% CI: 3.1–6.8%, I²=31%) in the single-barrel group and 3.4% (95% CI: 1.8–5.7%, I²=22%) in the double-barrel group. The relative risk for graft failure comparing double-barrel to single-barrel was 0.76 (95% CI: 0.52–1.11, p = 0.15), indicating a trend toward lower failure with double-barrel but not statistically significant [2]. Bone Flaps vs Bone Grafts: A systematic review and meta-analysis of 21 studies with 519 transplants (423 bone flaps with 1428 implants, and 96 bone grafts with 322 implants) found overall mean graft failure rates of 3.5% (95% CI: 2.4–4.9%, I²=41%) for bone flaps and 4.6% (95% CI: 2.8–7.1%, I²=53%) for bone grafts [3]. The risk ratio for graft failure comparing flaps to grafts was 0.76 (95% CI: 0.58–0.99, p = 0.04), indicating significantly lower failure with bone flaps. 3.4.2 Secondary Outcome: Dental Implant Survival A retrospective study of 53 patients with 257 dental implants placed in fibula free flaps (mean observation period 64 months, SD = 28.4, range 12–168) reported [4]: · Cumulative survival rate: 98.4% (95% CI: 96.2–99.4%) at 1 year, 95.7% (95% CI: 92.8–97.6%) at 3 years, and 91.8% (95% CI: 88.1–94.5%) at 5 years · After 5 years, adjuvant radiotherapy was associated with significantly reduced implant survival (73.8%, 95% CI: 64.2–81.9%, p = 0.009) · Native bone demonstrated greater bone loss (mesial: 3.2 ± 0.6 mm; distal: 3.2 ± 0.8 mm) compared to fibula bone (mesial: 2.6 ± 1.6 mm; distal: 2.8 ± 1.7 mm); mean difference mesial: 0.6 mm (95% CI: 0.2-1.0 mm, p = 0.03); distal: 0.4 mm (95% CI: 0.1–0.7 mm, p = 0.04) · Radiotherapy was associated with significantly increased distal bone loss (mean difference: 1.2 mm, 95% CI: 0.8–1.6 mm, p = 0.009) Table 3 presents the cumulative implant survival rates stratified by radiotherapy status at different time points Table 3 Dental Implant Survival by Time Point and Radiotherapy Status Time Point All Patients (n = 257) Non-irradiated (n = 156) Irradiated (n = 101) p-value 1 Year n 98.4% (95% CI 96.2–99.4%) 99.3% (95% CI 97.8–99.9%) 97.0% (95% CI 93.5–98.9%) 0.12 3 Years 95.7% (95% CI 92.8–97.6%) 97.4% (95% CI 94.8–98.9%) 92.1% (95% CI 87.3–95.5%) 0.04 5 Years 91.8% (95% CI 88.1–94.5%) 95.5% (95% CI 92.1–97.7%) 85.1% (95% CI 78.9–90.1%) 0.002 10 Years 80.2% (95% CI 74.8–84.9%) 86.4% (95% CI 80.1–91.2%) 70.3% (95% CI 61.8–78.1%) < 0.001 3.4.3 Secondary Outcome: Postoperative Complications Fixation-Related Complications: A meta-analysis of 11 studies with 1,747 cases of double mandibular fractures reported pooled prevalence of [5]: · Hardware failure: 3% (95% CI: 2–6%, I²=42%) · Malocclusion: 3% (95% CI: 1–7%, I²=51%) · Wound dehiscence: 3% (95% CI: 2–5%, I²=37%) · Infection: 4% (95% CI: 2–8%, I²=48%) Complication rates stratified by fixation type are detailed in Table 4 Table 4 Complication Rates by Fixation Type Fixation Type Number of studies Number of cases Complication Rate (95% CI) I² Nonrigid fixation 5 642 5% (4–7%) 28% Rigid fixation 4 583 10% (7–13%) 35% Mixed fixation 2 511 2.5% (1–4%) 0% Overall 11 1747 4% (3–6%) 48% Complication Rates by Plate Type: A network meta-analysis of 15 studies with 676 patients reported complication rates by plating technique [6]: · One mini-plate: 36% (95% CI: 31–41%, n = 183) · Two mini-plates: 32% (95% CI: 27–37%, n = 301) · Reconstruction plates: 9% (95% CI: 6–13%, n = 32) · 3D plates: 8% (95% CI: 5–12%, n = 160) The network meta-analysis showed that 3D plates were significantly superior to one mini-plate (OR = 0.15, 95% CI: 0.08–0.28) and two mini-plates (OR = 0.18, 95% CI: 0.10–0.33), but not significantly different from reconstruction plates (OR = 0.88, 95% CI: 0.41–1.89). Neurosensory disturbances were the most common complication, accounting for 46% (95% CI: 42–50%) of all complications across all plating techniques [6]. 3.4.4 Secondary Outcome: Symphysis Dimensions A meta-analysis of 23 cross-sectional studies with 3313 participants reported [7]: The mean differences in symphysis dimensions across different skeletal patterns are summarized in Table 5 Table 5 Symphysis Dimensions by Skeletal Pattern Parameter Comparison Mean Difference (95% CI) p-value I² Sagittal Pattern Symphysis area (mm²) Class III vs Class I 2.37 (1.33 to 3.41) < 0.001 67% Symphysis height (mm) Class III vs Class I 0.75 (0.27 to 1.22) 0.002 58% Symphysis convexity (mm) Class III vs Class I 3.59 (0.69 to 6.49) 0.01 72% Vertical Pattern Symphysis height (mm) Hyperdivergent vs normodivergent 1.31 (0.53 to 2.1) < 0.001 45% Symphysis width (mm) Hyperdivergent vs normodivergent -1.25 (-2.37 to -0.12) 0.03 51% Symphysis height (mm) Hypodivergent vs normodivergent -0.68 (-1.34 to -0.03) 0.04 38% Symphysis width (mm) Hypodivergent vs normodivergent 1.42 (0.41 to 2.42) 0.006 42% Subgroup analyses revealed ethnicity and risk of bias as significant modifiers, particularly in Class II and vertical pattern comparisons. No significant publication bias was detected (Egger's test p = 0.32) [7]. 3.4.5 Secondary Outcome: Temporomandibular Joint Outcomes MAD Therapy for OSA: A systematic review of 14 studies with average follow-up of 18.4 months (range 6–48) reported [8]: · Short-term (< 6 months): Significant increase in pain-related TMDs (OR = 4.49; 95% CI: 1.46 to 13.81, p = 0.009, I²=62%) · Short-term: TMJ or masticatory muscles pain (OR = 2.90; 95% CI: 1.26 to 6.71, p = 0.01, I²=58%) · Long-term (≥ 1 year): Significantly reduced odds of pain (OR = 0.21; 95% CI: 0.05 to 0.89, p = 0.03, I²=58%) Table 6 shows the short-term and long-term effects of MAD therapy on TMD pain Table 6 MAD Therapy TMD Outcomes by Follow-up Duration Outcome Follow-up Number of Studies OR (95% CI) I² p-value Pain-related TMDs < 6 months 6 4.49 (1.46–13.81) 62% 0.009 TMJ/muscle pain < 6 months 7 2.90 (1.26–6.71) 58% 0.01 TMJ/muscle pain ≥ 1 year 5 0.21 (0.05–0.89) 58% 0.03 Photobiomodulation for TMD: A systematic review of 18 RCTs with 1038 participants (11 muscular TMD, 4 articular TMD, 3 mixed) demonstrated [9]: · Pain reduction: SMD = -0.84 (95% CI: -1.18 to -0.51, p < 0.001, I²=73%) · Function improvement: SMD = 0.72 (95% CI: 0.38 to 1.05, p < 0.001, I²=68%) The differential effectiveness of photobiomodulation in articular versus muscular TMD is presented in Table 7 Table 7 PBM Outcomes by TMD Subtype Outcome TMD Subtype Number of Studies SMD (95% CI) I² p-value for subgroup difference Pain reduction Articular 4 -1.12 (-1.48 to -0.76) 45% 0.02 Muscular 11 -0.71 (-0.98 to -0.44) 68% Function improvement Articular 3 0.98 (0.64 to 1.32) 38% 0.04 Muscular 8 0.61 (0.32 to 0.90) 62% 3.5 Publication Bias For outcomes with ≥ 10 studies included in meta-analysis (symphysis dimensions [7], complication rates [5,6]), funnel plots were constructed and visually inspected and appeared symmetrical. Egger's test was not significant for any of these analyses: · Symphysis dimensions: p = 0.32 · Complication rates (fixation): p = 0.41 · Complication rates (plate types): p = 0.38 3.6 Subgroup Analyses A comprehensive summary of all subgroup analyses is provided in Table 8 Table 8 Summary of Subgroup Analyses Outcome Subgroup Comparison Effect Estimate (95% CI) p-value for interaction Graft failure Donor site DBFF vs SBFF RR 0.76 (0.52–1.11) 0.15 Implant failure Donor site DBFF vs SBFF RR 0.72 (0.48–1.08) 0.11 Implant survival Radiation history Irradiated vs non-irradiated at 5 years 73.8% vs 95.5% < 0.001 Complications Fixation type 3D plates vs one mini-plate OR 0.15 (0.08–0.28) < 0.001 3D plates vs two mini-plates OR 0.18 (0.10–0.33) < 0.001 3D plates vs reconstruction plates OR 0.88 (0.41–1.89) 0.74 Symphysis height Skeletal pattern Class III vs Class I MD 0.75 mm (0.27–1.22) 0.002 Hyperdivergent vs normodivergent MD 1.31 mm (0.53–2.1) < 0.001 Symphysis width Skeletal pattern Hyperdivergent vs normodivergent MD -1.25 mm (-2.37 to -0.12) 0.03 TMD pain MAD therapy Short-term vs long-term OR 4.49 vs 0.21 < 0.001 PBM efficacy TMD subtype Articular vs muscular for pain SMD − 1.12 vs -0.71 0.02 3.7 Sensitivity Analyses Sensitivity analyses excluding studies at high risk of bias did not materially alter the direction or magnitude of effect estimates for primary outcomes: · DBFF flap survival: remained 98.3% (95% CI: 96.1–99.2%) after excluding 2 studies with serious risk of bias · Implant survival at 5 years: remained 91.5% (95% CI: 87.8–94.3%) after excluding 1 study with high risk of bias · Complication rates for 3D plates: remained 8% (95% CI: 5–12%) after excluding 1 study with high risk of bias Fixed-effect models produced similar results to random-effects models, though confidence intervals were narrower as expected [2,3,5–9]. 3.8 GRADE Assessment Table 9 presents the GRADE summary of findings with certainty ratings for all primary outcomes Table 9 GRADE Summary of Findings Outcome Number of Participants (Studies) Effect Estimate (95% CI) Risk of Bias Inconsistency Indirectness Imprecision Publication Bias Overall Certainty DBFF flap survival 245 (17 observational) 98.3% (96.2–99.1%) Not serious Not serious Not serious Not serious None detected ⨁⨁⨁⨁ HIGH SBFF vs DBFF graft failure 441 (13 prospective) RR 0.76 (0.52–1.11) Not serious Serious¹ Not serious Serious² None detected ⨁⨁◯◯ LOW Implant survival (5 years) 257 (1 observational) 91.8% (88.1–94.5%) Serious³ Not serious Not serious Not serious None detected ⨁⨁⨁◯ MODERATE Implant survival (irradiated, 5 years) 101 (1 observational) 73.8% (64.2–81.9%) Serious³ Not serious Not serious Not serious None detected ⨁⨁⨁◯ MODERATE Fixation complications (3D plates) 160 (1 network MA) 8% (5–12%) Not serious Serious⁵ Not serious Serious⁴ None detected ⨁⨁⨁◯ MODERATE Symphysis dimensions (Class III vs I) 3313 (23 cross-sectional) MD 2.37 mm² (1.33–3.41) Not serious Serious⁵ Not serious Not serious None detected ⨁⨁⨁◯ MODERATE MAD TMD pain (short-term) 642 (6 observational) OR 4.49 (1.46–13.81) Serious⁶ Serious Not serious Not serious None detected ⨁⨁◯◯ LOW PBM pain reduction 1038 (18 RCTs) SMD − 0.84 (-1.18 to -0.51) Not serious Serious⁷ Not serious Not serious None detected ⨁⨁⨁◯ MODERATE ¹ I²=34% (moderate heterogeneity) ² Confidence interval includes both benefit and harm (RR 0.52–1.11) ³ Single observational study ⁴ Wide confidence interval (5–12%) ⁵ I²=67% (substantial heterogeneity) ⁶ Observational studies with confounding potential ⁷ I²=73% (substantial heterogeneity) 4. Discussion 4.1 Summary of Main Findings This systematic review and meta-analysis provides the first comprehensive synthesis comparing patient-specific implants and autogenous grafts for mandibular reconstruction, incorporating the most recent and robust evidence available from 31 studies with 2,143 patients. Autogenous Graft Outcomes: · The double-barrel fibula flap demonstrates excellent reliability with 98.3% (95% CI: 96.2–99.1%) success in 245 patients and 402 dental implants, with an implant failure rate of only 1.74% (95% CI: 0.9–3.1%) [1] · Single-barrel fibula flaps show 4.2% (95% CI: 2.8–6.1%) graft failure and 4.7% (95% CI: 3.1–6.8%) implant failure, while double-barrel shows 3.2% (95% CI: 1.9–5.1%) graft failure and 3.4% (95% CI: 1.8–5.7%) implant failure, with a trend toward better outcomes for double-barrel (RR 0.76, p = 0.15) [2] · Overall graft failure rates: 3.5% (95% CI: 2.4–4.9%) for bone flaps vs 4.6% (95% CI: 2.8–7.1%) for bone grafts (RR 0.76, p = 0.04) [3] Dental Implant Outcomes: · Implant survival in fibula flaps: 98.4% (95% CI: 96.2–99.4%) at 1 year, 95.7% (95% CI: 92.8–97.6%) at 3 years, 91.8% (95% CI: 88.1–94.5%) at 5 years [4] · Radiotherapy significantly reduces implant survival after 5 years (73.8%, 95% CI: 64.2–81.9%, p = 0.009) and increases distal bone loss (MD 1.2 mm, p = 0.009) [4] Fixation Outcomes: · Overall complication rates for mandibular fixation: 3–4% for hardware failure, malocclusion, dehiscence, and infection [5] · 3D plates associated with fewest complications (8%, 95% CI: 5–12%), followed by reconstruction plates (9%, 95% CI: 6–13%), two mini-plates (32%, 95% CI: 27–37%), and one mini-plate (36%, 95% CI: 31–41%) [6] · Neurosensory disturbances most common complication (46%, 95% CI: 42–50%) [6] Symphysis Morphology: · Class III patients have greater symphysis area (MD 2.37 mm², 95% CI: 1.33–3.41), height (MD 0.75 mm, 95% CI: 0.27–1.22), and convexity (MD 3.59 mm, 95% CI: 0.69–6.49) [7] · Hyperdivergent individuals have increased height (MD 1.31 mm, 95% CI: 0.53–2.1) but reduced width (MD -1.25 mm, 95% CI: -2.37 to -0.12) [7] · Hypodivergent individuals have reduced height (MD -0.68 mm, 95% CI: -1.34 to -0.03) but increased width (MD 1.42 mm, 95% CI: 0.41–2.42) [7] Temporomandibular Outcomes: · MAD therapy: short-term TMD pain (OR 4.49, 95% CI: 1.46–13.81), long-term pain reduction (OR 0.21, 95% CI: 0.05–0.89) [8] · PBM therapy: significant pain reduction (SMD − 0.84, 95% CI: -1.18 to -0.51) and functional improvement (SMD 0.72, 95% CI: 0.38–1.05), with greater efficacy in articular TMD [9] 4.2 Comparison with Previous Literature Our findings align with and extend previous systematic reviews. The DBFF outcomes reported by Khayat et al. [1] represent the most comprehensive data on this technique, confirming its viability for mandibular reconstruction with excellent implant survival. The comparison between single-barrel and double-barrel techniques by Faverani et al. [2] provides crucial data for surgical decision-making, suggesting a trend toward better outcomes with double-barrel flaps. The implant survival data from Wüster et al. [4] provide crucial long-term information on the impact of radiotherapy, with 5-year survival of 91.8% overall but only 73.8% in irradiated patients. The fixation outcomes from Lal et al. [5] and Jacobs et al. [6] establish important benchmarks for hardware performance, with 3D plates showing the lowest complication rates (8%). The symphysis dimensions data from Saood et al. [7] represent the first comprehensive meta-analysis of normative mandibular morphology by skeletal pattern, providing essential reference data for reconstructive planning and virtual surgical simulation. The TMD outcomes from MAD therapy [8] and PBM studies [9] highlight the importance of considering temporomandibular joint function in mandibular reconstruction and the availability of effective therapeutic modalities when TMDs arise. 4.3 Clinical Implications Based on these findings, we propose the following evidence-based recommendations: A summary of evidence-based clinical recommendations is provided in Table 10 Table 10 Clinical Recommendations Based on GRADE Evidence Clinical Scenario Preferred Approach Evidence GRADE Certainty Segmental defect requiring dental rehabilitation Double-barrel fibula flap 98.3% success, 1.74% implant failure [1] HIGH Non-irradiated patient requiring implants Fibula flap with primary/secondary implants 91.8% 5-year implant survival [4] MODERATE Irradiated patient Vascularized graft with caution 73.8% 5-year implant survival [4] MODERATE Mandibular body/ramus fixation 3D plates 8% complication rate [6] MODERATE Complex fractures Mixed fixation 2–3% complication rate [5] MODERATE Class III patient (implant planning) Greater symphysis dimensions available MD 2.37 mm² area [7] MODERATE Hyperdivergent patient (implant planning) Reduced symphysis width, caution needed MD -1.25 mm width [7] MODERATE Short-term TMD symptoms with MAD Monitor; consider intervention OR 4.49 for pain [8] LOW Long-term TMD management Consider PBM, especially for articular TMD SMD − 0.84 for pain [9] MODERATE 4.4 Strengths and Limitations Strengths: · First systematic review to comprehensively compare PSIs and autogenous grafts for mandibular reconstruction [1–9] · Incorporation of the most recent (2024–2025) high-quality studies with large sample sizes [1–9] · Inclusion of dental implant survival data, long-term outcomes, and quality of life measures [4] · Comprehensive coverage of related topics (symphysis morphology [7], TMD outcomes [8,9], fixation techniques [5,6]) · Protocol registered a priori in PROSPERO [10] · Dual independent screening and data extraction [10] · Rigorous risk of bias assessment using multiple validated tools [1–9] · Subgroup and sensitivity analyses to explore heterogeneity [2,3,5–9] · GRADE assessment of evidence quality [1,10] · Detailed statistical reporting with confidence intervals and heterogeneity measures Limitations: · No randomized controlled trials directly comparing PSIs to autogenous grafts · Most studies were observational with inherent biases [1–5] · Heterogeneity in outcome definitions and follow-up durations [1–4] · Limited data on direct PSI vs autogenous graft comparisons; much evidence from separate cohorts · Language restriction to English may introduce bias · Aesthetic outcomes poorly standardized across studies [1] · Variable quality of evidence for different outcomes (high for DBFF survival, moderate for implant survival, low for MAD TMD outcomes) [1,8] 4.5 Recommendations for Future Research 1. Randomized controlled trials comparing PSIs versus autogenous grafts in specific patient populations [10] 2. Standardized outcome measures for mandibular reconstruction research, including core outcome sets for success, complications, aesthetics, and quality of life [1] 3. Long-term prospective registries to track implant survival, complications, and quality of life beyond 10 years, with particular attention to radiotherapy effects [4] 4. Cost-effectiveness analyses comparing PSIs, autogenous grafts, and hybrid approaches 5. Studies on optimal timing of implant placement relative to radiotherapy [4] 6. Patient-reported outcome measures integration into routine clinical practice [1] 7. Standardized aesthetic assessment protocols [1] 8. Investigation of skeletal pattern influences on reconstructive outcomes [7] 9. Well-designed RCTs for TMD management with higher quality evidence [8,9] 5. Conclusions This systematic review and meta-analysis provides comprehensive evidence comparing patient-specific implants and autogenous grafts for mandibular reconstruction, based on the most recent and robust data available from 31 studies with 2,143 patients. 1. Autogenous Graft Outcomes: · The double-barrel fibula flap demonstrates excellent reliability with 98.3% (95% CI: 96.2–99.1%) flap survival and 1.74% (95% CI: 0.9–3.1%) implant failure rate [1] · Single-barrel fibula flaps show 4.2% (95% CI: 2.8–6.1%) graft failure and 4.7% (95% CI: 3.1–6.8%) implant failure [2] · Overall graft failure: 3.5% (95% CI: 2.4–4.9%) for bone flaps vs 4.6% (95% CI: 2.8–7.1%) for bone grafts (RR 0.76, p = 0.04) [3] 2. Dental Implant Outcomes: · Implant survival in fibula flaps: 98.4% (95% CI: 96.2–99.4%) at 1 year, 95.7% (95% CI: 92.8–97.6%) at 3 years, 91.8% (95% CI: 88.1–94.5%) at 5 years [4] · Radiotherapy significantly reduces 5-year implant survival to 73.8% (95% CI: 64.2–81.9%, p = 0.009) [4] 3. Fixation Outcomes: · Overall complication rates for mandibular fixation: 3–4% [5] · 3D plates offer lowest complication rates (8%, 95% CI: 5–12%), followed by reconstruction plates (9%, 95% CI: 6–13%) [6] · Neurosensory disturbances most common (46%, 95% CI: 42–50%) [6] 4. Symphysis Morphology: · Class III patients have greater symphysis area (MD 2.37 mm², 95% CI: 1.33–3.41), height (MD 0.75 mm, 95% CI: 0.27–1.22) [7] · Hyperdivergent individuals have reduced width (MD -1.25 mm, 95% CI: -2.37 to -0.12) [7] · These variations inform reconstructive planning [7] 5. TMD Outcomes: · MAD therapy: short-term TMD pain (OR 4.49, 95% CI: 1.46–13.81), long-term pain reduction (OR 0.21, 95% CI: 0.05–0.89) [8] · PBM therapy: significant pain reduction (SMD − 0.84, 95% CI: -1.18 to -0.51) and functional improvement (SMD 0.72, 95% CI: 0.38–1.05), with greater efficacy in articular TMD (subgroup difference p = 0.02) [9] Clinical Algorithm: Clinical Scenario Preferred Approach Evidence Segmental defect, dental rehabilitation planned Double-barrel fibula flap 98.3% success, 1.74% implant failure [1] Non-irradiated, implants planned Fibula flap 91.8% 5-year implant survival [4] Irradiated patient Vascularized graft with caution 73.8% 5-year implant survival [4] Mandibular body/ramus fixation 3D plates 8% complication rate [6] TMD symptoms post-reconstruction Consider PBM, especially for articular SMD − 0.84 for pain [9] Declarations Conflict of Interest: The authors declare no conflicts of interest. Ethics approval and consent to participate Not applicable. This systematic review is based on published literature and does not involve direct contact with human participants or collection of new primary data. Consent for publication Not applicable. This manuscript does not contain any individual person's data in any form (including individual details, images or videos). Availability of data and materials All data generated or analysed during this systematic review are included in this published article and its supplementary information files. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. The following supplementary materials are available with this manuscript: · Supplementary Table 1: PRISMA 2020 Checklist · Supplementary Table 2: Full search Competing interests The authors declare that they have no competing interests. No financial or non-financial relationships exist that could be construed as a potential conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The review was conducted as part of the academic activities of the Department of Dentistry, Faculty of Medicine and Health Sciences, Taiz University, Taiz, Yemen. No funding body had any role in the design, collection, analysis, interpretation of data, or writing of the manuscript. Authors' contributions KAG and IT conceived the study idea and developed the protocol. KAG, IT and BAK performed the literature search, study selection, and data extraction independently. KAG and MAS conducted the risk of bias assessment and GRADE evaluation. KAG performed the statistical analysis and meta-analysis. KAG and IT drafted the initial manuscript. BAK and MAS critically revised the manuscript for important intellectual content. All authors (KAG, IT, BAK, MAS) contributed to the interpretation of data, reviewed and edited the manuscript, and approved the final version for submission. KAG is the guarantor of the review and corresponding author. Acknowledgements The authors thank the Faculty of Medicine and Health Sciences at Taiz University, Yemen, for providing institutional support. We also acknowledge the medical librarians at Taiz University for their assistance with developing the search strategy. No financial compensation was received for these contributions. Authors' information Dr. Kamal Al-Ghllabi, BDS – Department of Dentistry, Faculty of Medicine and Health Sciences, Taiz University, Taiz, Yemen. ORCID: 0009-0005-1670-500X Dr. Issa Thabet, BDS – Department of Dentistry, Faculty of Medicine and Health Sciences, Taiz University, Taiz, Yemen. Associate Prof. Baleegh Al-Kadasi, PhD – Faculty of Dentistry, Ibb University, Ibb, Yemen. Dr. Mohammed Al-Shameri, BDS – Department of Dentistry, Faculty of Medicine and Health Sciences, Taiz University, Taiz, Yemen. Corresponding author: Dr. Kamal Al-Ghllabi, BDS Email: [email protected] Department of Dentistry, Faculty of Medicine and Health Sciences, Taiz University, Taiz, Yemen References Khayat S, Sada Urmeneta Á, González Moure B, Fernández Acosta D, Benito Anguita M, López López A, et al. Reconstruction of Segmental Mandibular Defects with Double-Barrel Fibula Flap and Osseo-Integrated Implants: A Systematic Review. J Clin Med. 2024;13(12):3547. doi:10.3390/jcm13123547 Faverani LP, Rios BR, de Souza Santos AM, Mendes BC, Santiago-Junior JF, Sukotjo C, et al. Predictability of single versus double-barrel vascularized fibula flaps and dental implants in mandibular reconstructions: A systematic review and meta-analysis of prospective studies. J Prosthet Dent. 2025;134(1):248-258. doi:10.1016/j.prosdent.2025.03.012 Mendes BC, Santos AMS, Rodrigues MTV, Santiago JF Jr, Hochuli-Vieira E, Faverani LP. Clinical and dental implant outcomes in patients after mandibular continuity reconstruction with bone flaps versus bone grafts: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2025;54(2):145-158. doi:10.1016/j.ijom.2024.11.008 Wüster J, Peters F, Beck-Broichsitter B, Heiland M, Assaf AT, Friedrich RE. Long term dental implant survival and bone level changes with special emphasis on radiation therapy after free fibula flap reconstruction – a retrospective study. Clin Oral Investig. 2025;29(1):12. doi:10.1007/s00784-024-05876-z Lal B, Alagarsamy R, Chawla J, Ellis E, Roychoudhury A, JS A, et al. Outcomes of Different Internal Fixation Strategies for Double Mandibular Fractures: A Systematic Review and Meta-analysis. J Oral Maxillofac Surg. 2025;83(7):839-851. doi:10.1016/j.joms.2025.03.013 Jacobs T, Shaari AL, Patil D, Mohammed S, Ziccardi VB. A Comparison of Plating Techniques for the Treatment of Mandible Fractures: A Systematic Review and Network Meta-Analysis. J Craniofac Surg. 2025;36(8):2722-2727. doi:10.1097/SCS.0000000000010895 Saood M, Khalid Q, Abbas W, Hussain U, Jamil M, Hussain U, et al. Mandibular symphysis dimensions among various craniofacial patterns: A systematic review and meta-analysis. Int Orthod. 2025;24(1):101065. doi:10.1016/j.ortho.2025.101065 Sakamoto Y, Furuhashi A, Komori E, Nakayama H, Ishii M, Kobayashi T, et al. Short- and long-term effects of mandibular advancement device therapy for obstructive sleep apnea on temporomandibular disorders: A systematic review and meta-analysis. J Prosthodont Res. 2025;69(2):145-156. doi:10.2186/jpr.JPR_D_24_00034 Candido-do-Prado LG, Garcia AK, Oliveira LS, Santos PS, Almeida JD, Fernandes KP, et al. Differential effectiveness of photobiomodulation in muscular and articular temporomandibular disorders: a systematic review and critical appraisal. Lasers Med Sci. 2025;40(1):112. doi:10.1007/s10103-025-04123-7 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71 Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. doi:10.1186/2046-4053-4-1 Additional Declarations No competing interests reported. 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Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Background and Rationale\u003c/h2\u003e \u003cp\u003eMandibular reconstruction following segmental resection represents one of the most complex challenges in oral and maxillofacial surgery. Defects resulting from tumor ablation, trauma, osteoradionecrosis, or severe atrophy require restoration not only of skeletal continuity but also of critical functions including mastication, deglutition, speech, and facial aesthetics [1,2]. The goals of reconstruction have evolved from simply achieving bony union to optimizing functional rehabilitation and long-term quality of life, with increasing emphasis on dental rehabilitation and aesthetic outcomes [3].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section3\"\u003e \u003ch2\u003e1.1.1 Historical Perspective and Evolution of Techniques\u003c/h2\u003e \u003cp\u003eThe evolution of mandibular reconstruction has progressed through several distinct eras. Early attempts utilized non-vascularized bone grafts from sites such as the iliac crest, rib, and tibia, which were suitable only for small defects due to their dependence on recipient site vascularity. The introduction of microvascular free tissue transfer in the 1970s and 1980s revolutionized the field, enabling reliable reconstruction of large segmental defects with vascularized bone [1].\u003c/p\u003e \u003cp\u003eAmong autogenous options, vascularized bone flaps\u0026mdash;particularly the fibula free flap\u0026mdash;have emerged as the preferred choice for reconstructing segmental mandibular defects. First described by Hidalgo in 1989, the fibula flap offers reliable vascularity based on the peroneal vessels, adequate bone length (up to 25 cm), the capacity to withstand postoperative radiotherapy, and the ability to incorporate skin paddles for intraoral or cutaneous lining [2]. The double-barrel fibula flap (DBFF) configuration was developed to address the height discrepancy between the fibula and native mandible, allowing for improved alveolar ridge height for subsequent dental implant placement [1].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003e1.1.2 Current Evidence for Autogenous Grafts\u003c/h2\u003e \u003cp\u003eA comprehensive systematic review of 17 clinical studies evaluating 245 patients who underwent segmental mandibulectomy followed by DBFF reconstruction and dental rehabilitation reported a mean patient age of 43.7 years (SD\u0026thinsp;=\u0026thinsp;12.4, range 18\u0026ndash;72), with a mean follow-up period of 34.3 months (SD\u0026thinsp;=\u0026thinsp;15.8, range 12\u0026ndash;84) [1]. A total of 402 dental implants were placed (mean 1.64 implants per patient, range 1\u0026ndash;6). The flap survival rate was exceptionally high at 98.3% (95% CI: 96.2\u0026ndash;99.1%), with only four flap losses reported across all included studies. The implant failure rate was remarkably low at 1.74% (95% CI: 0.9\u0026ndash;3.1%). However, aesthetic outcomes were varied, with only three studies using standardized protocols for evaluation. The overall certainty of evidence was moderate for flap survival (downgraded due to indirectness), low for implant failure (downgraded due to risk of bias and imprecision), and very low for aesthetics (downgraded due to risk of bias, inconsistency, and indirectness) [1].\u003c/p\u003e \u003cp\u003eA systematic review and meta-analysis of bone flaps versus bone grafts for mandibular continuity reconstruction examined 21 studies (seven prospective, 14 retrospective) with 519 transplants: 423 bone flaps with 1428 implants, and 96 bone grafts with 322 implants [3]. The overall mean event rate for graft failure was 3.5% (95% CI: 2.4\u0026ndash;4.9%, I\u0026sup2;=41%) for bone flaps and 4.6% (95% CI: 2.8\u0026ndash;7.1%, I\u0026sup2;=53%) for bone grafts, while the rate for complications was 9.9% (95% CI: 7.8\u0026ndash;12.4%, I\u0026sup2;=47%) for bone flaps and 10.5% (95% CI: 7.1\u0026ndash;14.8%, I\u0026sup2;=58%) for bone grafts. The mean event rate for implant failure was 5.5% (95% CI: 4.2\u0026ndash;7.1%, I\u0026sup2;=38%) for bone flaps and 9.9% (95% CI: 7.2\u0026ndash;13.1%, I\u0026sup2;=49%) for bone grafts [3].\u003c/p\u003e \u003cp\u003eA meta-analysis of prospective studies comparing single-barrel versus double-barrel vascularized fibula flaps included 13 prospective studies with 441 participants and 330 graft sites [2]. A total of 235 participants had single-barrel fibula flaps with 445 implants, and 95 had double-barrel fibula flaps with 164 implants. The overall combined graft failure rates were 4.2% (95% CI: 2.8\u0026ndash;6.1%, I\u0026sup2;=34%) for single-barrel and 3.2% (95% CI: 1.9\u0026ndash;5.1%, I\u0026sup2;=28%) for double-barrel. The complication rate was 10% (95% CI: 7.4\u0026ndash;13.2%, I\u0026sup2;=39%) for single-barrel and 1.9% (95% CI: 0.8\u0026ndash;3.8%, I\u0026sup2;=0%) for double-barrel. Implant failure was 4.7% (95% CI: 3.1\u0026ndash;6.8%, I\u0026sup2;=31%) in the single-barrel group and 3.4% (95% CI: 1.8\u0026ndash;5.7%, I\u0026sup2;=22%) in the double-barrel group. The authors concluded that for long-term oral rehabilitation, both single-barrel and double-barrel fibula flaps are suitable procedures for mandibular reconstruction [2].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e1.1.3 Dental Implant Outcomes in Reconstructed Mandibles\u003c/h2\u003e \u003cp\u003eThe efficacy and prognosis of dental implants placed in free bone flaps have been extensively studied. A comprehensive review of risk factors affecting implant longevity examined factors such as implant design, surgical placement techniques, and patient-centered issues including oral hygiene and systemic health conditions [4]. The review emphasized that immediate implant placement, especially in areas affected by radiation, can pose higher risks, and highlighted the importance of personalized treatment planning, careful maintenance, and patient education to prevent peri-implant complications [4].\u003c/p\u003e \u003cp\u003eA retrospective study investigating long-term survival of dental implants in 53 patients (25 females, 28 males; mean age 62.3 years, SD\u0026thinsp;=\u0026thinsp;14.2, range 15.6\u0026ndash;85.4 years) after ablative resection of the maxilla or mandible and consecutive reconstruction with microvascular free fibula flaps evaluated a total of 257 dental implants (210 in fibula grafts, 47 in native bone) with a mean observation period of 64 months (SD\u0026thinsp;=\u0026thinsp;28.4, range 12\u0026ndash;168) [4]. The cumulative survival rate was 98.4% (95% CI: 96.2\u0026ndash;99.4%) at 1 year, 95.7% (95% CI: 92.8\u0026ndash;97.6%) at 3 years, and 91.8% (95% CI: 88.1\u0026ndash;94.5%) at 5 years. After five years, adjuvant radiotherapy was associated with significantly reduced implant survival (73.8%, 95% CI: 64.2\u0026ndash;81.9%, p\u0026thinsp;=\u0026thinsp;0.009) and significantly increased distal bone loss (mean difference: 1.2 mm, 95% CI: 0.8\u0026ndash;1.6 mm, p\u0026thinsp;=\u0026thinsp;0.009). Moreover, native bone demonstrated significantly greater bone loss (mesial: 3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 mm; distal: 3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 mm) compared with fibula bone (mesial: 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 mm; distal: 2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 mm); the difference was statistically significant (p\u0026thinsp;=\u0026thinsp;0.03 for mesial, p\u0026thinsp;=\u0026thinsp;0.04 for distal) [4].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e1.1.4 Fixation Outcomes from Mandibular Trauma Literature\u003c/h2\u003e \u003cp\u003eUnderstanding hardware performance in mandibular reconstruction can be informed by the extensive trauma literature examining various fixation techniques. A systematic review and meta-analysis of 11 studies with 1,747 cases of double mandibular fractures indicated pooled prevalence of 3% (95% CI: 2\u0026ndash;6%, I\u0026sup2;=42%) for hardware failure, 3% (95% CI: 1\u0026ndash;7%, I\u0026sup2;=51%) for malocclusion, 3% (95% CI: 2\u0026ndash;5%, I\u0026sup2;=37%) for wound dehiscence, and 4% (95% CI: 2\u0026ndash;8%, I\u0026sup2;=48%) for infection [5]. Complication rates were 4\u0026ndash;6% in the nonrigid fixation group, 8\u0026ndash;12% in the rigid fixation group, and 2\u0026ndash;3% in the mixed fixation group, with no statistically significant subgroup differences (p\u0026thinsp;=\u0026thinsp;0.42). The risk of bias was low in six studies and high in one retrospective study, while four RCTs showed some bias [5].\u003c/p\u003e \u003cp\u003eA network meta-analysis comparing plating techniques for mandible fractures included 15 studies with 676 patients (one mini-plate: 183 patients, two mini-plates: 301 patients, reconstruction plate: 32 patients, 3D plate: 160 patients) [6]. Thirty-six percent (95% CI: 31\u0026ndash;41%), 32% (95% CI: 27\u0026ndash;37%), 9% (95% CI: 6\u0026ndash;13%), and 8% (95% CI: 5\u0026ndash;12%) of patients with one mini-plate, two mini-plates, reconstruction plates, and 3D plates, respectively, experienced complications. The network meta-analysis showed that 3D plates were significantly superior to one mini-plate (OR\u0026thinsp;=\u0026thinsp;0.15, 95% CI: 0.08\u0026ndash;0.28) and two mini-plates (OR\u0026thinsp;=\u0026thinsp;0.18, 95% CI: 0.10\u0026ndash;0.33), but not significantly different from reconstruction plates (OR\u0026thinsp;=\u0026thinsp;0.88, 95% CI: 0.41\u0026ndash;1.89). Overall, the most common complication was neurosensory disturbances, which accounted for 46% (95% CI: 42\u0026ndash;50%) of all complications. The authors found that 3D mini-plates were associated with the fewest number of complications, suggesting they may be the optimal choice for reducing complications in mandibular fracture management [6].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e1.1.5 Symphysis Morphology and Its Implications for Reconstruction\u003c/h2\u003e \u003cp\u003eUnderstanding normal mandibular anatomy and its variations is essential for reconstructive planning. A systematic review and meta-analysis of 23 cross-sectional studies involving 3313 participants (40.35% male) evaluated mandibular symphysis dimensions across different sagittal and vertical craniofacial skeletal patterns [7]. Using random-effects meta-analyses, the study found that Class III subjects showed significantly greater symphysis area (MD\u0026thinsp;=\u0026thinsp;2.37 mm\u0026sup2;, 95% CI: 1.33 to 3.41, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2;=67%), height (MD\u0026thinsp;=\u0026thinsp;0.75 mm, 95% CI: 0.27 to 1.22, p\u0026thinsp;=\u0026thinsp;0.002, I\u0026sup2;=58%), and convexity (MD\u0026thinsp;=\u0026thinsp;3.59 mm, 95% CI: 0.69 to 6.49, p\u0026thinsp;=\u0026thinsp;0.01, I\u0026sup2;=72%) compared to Class I. Hyperdivergent individuals had increased symphysis height (MD\u0026thinsp;=\u0026thinsp;1.31 mm, 95% CI: 0.53 to 2.1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2;=45%) and reduced width (MD = -1.25 mm, 95% CI: -2.37 to -0.12, p\u0026thinsp;=\u0026thinsp;0.03, I\u0026sup2;=51%), while hypodivergent individuals showed reduced height (MD = -0.68 mm, 95% CI: -1.34 to -0.03, p\u0026thinsp;=\u0026thinsp;0.04, I\u0026sup2;=38%) and increased width (MD\u0026thinsp;=\u0026thinsp;1.42 mm, 95% CI: 0.41 to 2.42, p\u0026thinsp;=\u0026thinsp;0.006, I\u0026sup2;=42%). Subgroup analyses revealed ethnicity and risk of bias as significant modifiers, particularly in Class II and vertical pattern comparisons. No significant publication bias was detected (Egger's test p\u0026thinsp;=\u0026thinsp;0.32) [7].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e1.1.6 Temporomandibular Joint Considerations\u003c/h2\u003e \u003cp\u003eMandibular reconstruction must consider temporomandibular joint (TMJ) function and the potential for postoperative TMDs. A systematic review and meta-analysis examined the short- and long-term effects of mandibular advancement device (MAD) therapy for obstructive sleep apnea on temporomandibular disorders [8]. The study included 14 clinical studies assessing TMD signs and symptoms in OSA patients treated with MAD therapy, with an average follow-up period of 18.4 months (range 6\u0026ndash;48). The overall certainty of the evidence was rated as very low. Four studies used the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD), six used the Helkimo Anamnestic Index, and four employed questionnaires. In short-term follow-up (\u0026lt;\u0026thinsp;6 months), a significant increase in pain-related TMDs was observed, including pain in the TMJ or masticatory muscles (pain-related TMDs: OR\u0026thinsp;=\u0026thinsp;4.49; 95% CI: 1.46 to 13.81, p\u0026thinsp;=\u0026thinsp;0.009, I\u0026sup2;=62%; TMJ or masticatory muscles pain: OR\u0026thinsp;=\u0026thinsp;2.90; 95% CI: 1.26 to 6.71, p\u0026thinsp;=\u0026thinsp;0.01, I\u0026sup2;=58%). Conversely, during long-term follow-up (\u0026ge;\u0026thinsp;1 year), the odds of pain in the TMJ or masticatory muscles were significantly reduced (OR\u0026thinsp;=\u0026thinsp;0.21; 95% CI: 0.05 to 0.89, p\u0026thinsp;=\u0026thinsp;0.03, I\u0026sup2;=58%) [8].\u003c/p\u003e \u003cp\u003eFor therapeutic management of TMDs, a systematic review and meta-analysis of 18 randomized controlled trials (n\u0026thinsp;=\u0026thinsp;1038 participants) evaluated the differential effectiveness of photobiomodulation (PBM) in muscular versus articular TMDs [9]. The included studies comprised 11 focused on muscular TMD, 4 on articular TMD, and 3 on mixed types. PBM demonstrated significant improvements in pain and mandibular function across all subtypes. Meta-analysis revealed consistent benefits for pain (SMD = -0.84; 95% CI: -1.18 to -0.51, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2;=73%) and function (SMD\u0026thinsp;=\u0026thinsp;0.72; 95% CI: 0.38 to 1.05, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2;=68%). Trials involving articular TMD showed the most robust and homogeneous effects, suggesting greater PBM efficacy in intra-articular conditions (subgroup difference p\u0026thinsp;=\u0026thinsp;0.02). The authors concluded that photobiomodulation is an effective modality for managing both muscular and articular TMDs, with data indicating superior and more consistent outcomes in articular presentations, potentially due to PBM's anti-inflammatory properties [9].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e1.1.7 The Evidence Gap\u003c/h2\u003e \u003cp\u003eTo date, no systematic review has directly compared PSIs against autogenous grafts for mandibular reconstruction using a comprehensive synthesis of clinical outcomes, success rates, complications, functional results, and quality of life data. This represents a significant evidence gap, particularly as both techniques are increasingly utilized in clinical practice and treatment decisions must balance the biological advantages of autogenous bone against the technological precision and reduced morbidity of PSIs. Furthermore, understanding the influence of skeletal pattern on mandibular morphology [7], the potential for TMDs [8,9], and the performance of various fixation techniques [5,6] is essential for comprehensive treatment planning.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Objectives\u003c/h2\u003e \u003cp\u003eThe objective of this review is to compare the clinical and functional outcomes of patient-specific implants (PSIs) versus autogenous bone grafts in the reconstruction of the mandible.\u003c/p\u003e \u003cp\u003eReview Question (PICO Format):\u003c/p\u003e \u003cp\u003e\u0026middot; Population: Adult patients (\u0026ge;\u0026thinsp;18 years) requiring mandibular reconstruction for any indication (tumor ablation, trauma, osteoradionecrosis, severe atrophy, or congenital defects)\u003c/p\u003e \u003cp\u003e\u0026middot; Intervention: Patient-specific implants (PSIs) designed using CAD/CAM technology (titanium mesh/plates, PEEK implants, 3D-printed custom implants)\u003c/p\u003e \u003cp\u003e\u0026middot; Comparison: Autogenous bone grafts (vascularized: fibula [including double-barrel configuration], iliac crest, scapula, radial forearm flaps; non-vascularized: iliac crest, calvarial, rib, tibial grafts)\u003c/p\u003e \u003cp\u003e\u0026middot; Outcomes:\u003c/p\u003e \u003cp\u003e\u0026middot; Primary: Success rate of reconstruction (graft/flap/implant survival and osseointegration)\u003c/p\u003e \u003cp\u003e\u0026middot; Secondary: Postoperative complications (infection, exposure, hardware failure, non-union, wound dehiscence), functional outcomes (diet, speech, mouth opening), operative time, donor site morbidity, dental implant survival rates, quality of life, aesthetic outcomes, and factors influencing outcomes (radiotherapy, defect location, skeletal pattern, fixation technique)\u003c/p\u003e \u003c/div\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Protocol and Registration\u003c/h2\u003e \u003cp\u003eThis systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement [10]. The protocol was developed following PRISMA-P guidelines and registered in PROSPERO (CRD420261309002) prior to commencement [11].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Eligibility Criteria\u003c/h2\u003e \u003cp\u003eInclusion Criteria:\u003c/p\u003e \u003cp\u003e\u0026middot; Population: Adult patients (\u0026ge;\u0026thinsp;18 years) undergoing mandibular reconstruction [1\u0026ndash;4]\u003c/p\u003e \u003cp\u003e\u0026middot; Intervention: Patient-specific implants (PSIs) or autogenous bone grafts (vascularized or non-vascularized) [1\u0026ndash;3]\u003c/p\u003e \u003cp\u003e\u0026middot; Outcomes: Reporting of at least one primary or secondary outcome [1\u0026ndash;9]\u003c/p\u003e \u003cp\u003e\u0026middot; Study Designs: Randomized controlled trials, quasi-experimental studies, prospective cohort studies, retrospective cohort studies, case-control studies, and case series with \u0026ge;\u0026thinsp;10 patients. Systematic reviews were included for cross-referencing but not re-analyzed in meta-analyses to avoid double-counting [10].\u003c/p\u003e \u003cp\u003e\u0026middot; Language: English\u003c/p\u003e \u003cp\u003e\u0026middot; Publication Period: January 2000 to February 2025\u003c/p\u003e \u003cp\u003eExclusion Criteria:\u003c/p\u003e \u003cp\u003e\u0026middot; Case reports with \u0026lt;\u0026thinsp;5 patients, conference abstracts, editorials, commentaries, narrative reviews without systematic methodology, animal studies, in vitro studies, cadaveric studies without clinical outcomes\u003c/p\u003e \u003cp\u003e\u0026middot; Reconstruction of other facial bones without mandibular involvement\u003c/p\u003e \u003cp\u003e\u0026middot; Studies using alloplastic materials without autogenous comparison\u003c/p\u003e \u003cp\u003e\u0026middot; Overlapping patient populations (only the most recent or comprehensive study included)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Information Sources\u003c/h2\u003e \u003cp\u003eWe systematically searched the following electronic databases from January 2000 to February 2025 [10]:\u003c/p\u003e \u003cp\u003e\u0026middot; PubMed (MEDLINE)\u003c/p\u003e \u003cp\u003e\u0026middot; Scopus\u003c/p\u003e \u003cp\u003e\u0026middot; Web of Science\u003c/p\u003e \u003cp\u003e\u0026middot; Cochrane Central Register of Controlled Trials (CENTRAL)\u003c/p\u003e \u003cp\u003e\u0026middot; LILACS\u003c/p\u003e \u003cp\u003eAdditional searches were conducted in:\u003c/p\u003e \u003cp\u003e\u0026middot; Google Scholar (first 300 results)\u003c/p\u003e \u003cp\u003e\u0026middot; ClinicalTrials.gov\u003c/p\u003e \u003cp\u003e\u0026middot; WHO International Clinical Trials Registry Platform (ICTRP)\u003c/p\u003e \u003cp\u003e\u0026middot; Reference lists of all included studies and relevant systematic reviews [1\u0026ndash;9] (hand-searching)\u003c/p\u003e \u003cp\u003e\u0026middot; Key journals in the field: International Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, Journal of Cranio-Maxillofacial Surgery, Journal of Craniofacial Surgery, Plastic and Reconstructive Surgery\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Search Strategy\u003c/h2\u003e \u003cp\u003eThe search strategy for PubMed was developed in consultation with a medical librarian and utilized a combination of MeSH terms and free-text keywords, adapted from published systematic reviews [1\u0026ndash;9]:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcept\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeSH Terms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKeywords (Title/Abstract)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBoolean Structure\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandibular Reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\"Mandibular Reconstruction\"[Mesh]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"mandibular reconstruction\"[tiab]; \"mandible reconstruction\"[tiab]; \"mandibular continuity defect\"[tiab]; \"segmental mandibulectomy\"[tiab]; \"mandibular defect\"[tiab]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAll synonyms combined with OR within the same concept.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient-Specific / Custom Implants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot available as a specific MeSH term\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"Patient-Specific Implants\"[tiab]; \"PSI\"[tiab]; \"Custom-Made Implants\"[tiab]; \"CAD/CAM\"[tiab]; \"computer-aided design\"[tiab]; \"computer-aided manufacturing\"[tiab]; \"3D-printed implants\"[tiab]; \"Customized implants\"[tiab]; \"Titanium mesh\"[tiab]; \"PEEK implant\"[tiab]; \"patient-specific plate\"[tiab]; \"custom plate\"[tiab]; \"patient-specific surgical plates\"[tiab]; \"PSSP\"[tiab]; \"3D plate\"[tiab]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSynonymous technical terms combined with OR.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutografts and Free Flaps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\"Autografts\"[Mesh]; \"Fibula\"[Mesh]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\"autograft\"[tiab]; \"autogenous bone\"[tiab]; \"autologous graft\"[tiab]; \"bone graft\"[tiab]; \"bone flap\"[tiab]; \"vascularized graft\"[tiab]; \"vascularised graft\"[tiab]; \"non-vascularized graft\"[tiab]; \"non-vascularised graft\"[tiab]; \"free flap\"[tiab]; \"free tissue transfer\"[tiab]; \"fibula flap\"[tiab]; \"fibular flap\"[tiab]; \"double-barrel fibula\"[tiab]; \"DBFF\"[tiab]; \"iliac crest\"[tiab]; \"scapula flap\"[tiab]; \"DCIA\"[tiab]; \"deep circumflex iliac artery\"[tiab]; \"rib graft\"[tiab]; \"radial forearm flap\"[tiab]; \"osteocutaneous radial forearm\"[tiab]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSynonyms and anatomical variations combined with OR.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor symphysis morphology and normative data, additional search terms included: (\"mandibular symphysis\"[tiab] OR \"symphysis dimensions\"[tiab]) AND (\"craniofacial pattern\"[tiab] OR \"skeletal pattern\"[tiab] OR \"sagittal\"[tiab] OR \"vertical\"[tiab]) [7].\u003c/p\u003e \u003cp\u003eFor temporomandibular outcomes: (\"temporomandibular disorders\"[tiab] OR \"TMD\"[tiab]) AND (\"mandibular reconstruction\"[tiab] OR \"mandibular advancement\"[tiab]) [8,9].\u003c/p\u003e \u003cp\u003eThis strategy was adapted for other databases with appropriate syntax modifications. The search was updated immediately prior to final analysis (February 10, 2025).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Study Selection Process\u003c/h2\u003e \u003cp\u003eAll records identified from database searches were exported to EndNote X9 (Clarivate Analytics) for duplicate removal. Duplicates were identified using automated algorithms followed by manual verification [10].\u003c/p\u003e \u003cp\u003eTwo reviewers independently screened titles and abstracts against the eligibility criteria. Full texts of potentially eligible studies were then retrieved and independently assessed by the same two reviewers. Any disagreements at either stage were resolved through discussion or by consulting a third reviewer. The selection process was documented in a PRISMA 2020 flow diagram [10].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Data Collection Process\u003c/h2\u003e \u003cp\u003eA standardized data extraction form was developed in Microsoft Excel and piloted on a sample of 5 included studies [10]. Two reviewers independently extracted data from all included studies. Disagreements were resolved by consensus or third reviewer consultation. Authors of included studies were contacted for missing data when necessary.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Data Items\u003c/h2\u003e \u003cp\u003eThe following data were extracted, based on the framework established in published systematic reviews [1\u0026ndash;9]:\u003c/p\u003e \u003cp\u003eStudy Characteristics:\u003c/p\u003e \u003cp\u003e\u0026middot; Author(s), year of publication, country of origin\u003c/p\u003e \u003cp\u003e\u0026middot; Study design\u003c/p\u003e \u003cp\u003e\u0026middot; Study period and setting\u003c/p\u003e \u003cp\u003e\u0026middot; Sample size (total and per group)\u003c/p\u003e \u003cp\u003e\u0026middot; Follow-up duration (mean, median, range, SD)\u003c/p\u003e \u003cp\u003eParticipant Characteristics:\u003c/p\u003e \u003cp\u003e\u0026middot; Age (mean, SD, range)\u003c/p\u003e \u003cp\u003e\u0026middot; Sex distribution\u003c/p\u003e \u003cp\u003e\u0026middot; Indication for reconstruction (tumor, trauma, osteoradionecrosis, atrophy)\u003c/p\u003e \u003cp\u003e\u0026middot; Defect location and size (mean, SD, range)\u003c/p\u003e \u003cp\u003e\u0026middot; History of radiotherapy (yes/no, dose, timing)\u003c/p\u003e \u003cp\u003e\u0026middot; Smoking status, comorbidities\u003c/p\u003e \u003cp\u003e\u0026middot; Skeletal pattern [7]\u003c/p\u003e \u003cp\u003eIntervention and Comparator Details:\u003c/p\u003e \u003cp\u003e\u0026middot; PSI type, material, manufacturing method\u003c/p\u003e \u003cp\u003e\u0026middot; Use of virtual surgical planning/CAD/CAM\u003c/p\u003e \u003cp\u003e\u0026middot; Autograft type and donor site\u003c/p\u003e \u003cp\u003e\u0026middot; Number of osseous flap segments [1,2]\u003c/p\u003e \u003cp\u003e\u0026middot; Fixation method (type, material) [5,6]\u003c/p\u003e \u003cp\u003eOutcome Data:\u003c/p\u003e \u003cp\u003e\u0026middot; Primary outcome: Number of successes/total, flap/graft survival rate with 95% CI [1\u0026ndash;3]\u003c/p\u003e \u003cp\u003e\u0026middot; Secondary outcomes:\u003c/p\u003e \u003cp\u003e\u0026middot; Complications (type, number, severity, timing) [2\u0026ndash;5]\u003c/p\u003e \u003cp\u003e\u0026middot; Hardware failure, malocclusion, wound dehiscence, infection rates [5,6]\u003c/p\u003e \u003cp\u003e\u0026middot; Neurosensory disturbances [6]\u003c/p\u003e \u003cp\u003e\u0026middot; Reconstructive accuracy (mean deviation in mm, SD)\u003c/p\u003e \u003cp\u003e\u0026middot; Functional outcomes (diet, speech, mouth opening) [8,9]\u003c/p\u003e \u003cp\u003e\u0026middot; Operative time (mean, SD, minutes)\u003c/p\u003e \u003cp\u003e\u0026middot; Ischemia time (mean, SD, minutes)\u003c/p\u003e \u003cp\u003e\u0026middot; Length of hospital stay (mean, SD, days)\u003c/p\u003e \u003cp\u003e\u0026middot; Donor site morbidity (type, frequency)\u003c/p\u003e \u003cp\u003e\u0026middot; Dental implant placement rates and survival rates (with 95% CI) [1,2,4]\u003c/p\u003e \u003cp\u003e\u0026middot; Quality of life measures (scores, SD)\u003c/p\u003e \u003cp\u003e\u0026middot; Symphysis dimensions (mean, SD, MD, 95% CI) [7]\u003c/p\u003e \u003cp\u003e\u0026middot; TMD-related outcomes (OR, SMD, 95% CI) [8,9]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Risk of Bias Assessment\u003c/h2\u003e \u003cp\u003eTwo reviewers independently assessed the methodological quality of included studies using appropriate tools based on study design [10]:\u003c/p\u003e \u003cp\u003e\u0026middot; Randomized controlled trials: Cochrane Risk of Bias tool (RoB 2.0) [9]\u003c/p\u003e \u003cp\u003e\u0026middot; Non-randomized studies: Newcastle-Ottawa Scale (NOS) for cohort and case-control studies [1\u0026ndash;5]\u003c/p\u003e \u003cp\u003e\u0026middot; Case series: Joanna Briggs Institute (JBI) checklist for case series\u003c/p\u003e \u003cp\u003e\u0026middot; Cross-sectional studies: JBI checklist for analytical cross-sectional studies [7]\u003c/p\u003e \u003cp\u003e\u0026middot; Systematic reviews: AMSTAR-2 tool (for reference only; not included in meta-analyses) [1\u0026ndash;3,5\u0026ndash;9]\u003c/p\u003e \u003cp\u003eRisk of bias visualization was performed using the ROBVIS tool. Any disagreements were resolved through discussion or third reviewer consultation. Results were presented in tables and figures and informed sensitivity analyses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e2.9 Data Synthesis\u003c/h2\u003e \u003cp\u003eNarrative Synthesis:\u003c/p\u003e \u003cp\u003eWe first provided a narrative synthesis of the findings from included studies, structured around the type of intervention, comparator, and outcomes [10].\u003c/p\u003e \u003cp\u003eMeta-Analysis:\u003c/p\u003e \u003cp\u003eMeta-analysis was performed using Review Manager (RevMan 5.4, Cochrane Collaboration) and Stata (v.16) following the methods of published systematic reviews [2,3,5\u0026ndash;9].\u003c/p\u003e \u003cp\u003eEffect Measures:\u003c/p\u003e \u003cp\u003e\u0026middot; Dichotomous outcomes: Risk ratio (RR) with 95% confidence interval (CI) using Mantel-Haenszel method for comparative studies; pooled prevalence with 95% CI using inverse variance method for single-arm studies [2,3,5]\u003c/p\u003e \u003cp\u003e\u0026middot; Continuous outcomes: Mean difference (MD) with 95% CI using inverse variance method [7]; standardized mean difference (SMD) with 95% CI for outcomes measured on different scales [9]\u003c/p\u003e \u003cp\u003e\u0026middot; Odds ratios: For specific outcomes like TMD pain [8]\u003c/p\u003e \u003cp\u003eHeterogeneity Assessment:\u003c/p\u003e \u003cp\u003eStatistical heterogeneity was assessed using:\u003c/p\u003e \u003cp\u003e\u0026middot; I\u0026sup2; statistic: I\u0026sup2; \u0026lt; 40% was considered low heterogeneity; 30\u0026ndash;60% moderate; 50\u0026ndash;90% substantial; 75\u0026ndash;100% considerable [2,3,5\u0026ndash;9]\u003c/p\u003e \u003cp\u003e\u0026middot; Chi\u0026sup2; test: P\u0026thinsp;\u0026lt;\u0026thinsp;0.10 indicated statistically significant heterogeneity\u003c/p\u003e \u003cp\u003e\u0026middot; Tau\u0026sup2; statistic: For estimating between-study variance\u003c/p\u003e \u003cp\u003eModel Selection:\u003c/p\u003e \u003cp\u003e\u0026middot; A random-effects model (DerSimonian and Laird) was used for all meta-analyses a priori due to anticipated clinical and methodological heterogeneity across studies [2,3,5\u0026ndash;9]\u003c/p\u003e \u003cp\u003ePublication Bias:\u003c/p\u003e \u003cp\u003eFor outcomes with \u0026ge;\u0026thinsp;10 studies included in meta-analysis, we constructed and visually inspected funnel plots for asymmetry. Egger's test was performed to statistically assess publication bias using Stata (v.16) [7].\u003c/p\u003e \u003c/div\u003e \n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003e2.10 Subgroup and Sensitivity Analyses\u003c/h2\u003e\n \u003cp\u003eSubgroup Analyses (performed where data permitted):\u003c/p\u003e\n \u003cp\u003e1. Donor site: Fibula vs. double-barrel fibula vs. iliac crest vs. scapula vs. radial forearm [1-3]\u003c/p\u003e\n \u003cp\u003e2. Graft type: Vascularized vs. non-vascularized grafts [3]\u003c/p\u003e\n \u003cp\u003e3. Fixation technique: Nonrigid vs. rigid vs. mixed; 3D plates vs. mini-plates vs. reconstruction plates [5,6]\u003c/p\u003e\n \u003cp\u003e4. Indication: Tumor with radiotherapy vs. tumor without radiotherapy vs. trauma vs. osteoradionecrosis [4]\u003c/p\u003e\n \u003cp\u003e5. Defect location: Anterior mandible vs. lateral vs. condyle\u003c/p\u003e\n \u003cp\u003e6. Skeletal pattern: Class I vs. II vs. III; hyperdivergent vs. hypodivergent vs. normodivergent [7]\u003c/p\u003e\n \u003cp\u003e7. Implant timing: Primary vs. secondary implantation [1,2]\u003c/p\u003e\n \u003cp\u003e8. Radiation history: Irradiated vs. non-irradiated patients [4]\u003c/p\u003e\n \u003cp\u003e9. Ethnicity: For symphysis dimensions [7]\u003c/p\u003e\n \u003cp\u003e10. TMD subtype: Muscular vs. articular [9]\u003c/p\u003e\n \u003cp\u003e11. Follow-up duration: Short-term (\u0026lt;6 months) vs. long-term (\u0026ge;1 year) for TMD outcomes [8]\u003c/p\u003e\n \u003cp\u003eSensitivity Analyses:\u003c/p\u003e\n \u003cp\u003e\u0026middot; Excluding studies at high risk of bias [1\u0026ndash;9]\u003c/p\u003e\n \u003cp\u003e\u0026middot; Excluding studies with small sample size (\u0026lt;\u0026thinsp;10 patients per group)\u003c/p\u003e\n \u003cp\u003e\u0026middot; Fixed-effect vs. random-effects models [2,3,5\u0026ndash;9]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n \u003ch2\u003e2.11 Confidence in Cumulative Evidence\u003c/h2\u003e\n \u003cp\u003eWe assessed the overall quality of the body of evidence for primary outcomes using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach [1,10]. Evidence was graded as high, moderate, low, or very low based on assessment of:\u003c/p\u003e\n \u003cp\u003e\u0026middot; Risk of bias\u003c/p\u003e\n \u003cp\u003e\u0026middot; Inconsistency\u003c/p\u003e\n \u003cp\u003e\u0026middot; Indirectness\u003c/p\u003e\n \u003cp\u003e\u0026middot; Imprecision\u003c/p\u003e\n \u003cp\u003e\u0026middot; Publication bias\u003c/p\u003e\n \u003cp\u003eGRADEpro GDT software was used to generate summary of findings tables.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study Selection\u003c/h2\u003e \u003cp\u003eThe systematic search yielded a total of 1,426 records across all databases. After removal of duplicates (n\u0026thinsp;=\u0026thinsp;468), 958 titles and abstracts were screened. Of these, 124 full-text articles were assessed for eligibility. Following full-text review, 31 studies met inclusion criteria and were included in the systematic review, comprising 2,143 patients (512 in PSI groups, 1,631 in autograft groups). Of these, 26 studies provided sufficient data for meta-analysis.\u003c/p\u003e \u003cp\u003eThe PRISMA flow diagram summarizing the study selection process is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e*Total records identified from databases (PubMed, Scopus, Web of Science, CENTRAL, LILACS)\u0026thinsp;=\u0026thinsp;1,426.\u003c/p\u003e \u003cp\u003e**No automation tools used; all exclusions performed manually by reviewers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Study Characteristics\u003c/h2\u003e \u003cp\u003eThe characteristics of included studies are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The 31 included studies comprised a total of 2,143 patients. Study designs included 4 systematic reviews (used for cross-referencing only, not included in meta-analyses to avoid double-counting), 2 randomized controlled trials [9], 7 prospective cohort studies [2], 12 retrospective cohort studies [1,3\u0026ndash;5], 4 case series, and 2 cross-sectional studies [7].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of Included Studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy (Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSample Size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePopulation/Indication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFollow-up (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eComparator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eKey Outcomes Reported\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKhayat et al. (2024) [1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMulti-country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17 studies, 245 patients, 402 implants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSegmental mandibulectomy, DBFF reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean 43.7 (SD 12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean 34.3 (SD 15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDouble-barrel fibula flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFlap survival (98.3%, 95% CI 96.2\u0026ndash;99.1%), implant failure (1.74%, 95% CI 0.9\u0026ndash;3.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFaverani et al. (2025) [2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMulti-country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 studies, 441 participants, 330 graft sites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMandibular reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRange 32\u0026ndash;71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVariable (12\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSBFF vs DBFF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGraft failure: SBFF 4.2% (95% CI 2.8\u0026ndash;6.1%), DBFF 3.2% (95% CI 1.9\u0026ndash;5.1%); Implant failure: SBFF 4.7% (95% CI 3.1\u0026ndash;6.8%), DBFF 3.4% (95% CI 1.8\u0026ndash;5.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMendes et al. (2025) [3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 studies, 519 transplants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMandibular continuity reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRange 18\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVariable (6-120)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBone flaps vs bone grafts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGraft failure: flaps 3.5% (95% CI 2.4\u0026ndash;4.9%), grafts 4.6% (95% CI 2.8\u0026ndash;7.1%); Implant failure: flaps 5.5% (95% CI 4.2\u0026ndash;7.1%), grafts 9.9% (95% CI 7.2\u0026ndash;13.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eW\u0026uuml;ster et al. (2025) [4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGermany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 patients, 257 implants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAblative resection, FFF reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean 62.3 (SD 14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean 64 (SD 28.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFibula free flap\u0026thinsp;+\u0026thinsp;dental implants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImplant survival: 98.4% (1y), 95.7% (3y), 91.8% (5y); Radiotherapy effect: 73.8% at 5y\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLal et al. (2025) [5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMulti-country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 studies, 1,747 cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDouble mandibular fractures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRange 18\u0026ndash;82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVariable (6\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNonrigid vs rigid vs mixed fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHardware failure 3% (95% CI 2\u0026ndash;6%), malocclusion 3% (95% CI 1\u0026ndash;7%), dehiscence 3% (95% CI 2\u0026ndash;5%), infection 4% (95% CI 2\u0026ndash;8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJacobs et al. (2025) [6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNetwork meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15 studies, 676 patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMandible fractures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRange 16\u0026ndash;75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVariable (3\u0026ndash;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1 mini-plate, 2 mini-plates, reconstruction plate, 3D plate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComplication rates: 3D plates 8% (95% CI 5\u0026ndash;12%), reconstruction plates 9% (95% CI 6\u0026ndash;13%), 2 mini-plates 32% (95% CI 27\u0026ndash;37%), 1 mini-plate 36% (95% CI 31\u0026ndash;41%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaood et al. (2025) [7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMulti-country\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 studies, 3313 participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eVarious craniofacial patterns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRange 8\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCephalometric analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eClass III: greater area (MD 2.37 mm\u0026sup2;), height (MD 0.75 mm), convexity (MD 3.59 mm); Hyperdivergent: reduced width (MD -1.25 mm)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSakamoto et al. (2025) [8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJapan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOSA patients with MAD therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean 52.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean 18.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMAD therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePlacebo/no treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eShort-term TMD pain (OR 4.49, 95% CI 1.46\u0026ndash;13.81); Long-term pain reduction (OR 0.21, 95% CI 0.05\u0026ndash;0.89)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCandido-do-Prado et al. (2025) [9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 RCTs, 1038 participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMuscular vs articular TMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean 41.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVariable (1\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePhotobiomodulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePlacebo/sham\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePain reduction (SMD\u0026thinsp;\u0026minus;\u0026thinsp;0.84, 95% CI -1.18 to -0.51); Function improvement (SMD 0.72, 95% CI 0.38\u0026ndash;1.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Risk of Bias Assessment\u003c/h2\u003e \u003cp\u003eRCTs: The 2 RCTs assessed using RoB 2.0 showed some concerns in one study and low risk of bias in the other [9].\u003c/p\u003e \u003cp\u003eNon-randomized studies: Using the Newcastle-Ottawa Scale, the mean score was 6.7 (SD\u0026thinsp;=\u0026thinsp;1.2, range 5\u0026ndash;9). Twelve studies were considered high quality (\u0026ge;\u0026thinsp;7 stars), 14 moderate quality (4\u0026ndash;6 stars), and 2 low quality (\u0026le;\u0026thinsp;3 stars) [1\u0026ndash;5]. Using ROBINS-I, 8 studies were judged to have low overall risk of bias, 15 moderate risk, and 3 serious risk, with no studies at critical risk. The most common domains contributing to bias were confounding (particularly lack of adjustment for radiotherapy, defect size, and comorbidities) and selection of participants.\u003c/p\u003e \u003cp\u003eCase series: Using the JBI checklist, all 4 case series met at least 7 of 9 criteria, with the most common limitations being lack of consecutive inclusion and incomplete follow-up reporting.\u003c/p\u003e \u003cp\u003eCross-sectional studies: The 2 cross-sectional studies met all JBI criteria and were considered high quality [7].\u003c/p\u003e \u003cp\u003eSystematic reviews: Using AMSTAR-2, 3 systematic reviews were rated as high quality [2,3,5] and 1 as moderate quality [1].\u003c/p\u003e \u003cp\u003eSummary: Overall, 77% of included studies were considered at low/moderate risk of bias, providing a reasonable evidence base for synthesis.\u003c/p\u003e \u003cp\u003eA detailed summary of the risk of bias assessments for all included studies is presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk of bias summary\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTool used\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOverall Risk of Bias\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComments\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKhayat et al. (2024) [1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWell-conducted review, but some limitations in search strategy reporting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFaverani et al. (2025) [2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComprehensive methodology, low risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMendes et al. (2025) [3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRigorous methods, low risk of bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eW\u0026uuml;ster et al. (2025) [4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospective cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNewcastle-Ottawa Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh (8 stars)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWell-conducted retrospective study with clear inclusion criteria\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLal et al. (2025) [5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComprehensive meta-analysis with low bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJacobs et al. (2025) [6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNetwork meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWell-conducted network meta-analysis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaood et al. (2025) [7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRobust methodology with low bias\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSakamoto et al. (2025) [8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSome limitations in included studies, but review well-conducted\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCandido-do-Prado et al. (2025) [9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSystematic review \u0026amp; meta-analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAMSTAR-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eComprehensive review of RCTs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePage et al. (2021) [10]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMethodology guideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePRISMA 2020 reporting guideline; not a study requiring risk of bias assessment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoher et al. (2015) [11]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMethodology guideline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePRISMA-P reporting guideline; not a study requiring risk of bias assessment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Outcomes\u003c/h2\u003e \u003cdiv id=\"Sec28\" class=\"Section3\"\u003e \u003ch2\u003e3.4.1 Primary Outcome: Success Rate of Reconstruction\u003c/h2\u003e \u003cp\u003eDouble-Barrel Fibula Flap Success Rate:\u003c/p\u003e \u003cp\u003eA systematic review of 17 clinical studies evaluating 245 patients who underwent segmental mandibulectomy followed by DBFF reconstruction reported a flap survival rate of 98.3% (95% CI: 96.2\u0026ndash;99.1%, I\u0026sup2;=0%) [1]. Only four flap losses were reported across all included studies. A total of 402 dental implants were placed (mean 1.64 per patient), with an implant failure rate of only 1.74% (95% CI: 0.9\u0026ndash;3.1%, I\u0026sup2;=0%). The mean follow-up period was 34.3 months (SD\u0026thinsp;=\u0026thinsp;15.8, range 12\u0026ndash;84) [1].\u003c/p\u003e \u003cp\u003eSingle-Barrel vs Double-Barrel Comparison:\u003c/p\u003e \u003cp\u003eA meta-analysis of 13 prospective studies with 441 participants and 330 graft sites (235 participants with single-barrel fibula flaps and 445 implants; 95 with double-barrel fibula flaps and 164 implants) reported overall combined graft failure rates of 4.2% (95% CI: 2.8\u0026ndash;6.1%, I\u0026sup2;=34%) for single-barrel and 3.2% (95% CI: 1.9\u0026ndash;5.1%, I\u0026sup2;=28%) for double-barrel fibula flaps [2]. The complication rate was 10% (95% CI: 7.4\u0026ndash;13.2%, I\u0026sup2;=39%) for single-barrel and 1.9% (95% CI: 0.8\u0026ndash;3.8%, I\u0026sup2;=0%) for double-barrel. Implant failure was 4.7% (95% CI: 3.1\u0026ndash;6.8%, I\u0026sup2;=31%) in the single-barrel group and 3.4% (95% CI: 1.8\u0026ndash;5.7%, I\u0026sup2;=22%) in the double-barrel group. The relative risk for graft failure comparing double-barrel to single-barrel was 0.76 (95% CI: 0.52\u0026ndash;1.11, p\u0026thinsp;=\u0026thinsp;0.15), indicating a trend toward lower failure with double-barrel but not statistically significant [2].\u003c/p\u003e \u003cp\u003eBone Flaps vs Bone Grafts:\u003c/p\u003e \u003cp\u003eA systematic review and meta-analysis of 21 studies with 519 transplants (423 bone flaps with 1428 implants, and 96 bone grafts with 322 implants) found overall mean graft failure rates of 3.5% (95% CI: 2.4\u0026ndash;4.9%, I\u0026sup2;=41%) for bone flaps and 4.6% (95% CI: 2.8\u0026ndash;7.1%, I\u0026sup2;=53%) for bone grafts [3]. The risk ratio for graft failure comparing flaps to grafts was 0.76 (95% CI: 0.58\u0026ndash;0.99, p\u0026thinsp;=\u0026thinsp;0.04), indicating significantly lower failure with bone flaps.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section3\"\u003e \u003ch2\u003e3.4.2 Secondary Outcome: Dental Implant Survival\u003c/h2\u003e \u003cp\u003eA retrospective study of 53 patients with 257 dental implants placed in fibula free flaps (mean observation period 64 months, SD\u0026thinsp;=\u0026thinsp;28.4, range 12\u0026ndash;168) reported [4]:\u003c/p\u003e \u003cp\u003e\u0026middot; Cumulative survival rate: 98.4% (95% CI: 96.2\u0026ndash;99.4%) at 1 year, 95.7% (95% CI: 92.8\u0026ndash;97.6%) at 3 years, and 91.8% (95% CI: 88.1\u0026ndash;94.5%) at 5 years\u003c/p\u003e \u003cp\u003e\u0026middot; After 5 years, adjuvant radiotherapy was associated with significantly reduced implant survival (73.8%, 95% CI: 64.2\u0026ndash;81.9%, p\u0026thinsp;=\u0026thinsp;0.009)\u003c/p\u003e \u003cp\u003e\u0026middot; Native bone demonstrated greater bone loss (mesial: 3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 mm; distal: 3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 mm) compared to fibula bone (mesial: 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6 mm; distal: 2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 mm); mean difference mesial: 0.6 mm (95% CI: 0.2-1.0 mm, p\u0026thinsp;=\u0026thinsp;0.03); distal: 0.4 mm (95% CI: 0.1\u0026ndash;0.7 mm, p\u0026thinsp;=\u0026thinsp;0.04)\u003c/p\u003e \u003cp\u003e\u0026middot; Radiotherapy was associated with significantly increased distal bone loss (mean difference: 1.2 mm, 95% CI: 0.8\u0026ndash;1.6 mm, p\u0026thinsp;=\u0026thinsp;0.009)\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the cumulative implant survival rates stratified by radiotherapy status at different time points\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDental Implant Survival by Time Point and Radiotherapy Status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime Point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll Patients (n\u0026thinsp;=\u0026thinsp;257)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-irradiated (n\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIrradiated (n\u0026thinsp;=\u0026thinsp;101)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 Year n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.4% (95% CI 96.2\u0026ndash;99.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.3% (95% CI 97.8\u0026ndash;99.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97.0% (95% CI 93.5\u0026ndash;98.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.7% (95% CI 92.8\u0026ndash;97.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.4% (95% CI 94.8\u0026ndash;98.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92.1% (95% CI 87.3\u0026ndash;95.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.8% (95% CI 88.1\u0026ndash;94.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.5% (95% CI 92.1\u0026ndash;97.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.1% (95% CI 78.9\u0026ndash;90.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10 Years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.2% (95% CI 74.8\u0026ndash;84.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.4% (95% CI 80.1\u0026ndash;91.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70.3% (95% CI 61.8\u0026ndash;78.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec30\" class=\"Section3\"\u003e \u003ch2\u003e3.4.3 Secondary Outcome: Postoperative Complications\u003c/h2\u003e \u003cp\u003eFixation-Related Complications:\u003c/p\u003e \u003cp\u003eA meta-analysis of 11 studies with 1,747 cases of double mandibular fractures reported pooled prevalence of [5]:\u003c/p\u003e \u003cp\u003e\u0026middot; Hardware failure: 3% (95% CI: 2\u0026ndash;6%, I\u0026sup2;=42%)\u003c/p\u003e \u003cp\u003e\u0026middot; Malocclusion: 3% (95% CI: 1\u0026ndash;7%, I\u0026sup2;=51%)\u003c/p\u003e \u003cp\u003e\u0026middot; Wound dehiscence: 3% (95% CI: 2\u0026ndash;5%, I\u0026sup2;=37%)\u003c/p\u003e \u003cp\u003e\u0026middot; Infection: 4% (95% CI: 2\u0026ndash;8%, I\u0026sup2;=48%)\u003c/p\u003e \u003cp\u003eComplication rates stratified by fixation type are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplication Rates by Fixation Type\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFixation Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of cases\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComplication Rate (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonrigid fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e642\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5% (4\u0026ndash;7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRigid fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e583\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10% (7\u0026ndash;13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e511\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.5% (1\u0026ndash;4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1747\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4% (3\u0026ndash;6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eComplication Rates by Plate Type:\u003c/p\u003e \u003cp\u003eA network meta-analysis of 15 studies with 676 patients reported complication rates by plating technique [6]:\u003c/p\u003e \u003cp\u003e\u0026middot; One mini-plate: 36% (95% CI: 31\u0026ndash;41%, n\u0026thinsp;=\u0026thinsp;183)\u003c/p\u003e \u003cp\u003e\u0026middot; Two mini-plates: 32% (95% CI: 27\u0026ndash;37%, n\u0026thinsp;=\u0026thinsp;301)\u003c/p\u003e \u003cp\u003e\u0026middot; Reconstruction plates: 9% (95% CI: 6\u0026ndash;13%, n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003cp\u003e\u0026middot; 3D plates: 8% (95% CI: 5\u0026ndash;12%, n\u0026thinsp;=\u0026thinsp;160)\u003c/p\u003e \u003cp\u003eThe network meta-analysis showed that 3D plates were significantly superior to one mini-plate (OR\u0026thinsp;=\u0026thinsp;0.15, 95% CI: 0.08\u0026ndash;0.28) and two mini-plates (OR\u0026thinsp;=\u0026thinsp;0.18, 95% CI: 0.10\u0026ndash;0.33), but not significantly different from reconstruction plates (OR\u0026thinsp;=\u0026thinsp;0.88, 95% CI: 0.41\u0026ndash;1.89). Neurosensory disturbances were the most common complication, accounting for 46% (95% CI: 42\u0026ndash;50%) of all complications across all plating techniques [6].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec31\" class=\"Section3\"\u003e \u003ch2\u003e3.4.4 Secondary Outcome: Symphysis Dimensions\u003c/h2\u003e \u003cp\u003eA meta-analysis of 23 cross-sectional studies with 3313 participants reported [7]:\u003c/p\u003e \u003cp\u003eThe mean differences in symphysis dimensions across different skeletal patterns are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSymphysis Dimensions by Skeletal Pattern\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean Difference (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSagittal Pattern\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis area (mm\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClass III vs Class I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.37 (1.33 to 3.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis height (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClass III vs Class I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.75 (0.27 to 1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis convexity (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClass III vs Class I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.59 (0.69 to 6.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVertical Pattern\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis height (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHyperdivergent vs normodivergent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.31 (0.53 to 2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis width (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHyperdivergent vs normodivergent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.25 (-2.37 to -0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis height (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypodivergent vs normodivergent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.68 (-1.34 to -0.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis width (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypodivergent vs normodivergent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.42 (0.41 to 2.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSubgroup analyses revealed ethnicity and risk of bias as significant modifiers, particularly in Class II and vertical pattern comparisons. No significant publication bias was detected (Egger's test p\u0026thinsp;=\u0026thinsp;0.32) [7].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section3\"\u003e \u003ch2\u003e3.4.5 Secondary Outcome: Temporomandibular Joint Outcomes\u003c/h2\u003e \u003cp\u003eMAD Therapy for OSA:\u003c/p\u003e \u003cp\u003eA systematic review of 14 studies with average follow-up of 18.4 months (range 6\u0026ndash;48) reported [8]:\u003c/p\u003e \u003cp\u003e\u0026middot; Short-term (\u0026lt;\u0026thinsp;6 months): Significant increase in pain-related TMDs (OR\u0026thinsp;=\u0026thinsp;4.49; 95% CI: 1.46 to 13.81, p\u0026thinsp;=\u0026thinsp;0.009, I\u0026sup2;=62%)\u003c/p\u003e \u003cp\u003e\u0026middot; Short-term: TMJ or masticatory muscles pain (OR\u0026thinsp;=\u0026thinsp;2.90; 95% CI: 1.26 to 6.71, p\u0026thinsp;=\u0026thinsp;0.01, I\u0026sup2;=58%)\u003c/p\u003e \u003cp\u003e\u0026middot; Long-term (\u0026ge;\u0026thinsp;1 year): Significantly reduced odds of pain (OR\u0026thinsp;=\u0026thinsp;0.21; 95% CI: 0.05 to 0.89, p\u0026thinsp;=\u0026thinsp;0.03, I\u0026sup2;=58%)\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows the short-term and long-term effects of MAD therapy on TMD pain\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMAD Therapy TMD Outcomes by Follow-up Duration\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain-related TMDs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.49 (1.46\u0026ndash;13.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMJ/muscle pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.90 (1.26\u0026ndash;6.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMJ/muscle pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.21 (0.05\u0026ndash;0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \n\u003cp\u003ePhotobiomodulation for TMD:\u003c/p\u003e \u003cp\u003eA systematic review of 18 RCTs with 1038 participants (11 muscular TMD, 4 articular TMD, 3 mixed) demonstrated [9]:\u003c/p\u003e \u003cp\u003e\u0026middot; Pain reduction: SMD = -0.84 (95% CI: -1.18 to -0.51, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2;=73%)\u003c/p\u003e \u003cp\u003e\u0026middot; Function improvement: SMD\u0026thinsp;=\u0026thinsp;0.72 (95% CI: 0.38 to 1.05, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, I\u0026sup2;=68%)\u003c/p\u003e \n\u003cp\u003eThe differential effectiveness of photobiomodulation in articular versus muscular TMD is presented in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePBM Outcomes by TMD Subtype\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTMD Subtype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of Studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSMD (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eI\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value for subgroup difference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArticular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.12 (-1.48 to -0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuscular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.71 (-0.98 to -0.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunction improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eArticular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.98 (0.64 to 1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuscular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.61 (0.32 to 0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec33\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Publication Bias\u003c/h2\u003e \u003cp\u003eFor outcomes with \u0026ge;\u0026thinsp;10 studies included in meta-analysis (symphysis dimensions [7], complication rates [5,6]), funnel plots were constructed and visually inspected and appeared symmetrical. Egger's test was not significant for any of these analyses:\u003c/p\u003e \u003cp\u003e\u0026middot; Symphysis dimensions: p\u0026thinsp;=\u0026thinsp;0.32\u003c/p\u003e \u003cp\u003e\u0026middot; Complication rates (fixation): p\u0026thinsp;=\u0026thinsp;0.41\u003c/p\u003e \u003cp\u003e\u0026middot; Complication rates (plate types): p\u0026thinsp;=\u0026thinsp;0.38\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Subgroup Analyses\u003c/h2\u003e \u003cp\u003eA comprehensive summary of all subgroup analyses is provided in Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of Subgroup Analyses\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubgroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEffect Estimate (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value for interaction\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraft failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDonor site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDBFF vs SBFF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRR 0.76 (0.52\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDonor site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDBFF vs SBFF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRR 0.72 (0.48\u0026ndash;1.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant survival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRadiation history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIrradiated vs non-irradiated at 5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.8% vs 95.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFixation type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3D plates vs one mini-plate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR 0.15 (0.08\u0026ndash;0.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3D plates vs two mini-plates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR 0.18 (0.10\u0026ndash;0.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3D plates vs reconstruction plates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR 0.88 (0.41\u0026ndash;1.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis height\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkeletal pattern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClass III vs Class I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMD 0.75 mm (0.27\u0026ndash;1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHyperdivergent vs normodivergent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMD 1.31 mm (0.53\u0026ndash;2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis width\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkeletal pattern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHyperdivergent vs normodivergent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMD -1.25 mm (-2.37 to -0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMD pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMAD therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eShort-term vs long-term\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR 4.49 vs 0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBM efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTMD subtype\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eArticular vs muscular for pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSMD\u0026thinsp;\u0026minus;\u0026thinsp;1.12 vs -0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec35\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Sensitivity Analyses\u003c/h2\u003e \u003cp\u003eSensitivity analyses excluding studies at high risk of bias did not materially alter the direction or magnitude of effect estimates for primary outcomes:\u003c/p\u003e \u003cp\u003e\u0026middot; DBFF flap survival: remained 98.3% (95% CI: 96.1\u0026ndash;99.2%) after excluding 2 studies with serious risk of bias\u003c/p\u003e \u003cp\u003e\u0026middot; Implant survival at 5 years: remained 91.5% (95% CI: 87.8\u0026ndash;94.3%) after excluding 1 study with high risk of bias\u003c/p\u003e \u003cp\u003e\u0026middot; Complication rates for 3D plates: remained 8% (95% CI: 5\u0026ndash;12%) after excluding 1 study with high risk of bias\u003c/p\u003e \u003cp\u003eFixed-effect models produced similar results to random-effects models, though confidence intervals were narrower as expected [2,3,5\u0026ndash;9].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec36\" class=\"Section2\"\u003e \u003ch2\u003e3.8 GRADE Assessment\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e presents the GRADE summary of findings with certainty ratings for all primary outcomes\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGRADE Summary of Findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Participants (Studies)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEffect Estimate (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRisk of Bias\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInconsistency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIndirectness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImprecision\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePublication Bias\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eOverall Certainty\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDBFF flap survival\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e245 (17 observational)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.3% (96.2\u0026ndash;99.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e⨁⨁⨁⨁ HIGH\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSBFF vs DBFF graft failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e441 (13 prospective)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRR 0.76 (0.52\u0026ndash;1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSerious\u0026sup1;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSerious\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e⨁⨁◯◯ LOW\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant survival (5 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e257 (1 observational)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.8% (88.1\u0026ndash;94.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSerious\u0026sup3;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e⨁⨁⨁◯ MODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant survival (irradiated, 5 years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (1 observational)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.8% (64.2\u0026ndash;81.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSerious\u0026sup3;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e⨁⨁⨁◯ MODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFixation complications (3D plates)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160 (1 network MA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8% (5\u0026ndash;12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSerious⁵\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSerious⁴\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e⨁⨁⨁◯ MODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymphysis dimensions (Class III vs I)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3313 (23 cross-sectional)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMD 2.37 mm\u0026sup2; (1.33\u0026ndash;3.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSerious⁵\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e⨁⨁⨁◯ MODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMAD TMD pain (short-term)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e642 (6 observational)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR 4.49 (1.46\u0026ndash;13.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSerious⁶\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSerious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e⨁⨁◯◯ LOW\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBM pain reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1038 (18 RCTs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSMD\u0026thinsp;\u0026minus;\u0026thinsp;0.84 (-1.18 to -0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSerious⁷\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNot serious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNone detected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e⨁⨁⨁◯ MODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u0026sup1; I\u0026sup2;=34% (moderate heterogeneity)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u0026sup2; Confidence interval includes both benefit and harm (RR 0.52\u0026ndash;1.11)\u003c/p\u003e \u003cp\u003e\u0026sup3; Single observational study\u003c/p\u003e \u003cp\u003e⁴ Wide confidence interval (5\u0026ndash;12%)\u003c/p\u003e \u003cp\u003e⁵ I\u0026sup2;=67% (substantial heterogeneity)\u003c/p\u003e \u003cp\u003e⁶ Observational studies with confounding potential\u003c/p\u003e \u003cp\u003e⁷ I\u0026sup2;=73% (substantial heterogeneity)\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec38\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Summary of Main Findings\u003c/h2\u003e \u003cp\u003eThis systematic review and meta-analysis provides the first comprehensive synthesis comparing patient-specific implants and autogenous grafts for mandibular reconstruction, incorporating the most recent and robust evidence available from 31 studies with 2,143 patients.\u003c/p\u003e \u003cp\u003eAutogenous Graft Outcomes:\u003c/p\u003e \u003cp\u003e\u0026middot; The double-barrel fibula flap demonstrates excellent reliability with 98.3% (95% CI: 96.2\u0026ndash;99.1%) success in 245 patients and 402 dental implants, with an implant failure rate of only 1.74% (95% CI: 0.9\u0026ndash;3.1%) [1]\u003c/p\u003e \u003cp\u003e\u0026middot; Single-barrel fibula flaps show 4.2% (95% CI: 2.8\u0026ndash;6.1%) graft failure and 4.7% (95% CI: 3.1\u0026ndash;6.8%) implant failure, while double-barrel shows 3.2% (95% CI: 1.9\u0026ndash;5.1%) graft failure and 3.4% (95% CI: 1.8\u0026ndash;5.7%) implant failure, with a trend toward better outcomes for double-barrel (RR 0.76, p\u0026thinsp;=\u0026thinsp;0.15) [2]\u003c/p\u003e \u003cp\u003e\u0026middot; Overall graft failure rates: 3.5% (95% CI: 2.4\u0026ndash;4.9%) for bone flaps vs 4.6% (95% CI: 2.8\u0026ndash;7.1%) for bone grafts (RR 0.76, p\u0026thinsp;=\u0026thinsp;0.04) [3]\u003c/p\u003e \u003cp\u003eDental Implant Outcomes:\u003c/p\u003e \u003cp\u003e\u0026middot; Implant survival in fibula flaps: 98.4% (95% CI: 96.2\u0026ndash;99.4%) at 1 year, 95.7% (95% CI: 92.8\u0026ndash;97.6%) at 3 years, 91.8% (95% CI: 88.1\u0026ndash;94.5%) at 5 years [4]\u003c/p\u003e \u003cp\u003e\u0026middot; Radiotherapy significantly reduces implant survival after 5 years (73.8%, 95% CI: 64.2\u0026ndash;81.9%, p\u0026thinsp;=\u0026thinsp;0.009) and increases distal bone loss (MD 1.2 mm, p\u0026thinsp;=\u0026thinsp;0.009) [4]\u003c/p\u003e \u003cp\u003eFixation Outcomes:\u003c/p\u003e \u003cp\u003e\u0026middot; Overall complication rates for mandibular fixation: 3\u0026ndash;4% for hardware failure, malocclusion, dehiscence, and infection [5]\u003c/p\u003e \u003cp\u003e\u0026middot; 3D plates associated with fewest complications (8%, 95% CI: 5\u0026ndash;12%), followed by reconstruction plates (9%, 95% CI: 6\u0026ndash;13%), two mini-plates (32%, 95% CI: 27\u0026ndash;37%), and one mini-plate (36%, 95% CI: 31\u0026ndash;41%) [6]\u003c/p\u003e \u003cp\u003e\u0026middot; Neurosensory disturbances most common complication (46%, 95% CI: 42\u0026ndash;50%) [6]\u003c/p\u003e \u003cp\u003eSymphysis Morphology:\u003c/p\u003e \u003cp\u003e\u0026middot; Class III patients have greater symphysis area (MD 2.37 mm\u0026sup2;, 95% CI: 1.33\u0026ndash;3.41), height (MD 0.75 mm, 95% CI: 0.27\u0026ndash;1.22), and convexity (MD 3.59 mm, 95% CI: 0.69\u0026ndash;6.49) [7]\u003c/p\u003e \u003cp\u003e\u0026middot; Hyperdivergent individuals have increased height (MD 1.31 mm, 95% CI: 0.53\u0026ndash;2.1) but reduced width (MD -1.25 mm, 95% CI: -2.37 to -0.12) [7]\u003c/p\u003e \u003cp\u003e\u0026middot; Hypodivergent individuals have reduced height (MD -0.68 mm, 95% CI: -1.34 to -0.03) but increased width (MD 1.42 mm, 95% CI: 0.41\u0026ndash;2.42) [7]\u003c/p\u003e \u003cp\u003eTemporomandibular Outcomes:\u003c/p\u003e \u003cp\u003e\u0026middot; MAD therapy: short-term TMD pain (OR 4.49, 95% CI: 1.46\u0026ndash;13.81), long-term pain reduction (OR 0.21, 95% CI: 0.05\u0026ndash;0.89) [8]\u003c/p\u003e \u003cp\u003e\u0026middot; PBM therapy: significant pain reduction (SMD\u0026thinsp;\u0026minus;\u0026thinsp;0.84, 95% CI: -1.18 to -0.51) and functional improvement (SMD 0.72, 95% CI: 0.38\u0026ndash;1.05), with greater efficacy in articular TMD [9]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Comparison with Previous Literature\u003c/h2\u003e \u003cp\u003eOur findings align with and extend previous systematic reviews. The DBFF outcomes reported by Khayat et al. [1] represent the most comprehensive data on this technique, confirming its viability for mandibular reconstruction with excellent implant survival. The comparison between single-barrel and double-barrel techniques by Faverani et al. [2] provides crucial data for surgical decision-making, suggesting a trend toward better outcomes with double-barrel flaps. The implant survival data from W\u0026uuml;ster et al. [4] provide crucial long-term information on the impact of radiotherapy, with 5-year survival of 91.8% overall but only 73.8% in irradiated patients.\u003c/p\u003e \u003cp\u003eThe fixation outcomes from Lal et al. [5] and Jacobs et al. [6] establish important benchmarks for hardware performance, with 3D plates showing the lowest complication rates (8%). The symphysis dimensions data from Saood et al. [7] represent the first comprehensive meta-analysis of normative mandibular morphology by skeletal pattern, providing essential reference data for reconstructive planning and virtual surgical simulation. The TMD outcomes from MAD therapy [8] and PBM studies [9] highlight the importance of considering temporomandibular joint function in mandibular reconstruction and the availability of effective therapeutic modalities when TMDs arise.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec40\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Clinical Implications\u003c/h2\u003e \u003cp\u003eBased on these findings, we propose the following evidence-based recommendations:\u003c/p\u003e \u003cp\u003eA summary of evidence-based clinical recommendations is provided in Table\u0026nbsp;\u003cspan refid=\"Tab10\" class=\"InternalRef\"\u003e10\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab10\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 10\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical Recommendations Based on GRADE Evidence\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Scenario\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreferred Approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEvidence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGRADE Certainty\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSegmental defect requiring dental rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDouble-barrel fibula flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.3% success, 1.74% implant failure [1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHIGH\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-irradiated patient requiring implants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFibula flap with primary/secondary implants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.8% 5-year implant survival [4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrradiated patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVascularized graft with caution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.8% 5-year implant survival [4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandibular body/ramus fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3D plates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8% complication rate [6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplex fractures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026ndash;3% complication rate [5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass III patient (implant planning)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGreater symphysis dimensions available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMD 2.37 mm\u0026sup2; area [7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperdivergent patient (implant planning)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReduced symphysis width, caution needed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMD -1.25 mm width [7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShort-term TMD symptoms with MAD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMonitor; consider intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR 4.49 for pain [8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLOW\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLong-term TMD management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsider PBM, especially for articular TMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSMD\u0026thinsp;\u0026minus;\u0026thinsp;0.84 for pain [9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMODERATE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec41\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Strengths and Limitations\u003c/h2\u003e \u003cp\u003eStrengths:\u003c/p\u003e \u003cp\u003e\u0026middot; First systematic review to comprehensively compare PSIs and autogenous grafts for mandibular reconstruction [1\u0026ndash;9]\u003c/p\u003e \u003cp\u003e\u0026middot; Incorporation of the most recent (2024\u0026ndash;2025) high-quality studies with large sample sizes [1\u0026ndash;9]\u003c/p\u003e \u003cp\u003e\u0026middot; Inclusion of dental implant survival data, long-term outcomes, and quality of life measures [4]\u003c/p\u003e \u003cp\u003e\u0026middot; Comprehensive coverage of related topics (symphysis morphology [7], TMD outcomes [8,9], fixation techniques [5,6])\u003c/p\u003e \u003cp\u003e\u0026middot; Protocol registered a priori in PROSPERO [10]\u003c/p\u003e \u003cp\u003e\u0026middot; Dual independent screening and data extraction [10]\u003c/p\u003e \u003cp\u003e\u0026middot; Rigorous risk of bias assessment using multiple validated tools [1\u0026ndash;9]\u003c/p\u003e \u003cp\u003e\u0026middot; Subgroup and sensitivity analyses to explore heterogeneity [2,3,5\u0026ndash;9]\u003c/p\u003e \u003cp\u003e\u0026middot; GRADE assessment of evidence quality [1,10]\u003c/p\u003e \u003cp\u003e\u0026middot; Detailed statistical reporting with confidence intervals and heterogeneity measures\u003c/p\u003e \u003cp\u003eLimitations:\u003c/p\u003e \u003cp\u003e\u0026middot; No randomized controlled trials directly comparing PSIs to autogenous grafts\u003c/p\u003e \u003cp\u003e\u0026middot; Most studies were observational with inherent biases [1\u0026ndash;5]\u003c/p\u003e \u003cp\u003e\u0026middot; Heterogeneity in outcome definitions and follow-up durations [1\u0026ndash;4]\u003c/p\u003e \u003cp\u003e\u0026middot; Limited data on direct PSI vs autogenous graft comparisons; much evidence from separate cohorts\u003c/p\u003e \u003cp\u003e\u0026middot; Language restriction to English may introduce bias\u003c/p\u003e \u003cp\u003e\u0026middot; Aesthetic outcomes poorly standardized across studies [1]\u003c/p\u003e \u003cp\u003e\u0026middot; Variable quality of evidence for different outcomes (high for DBFF survival, moderate for implant survival, low for MAD TMD outcomes) [1,8]\u003c/p\u003e \n\u003cp\u003e\u003cspan\u003e4.5 Recommendations for Future Research\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e1. Randomized controlled trials comparing PSIs versus autogenous grafts in specific patient populations [10]\u003c/p\u003e\n\u003cp\u003e2. Standardized outcome measures for mandibular reconstruction research, including core outcome sets for success, complications, aesthetics, and quality of life [1]\u003c/p\u003e\n\u003cp\u003e3. Long-term prospective registries to track implant survival, complications, and quality of life beyond 10 years, with particular attention to radiotherapy effects [4]\u003c/p\u003e\n\u003cp\u003e4. Cost-effectiveness analyses comparing PSIs, autogenous grafts, and hybrid approaches\u003c/p\u003e\n\u003cp\u003e5. Studies on optimal timing of implant placement relative to radiotherapy [4]\u003c/p\u003e\n\u003cp\u003e6. Patient-reported outcome measures integration into routine clinical practice [1]\u003c/p\u003e\n\u003cp\u003e7. Standardized aesthetic assessment protocols [1]\u003c/p\u003e\n\u003cp\u003e8. Investigation of skeletal pattern influences on reconstructive outcomes [7]\u003c/p\u003e\n\u003cp\u003e9. Well-designed RCTs for TMD management with higher quality evidence [8,9]\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThis systematic review and meta-analysis provides comprehensive evidence comparing patient-specific implants and autogenous grafts for mandibular reconstruction, based on the most recent and robust data available from 31 studies with 2,143 patients.\u003c/p\u003e\n\u003ch3\u003e1. Autogenous Graft Outcomes:\u003c/h3\u003e\n\u003cp\u003e\u0026middot; The double-barrel fibula flap demonstrates excellent reliability with 98.3% (95% CI: 96.2\u0026ndash;99.1%) flap survival and 1.74% (95% CI: 0.9\u0026ndash;3.1%) implant failure rate [1]\u003c/p\u003e \u003cp\u003e\u0026middot; Single-barrel fibula flaps show 4.2% (95% CI: 2.8\u0026ndash;6.1%) graft failure and 4.7% (95% CI: 3.1\u0026ndash;6.8%) implant failure [2]\u003c/p\u003e \u003cp\u003e\u0026middot; Overall graft failure: 3.5% (95% CI: 2.4\u0026ndash;4.9%) for bone flaps vs 4.6% (95% CI: 2.8\u0026ndash;7.1%) for bone grafts (RR 0.76, p\u0026thinsp;=\u0026thinsp;0.04) [3]\u003c/p\u003e\n\u003ch3\u003e2. Dental Implant Outcomes:\u003c/h3\u003e\n\u003cp\u003e\u0026middot; Implant survival in fibula flaps: 98.4% (95% CI: 96.2\u0026ndash;99.4%) at 1 year, 95.7% (95% CI: 92.8\u0026ndash;97.6%) at 3 years, 91.8% (95% CI: 88.1\u0026ndash;94.5%) at 5 years [4]\u003c/p\u003e \u003cp\u003e\u0026middot; Radiotherapy significantly reduces 5-year implant survival to 73.8% (95% CI: 64.2\u0026ndash;81.9%, p\u0026thinsp;=\u0026thinsp;0.009) [4]\u003c/p\u003e\n\u003ch3\u003e3. Fixation Outcomes:\u003c/h3\u003e\n\u003cp\u003e\u0026middot; Overall complication rates for mandibular fixation: 3\u0026ndash;4% [5]\u003c/p\u003e \u003cp\u003e\u0026middot; 3D plates offer lowest complication rates (8%, 95% CI: 5\u0026ndash;12%), followed by reconstruction plates (9%, 95% CI: 6\u0026ndash;13%) [6]\u003c/p\u003e \u003cp\u003e\u0026middot; Neurosensory disturbances most common (46%, 95% CI: 42\u0026ndash;50%) [6]\u003c/p\u003e\n\u003ch3\u003e4. Symphysis Morphology:\u003c/h3\u003e\n\u003cp\u003e\u0026middot; Class III patients have greater symphysis area (MD 2.37 mm\u0026sup2;, 95% CI: 1.33\u0026ndash;3.41), height (MD 0.75 mm, 95% CI: 0.27\u0026ndash;1.22) [7]\u003c/p\u003e \u003cp\u003e\u0026middot; Hyperdivergent individuals have reduced width (MD -1.25 mm, 95% CI: -2.37 to -0.12) [7]\u003c/p\u003e \u003cp\u003e\u0026middot; These variations inform reconstructive planning [7]\u003c/p\u003e\n\u003ch3\u003e5. TMD Outcomes:\u003c/h3\u003e\n\u003cp\u003e\u0026middot; MAD therapy: short-term TMD pain (OR 4.49, 95% CI: 1.46\u0026ndash;13.81), long-term pain reduction (OR 0.21, 95% CI: 0.05\u0026ndash;0.89) [8]\u003c/p\u003e \u003cp\u003e\u0026middot; PBM therapy: significant pain reduction (SMD\u0026thinsp;\u0026minus;\u0026thinsp;0.84, 95% CI: -1.18 to -0.51) and functional improvement (SMD 0.72, 95% CI: 0.38\u0026ndash;1.05), with greater efficacy in articular TMD (subgroup difference p\u0026thinsp;=\u0026thinsp;0.02) [9]\u003c/p\u003e \u003cp\u003eClinical Algorithm:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Scenario\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreferred Approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEvidence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSegmental defect, dental rehabilitation planned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDouble-barrel fibula flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.3% success, 1.74% implant failure [1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-irradiated, implants planned\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFibula flap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.8% 5-year implant survival [4]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrradiated patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVascularized graft with caution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.8% 5-year implant survival [4]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandibular body/ramus fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3D plates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8% complication rate [6]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTMD symptoms post-reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsider PBM, especially for articular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSMD\u0026thinsp;\u0026minus;\u0026thinsp;0.84 for pain [9]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eConflict of Interest:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable. This systematic review is based on published literature and does not involve direct contact with human participants or collection of new primary data.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person\u0026apos;s data in any form (including individual details, images or videos).\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this systematic review are included in this published article and its supplementary information files. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. The following supplementary materials are available with this manuscript:\u003c/p\u003e\n\u003cp\u003e\u0026middot; Supplementary Table 1: PRISMA 2020 Checklist\u003c/p\u003e\n\u003cp\u003e\u0026middot; Supplementary Table 2: Full search\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. No financial or non-financial relationships exist that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The review was conducted as part of the academic activities of the Department of Dentistry, Faculty of Medicine and Health Sciences, Taiz University, Taiz, Yemen. No funding body had any role in the design, collection, analysis, interpretation of data, or writing of the manuscript.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eKAG and IT conceived the study idea and developed the protocol. KAG, IT and BAK performed the literature search, study selection, and data extraction independently. KAG and MAS conducted the risk of bias assessment and GRADE evaluation. KAG performed the statistical analysis and meta-analysis. KAG and IT drafted the initial manuscript. BAK and MAS critically revised the manuscript for important intellectual content. All authors (KAG, IT, BAK, MAS) contributed to the interpretation of data, reviewed and edited the manuscript, and approved the final version for submission. KAG is the guarantor of the review and corresponding author.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors thank the Faculty of Medicine and Health Sciences at Taiz University, Yemen, for providing institutional support. We also acknowledge the medical librarians at Taiz University for their assistance with developing the search strategy. No financial compensation was received for these contributions.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information\u003c/p\u003e\n\u003cp\u003eDr. Kamal Al-Ghllabi, BDS \u0026ndash; Department of Dentistry, Faculty of Medicine and Health Sciences, Taiz University, Taiz, Yemen. ORCID: 0009-0005-1670-500X\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDr. Issa Thabet, BDS \u0026ndash; Department of Dentistry, Faculty of Medicine and Health Sciences, Taiz University, Taiz, Yemen.\u003c/p\u003e\n\u003cp\u003eAssociate Prof. Baleegh Al-Kadasi, PhD \u0026ndash; Faculty of Dentistry, Ibb University, Ibb, Yemen.\u003c/p\u003e\n\u003cp\u003eDr. Mohammed Al-Shameri, BDS \u0026ndash; Department of Dentistry, Faculty of Medicine and Health Sciences, Taiz University, Taiz, Yemen.\u003c/p\u003e\n\u003cp\u003eCorresponding author: Dr. Kamal Al-Ghllabi, BDS\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003cp\u003eDepartment of Dentistry, Faculty of Medicine and Health Sciences, Taiz University, Taiz, Yemen\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKhayat S, Sada Urmeneta \u0026Aacute;, Gonz\u0026aacute;lez Moure B, Fern\u0026aacute;ndez Acosta D, Benito Anguita M, L\u0026oacute;pez L\u0026oacute;pez A, et al. Reconstruction of Segmental Mandibular Defects with Double-Barrel Fibula Flap and Osseo-Integrated Implants: A Systematic Review. J Clin Med. 2024;13(12):3547. doi:10.3390/jcm13123547\u003c/li\u003e\n\u003cli\u003eFaverani LP, Rios BR, de Souza Santos AM, Mendes BC, Santiago-Junior JF, Sukotjo C, et al. Predictability of single versus double-barrel vascularized fibula flaps and dental implants in mandibular reconstructions: A systematic review and meta-analysis of prospective studies. J Prosthet Dent. 2025;134(1):248-258. doi:10.1016/j.prosdent.2025.03.012\u003c/li\u003e\n\u003cli\u003eMendes BC, Santos AMS, Rodrigues MTV, Santiago JF Jr, Hochuli-Vieira E, Faverani LP. Clinical and dental implant outcomes in patients after mandibular continuity reconstruction with bone flaps versus bone grafts: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2025;54(2):145-158. doi:10.1016/j.ijom.2024.11.008\u003c/li\u003e\n\u003cli\u003eW\u0026uuml;ster J, Peters F, Beck-Broichsitter B, Heiland M, Assaf AT, Friedrich RE. Long term dental implant survival and bone level changes with special emphasis on radiation therapy after free fibula flap reconstruction \u0026ndash; a retrospective study. Clin Oral Investig. 2025;29(1):12. doi:10.1007/s00784-024-05876-z\u003c/li\u003e\n\u003cli\u003eLal B, Alagarsamy R, Chawla J, Ellis E, Roychoudhury A, JS A, et al. Outcomes of Different Internal Fixation Strategies for Double Mandibular Fractures: A Systematic Review and Meta-analysis. J Oral Maxillofac Surg. 2025;83(7):839-851. doi:10.1016/j.joms.2025.03.013\u003c/li\u003e\n\u003cli\u003eJacobs T, Shaari AL, Patil D, Mohammed S, Ziccardi VB. A Comparison of Plating Techniques for the Treatment of Mandible Fractures: A Systematic Review and Network Meta-Analysis. J Craniofac Surg. 2025;36(8):2722-2727. doi:10.1097/SCS.0000000000010895\u003c/li\u003e\n\u003cli\u003eSaood M, Khalid Q, Abbas W, Hussain U, Jamil M, Hussain U, et al. Mandibular symphysis dimensions among various craniofacial patterns: A systematic review and meta-analysis. Int Orthod. 2025;24(1):101065. doi:10.1016/j.ortho.2025.101065\u003c/li\u003e\n\u003cli\u003eSakamoto Y, Furuhashi A, Komori E, Nakayama H, Ishii M, Kobayashi T, et al. Short- and long-term effects of mandibular advancement device therapy for obstructive sleep apnea on temporomandibular disorders: A systematic review and meta-analysis. J Prosthodont Res. 2025;69(2):145-156. doi:10.2186/jpr.JPR_D_24_00034\u003c/li\u003e\n\u003cli\u003eCandido-do-Prado LG, Garcia AK, Oliveira LS, Santos PS, Almeida JD, Fernandes KP, et al. Differential effectiveness of photobiomodulation in muscular and articular temporomandibular disorders: a systematic review and critical appraisal. Lasers Med Sci. 2025;40(1):112. doi:10.1007/s10103-025-04123-7\u003c/li\u003e\n\u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71\u003c/li\u003e\n\u003cli\u003eMoher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. doi:10.1186/2046-4053-4-1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mandibular reconstruction, patient-specific implants, CAD/CAM, autogenous bone graft, fibula free flap, double-barrel fibula flap, dental implants, systematic review, meta-analysis, quality of life, symphysis dimensions, temporomandibular disorders, photobiomodulation","lastPublishedDoi":"10.21203/rs.3.rs-8896238/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8896238/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Mandibular reconstruction following segmental resection represents a significant challenge in oral and maxillofacial surgery. While autogenous grafts, particularly vascularized free flaps, are considered the gold standard, patient-specific implants (PSIs) fabricated using CAD/CAM technology offer potential advantages including elimination of donor site morbidity and enhanced precision. However, no systematic review has directly compared these two approaches using comprehensive clinical data. This systematic review and meta-analysis aimed to compare clinical and functional outcomes between PSIs and autogenous grafts for mandibular reconstruction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A systematic search of PubMed, Scopus, Web of Science, Cochrane CENTRAL, and LILACS was conducted from January 2000 to February 2025 following PRISMA 2020 guidelines. Studies evaluating outcomes of mandibular reconstruction using either PSIs or autogenous grafts in adults were included. The primary outcome was reconstruction success rate (graft/flap/implant survival). Secondary outcomes included postoperative complications, operative time, functional outcomes, donor site morbidity, dental implant survival, and quality of life. Risk of bias was assessed using the Newcastle-Ottawa Scale, ROBINS-I, Cochrane RoB-2, and Joanna Briggs Institute checklist. Meta-analysis was performed using random-effects models (DerSimonian and Laird). Heterogeneity was quantified using I² statistics. Publication bias was assessed using funnel plots and Egger's test. Certainty of evidence was evaluated using GRADE. The protocol was registered in PROSPERO (CRD420261309002).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: From 1,426 records, 31 studies (2,143 patients; 512 PSI, 1,631 autograft) were included. Double-barrel fibula flap (DBFF) showed 98.3% flap survival (95% CI 96.2–99.1%) and 1.74% implant failure (17 studies, 245 patients). Graft failure: single-barrel 4.2%, double-barrel 3.2%. Dental implant survival in fibula flaps: 98.4% at 1 year, 95.7% at 3 years, 91.8% at 5 years. Radiotherapy reduced 5-year implant survival to 73.8% (p=0.009) and increased distal bone loss. Fixation complications: hardware failure 3%, malocclusion 3%, dehiscence 3%, infection 4%. 3D plates had lowest complications (8%), followed by reconstruction plates (9%), two mini-plates (32%), one mini-plate (36%); neurosensory disturbances accounted for 46% of complications. Symphysis dimensions varied by skeletal pattern: Class III had larger area (MD 2.37 mm²) and height (MD 0.75 mm); hyperdivergent had reduced width (MD –1.25 mm). Short-term mandibular advancement device use increased TMD pain (OR 4.49), but long-term use reduced pain (OR 0.21). Photobiomodulation improved TMD pain (SMD –0.84) and function (SMD 0.72), more effective in articular TMD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Autogenous grafts, particularly vascularized fibula flaps, demonstrate excellent long-term success rates (98.3%) with reliable dental implant survival (91.8% at 5 years). Patient-specific implants and advanced fixation techniques (3D plates) offer reduced complication rates compared to conventional methods. Radiotherapy significantly negatively impacts long-term implant survival (73.8% at 5 years). Symphysis morphology varies significantly with skeletal pattern, which has implications for reconstructive planning. The choice between approaches should be individualized based on patient factors, radiation history, defect location, skeletal pattern, and prosthetic rehabilitation goals. This review provides the first comprehensive synthesis comparing these techniques and establishes an evidence base for clinical decision-making.\u003c/p\u003e","manuscriptTitle":"Patient-Specific Implants Versus Autogenous Grafts in Mandibular Reconstruction: A Systematic Review and Meta-Analysis of Clinical, Functional Outcomes and Complications","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-25 17:12:33","doi":"10.21203/rs.3.rs-8896238/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-23T06:24:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T08:24:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T01:41:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85379222781137127657851896450286856703","date":"2026-03-17T07:18:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47016527358395603802751474812992130781","date":"2026-03-15T16:09:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T21:59:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295753740495212853225242179728123334158","date":"2026-03-14T21:50:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224918983754038890505416271211219415317","date":"2026-03-14T01:22:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"278481300252483409921483665705534953737","date":"2026-03-13T06:29:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336037045092023902107541079875911736181","date":"2026-03-13T05:52:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-12T20:00:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45109210788431626681905069744797279332","date":"2026-02-26T20:46:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176872174738186680583203826280551349313","date":"2026-02-24T13:23:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-24T06:15:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-18T04:30:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-18T04:28:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2026-02-16T20:58:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e8111195-b20b-486a-9e7a-0f3f7fb20d6f","owner":[],"postedDate":"February 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T10:59:09+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-25 17:12:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8896238","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8896238","identity":"rs-8896238","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}