Bone remodeling of the modified vascularized free iliac flap in jaw reconstruction

Bone remodeling of the modified vascularized free iliac flap in jaw reconstruction | 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 Research Article Bone remodeling of the modified vascularized free iliac flap in jaw reconstruction Ze-Zhao Liu, Wei Wang, Zheng-Dong Lu, Hou-Ji Peng, Jie Zhang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6746980/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Objective: This study investigates the postoperative bone remodeling patterns of the iliacbone after jaw reconstruction with the modified vascularized free iliac flap, which preserves the lateral cortical bone. Methods: Patients undergoing jawbone reconstruction with the modified vascularized free iliac bone flap between January 2022 and February 2023 were recruited. Maxillofacial spiral CT scans were collected at 1 week, 6 months, and 1 year postoperatively. The nascent cortical bone thickness, total bone thickness, and cancellous bone density of the iliac bone flap were measured at three specified planes on the spiral CT images. Results: Seven patients were recruited for bone remodeling analysis. Cortical bone regeneration was observed at the iliac bone in all patients. At 1 year postoperatively, the mean cortical bone thickening was 1.18 mm, 1.17 mm, and 1.01 mm at the three measurement planes, respectively. Significant increases were noted in the overall thickness of the iliac bone and the cancellous bone density were reduced significantly at 6 months compared to 1 week postoperatively. From 6 months to 1 year postoperatively, there was a slight increase in cortical bone thickness and a further decrease in cancellous bone density. Conclusion: The modified vascularized free iliac flap shows gradual increases in cortical bone thickness and total iliac bone thickness, along with a gradual decrease in cancellous bone density. The bone remodeling is more active in the first 6 months after surgery. The modified vascularized free iliac flap represents a viable alternative for jaw reconstruction. Clinical trial number: not applicable. Jaw reconstruction Vascularized free iliac flap Cortical bone Bone remodeling Figures Figure 1 Figure 2 Introduction The maxilla and mandible constitute vital bony components within the maxillofacial region, integral to various anatomical structures and essential physiological functions such as mastication, swallowing, speech, and respiration[ 1 ]. To address maxillofacial defects arising from tumors, trauma, or surgical interventions, vascularized free flaps represent the predominant restorative approach, offering superior restoration of both form and function. Several types of vascularized free flaps have proven effective in maxillofacial reconstruction, with the vascularized free fibula and iliac flaps being the most frequently utilized[ 2 – 5 ]. The free fibula flap offers advantages including larger vessel diameters, facile multi-segmental osteotomy, and contouring capabilities, with low donor-site complications[ 6 , 7 ]. However, its limited soft-tissue volume may prove inadequate for defect filling. Moreover, the width of the fibula typically falls short of that required for jawbone reconstruction, potentially necessitating additional surgical intervention for subsequent implantation. Conversely, the iliac flap capitalizes on its naturally curved iliac crest, which resembles the physiological curvature of the mandible, and offers sufficient bone height and thickness conducive to implant integration[ 3 , 8 ]. Nevertheless, challenges associated with the iliac flap include limited donor bone length, narrow vascular pedicle, and higher incidence of donor-site complications. Modification of the iliac flap, preserving the lateral cortical bone, and utilizing a rotary deep iliac artery to carry the medial cortical bone may reduce complications associated with vascularized free iliac flaps. Taylor et al.[ 9 ] applied a sagittal split iliac flap in a 13-year-old patient with hemifacial microsomia to preserve the normal contour and donor site development. David et al.[ 10 ] reported the use of the "split iliac flap" in 5 patients with various diagnoses and concluded that the split ilium is not too bulky. This modified iliac flap offers potential advantages over conventional techniques: first, preserving the lateral cortical bone to minimize donor site damage and complications; and second, allowing more precise control over the bone thickness of the harvested flap for improved restoration of craniofacial aesthetics. With the advancement of computer-assisted surgery (CAS), reconstructive procedures have benefited from enhanced accuracy and predictability[ 11 ], and facilitates a more precise determination of iliac bone flap thickness required for maxillofacial reconstruction. Additionally, several studies have demonstrated varying degrees of bone resorption following vascularized free bone grafting, which may adversely affect the subsequent placement of dental implants[ 12 , 13 ]. It is noteworthy that modified vascularized free iliac flap shows noticeable new cortical bone formation on the split side of the iliac bone flap. Currently, there are no reports on bone remodeling outcomes following the use of modified vascularized free iliac flaps for jaw reconstructions. In this prospective study, we longitudinally observed and measured bone remodeling of the iliac bone flap after jaw reconstruction with modified vascularized free iliac flap and investigated factors that may influence bone remodeling. Materials and Methods Study population The study protocol was conducted in accordance with the Declaration of Helsinki. Approval was obtained from the Institutional Review Board of the Peking University School of Stomatology (approval number: PKUSSIRB-202171211). This prospective study was conducted from January 2022 to February 2023 at the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, including patients with benign or malignant tumors of the maxillofacial region who underwent mandibular or maxillary reconstruction using modified vascularized iliac bone flaps. Preoperative counseling was provided to patients who provided informed consent by signing the consent forms. The inclusion criteria were as follows: 1) age between 18 and 80 years, tumors involving the soft and hard tissues of the oral and maxillofacial region requiring jaw resection, 2) periosteum removal during surgery, 3) jaw reconstruction using modified vascularized iliac bone flaps, and 4) absence of significant surgical contraindications. Patients meeting any of the following conditions were excluded: 1) postoperative spiral computed tomography (CT) images showing bilateral cortical bone in the iliac flap, which affected measurements of new cortical bone formation; 2) patients who underwent flap replacement postoperatively due to vascular compromise or other factors; and 3) interference with measurement caused by titanium plate and screw artifacts on postoperative CT images. Surgical procedure All patients underwent preoperative maxillofacial CT scans (field of view, 20 cm; pitch, 1.0; slice thickness, 1.25 mm; 140–160 mA, pixel density, 512 × 512), and virtual surgical planning (VSP) was generated using ProPlan CMF 3.0 software (Materialise, Leuven, Belgium). Mirror models were used to simulate jaw reconstruction and to preliminarily determine the required iliac bone flap thickness (Fig. 1 . a). Surgical guides and jaw reconstruction models were designed using the Mimics Medical software (version 21.0; Materialize, Leuven, Belgium). During the surgery, the donor site on one side of the buttock was padded. A deep circumflex iliac artery perforator myofascial flap was prepared intraoperatively, involving the dissection of the internal oblique, transversus abdominis, and rectus abdominis muscles. The deep circumflex iliac artery was dissected in reverse at the medial aspect of the anterior superior iliac spine with preservation of the lateral cutaneous nerve of the thigh and transection of the iliacus muscle. The lateral periosteum of the iliac crest was stripped to expose the outer bone and a bone-cutting guide was placed and fixed. The iliac crest was cut based on the cutting guide, preserving a 3–5 mm outer cortical bone plate, and longitudinally split (Fig. 1 . b). The cortical bone was cut at the inner lower edge (Fig. 1 .c) to obtain the required iliac bone segment (Fig. 1 . d), with a vascularized deep circumflex iliac artery iliac flap incorporating the inner cortical bone (Fig. 1 . e). Pre-bent titanium plates were used with three-dimensional (3D) printed jaw reconstruction models to assist jaw reconstruction (Fig. 1 . f). Imaging analysis Postoperative follow-up was scheduled at 1 week, 6 months, and 1 year, with maxillofacial spiral CT imaging performed at the Peking University School and Hospital of Stomatology. Observations and measurements of spiral CT images were conducted using the PACS archiving and communication system at the Peking University School and Hospital of Stomatology. The iliac flap was examined in the bone window (800 Hounsfield units (HU)). The viewing axis was adjusted so that one axis was parallel to the long axis of the flap and another axis intersected perpendicularly through the iliac flap. After adjusting the viewing axis, horizontal planes were marked in the sagittal window at distances of 5 and 10 mm from the iliac crest and 5 mm from the distal end of the iliac flap. These planes represent the postoperative bone reconstruction at the levels of the alveolar ridge (Ar level), root end of the implant (Ri level), and end of the iliac flap (Ei level). Measurements of CT images were performed 1 week, 6 months, and 1 year postoperatively (Figs. 1 . a, d, g). Cortical bone thickness was calculated by dividing the area by the length. The "freehand ROI" tool of the software was used to meticulously outline the area of cortical bone, and the "line" tool was used to measure the observable length of cortical bone. In cases where titanium screws were present in the measurement plane, the cortical bone thickness was measured, excluding the titanium screw portions. Cortical bone thickness was measured 1 week, 6 months, and 1 year postoperatively (Figs. 1 . b, e, h). The overall thickness of the iliac flap was measured as follows: using the "line" tool, the length of the iliac flap was measured, and the flap was divided into four equal parts based on total length. The thickness of the flap was measured at three points along these division lines, and the average value represented the thickness of the iliac flap at that plane. Cancellous bone density was quantitatively evaluated using the Hounsfield units. On the observation plane, using the "ellipse" tool, three circles with an area of approximately 4 mm² were outlined at the midpoint of each division line. If a circle was close to the image of the titanium plates or screws, it was positioned at least 5 mm away from them. The average spiral CT value represented the cancellous bone density at the measurement plane. Cortical bone thickness and overall bone flap thickness were measured 1 week, 6 months, and 1 year postoperatively (Figs. 2 .c, f, i). All measurements were independently conducted by three researchers and the average of their measurements was taken as the final measurement result. Statistical Analysis Statistical analyses were performed using IBM SPSS Statistics (version 20.0; IBM Corp., Armonk, NY, USA). Intra-class correlation coefficients (ICC) were used to assess inter-observer reliability, with ICC more than 0.8 indicating good consistency. Data are presented as the mean ± standard deviation (SD). The influencing factors included tumor type, tumor location, type of titanium fixation plate, postoperative complications, postoperative radiotherapy, postoperative chemotherapy, and systemic medications. First, Levene's test was used to assess the homogeneity of variances. Based on the results, independent sample t-tests or Kruskal-Wallis tests were used to analyze the impact of these factors on bone reconstruction. Statistical significance was set at p < 0.05. Results The clinical characteristics of the patients are summarized in Table 1 . From January 2022 to February 2023, 7 patients who underwent modified vascularized free iliac flap reconstruction for mandibular or maxillary defects were recruited, and all surgeries were successful. Due to COVID-19, some patients did not undergo postoperative spiral CT imaging at the 6-month follow-up. The average age of the seven patients was 46.2 years (SD = 9.3), comprising two males and five females. The majority of the cases involved malignant tumors (n = 6). Among these cases, three patients had lesions in the maxilla, whereas the remaining four had lesions in the mandible. Two patients regularly took antihypertensive drugs owing to hypertension. Following surgery, three patients received additional treatment. Postoperative complications included one patient who developed surgical site infection. Table 1 Clinical characteristics of the patients Case Sex Age (years) The lesion site Pathology Bone flap size(cm) Number of bone segments Internal fixation material Further treatment Systemic medication Complication Outcome 1 F 55 Mandible *SCC 8×3 2 Reconstruction plate Irbesartan tablet Alive 2 F 47 Maxilla *SCC 8×2.5 3 Mini-plate×2 Radiotherapy and Chemotherapeutic Amlodipine besylate tablet Alive 3 F 59 Mandible Malignant sarcoma 6×4 2 Reconstruction plate×2 Radiotherapy Alive 4 M 32 Maxilla *SCC 6×3 1 Mini-plate×2 Alive 5 F 36 Mandible Ameloblastic Fibrosarcoma 7×3.5 2 Reconstruction plate and Mini-plate Radiotherapy and Chemotherapeutic Alive 6 F 52 Maxilla *SCC 5×2 1 Mini-plate×2 Alive 7 M 42 Mandible Adamantoblastoma 7×3 2 Reconstruction plate×2 Infection Alive Mean 46.24 SD 9.25 * Squamous cell carcinoma The ICCs for the cortical bone thickness, overall bone graft thickness, and cancellous bone density measured by the three researchers were 0.889, 0.972, and 0.958, respectively, indicating good consistency. The postoperative changes in cortical bone thickness are shown in Table 2 . New cortical bone formation was observed on the split-side in all patients one year postoperatively. The cortical bone thickness was 0 mm at one week postoperatively and averaged 1.18 mm (Ar level), 1.18 mm (Ri level), and 1.01 mm (Ei level) at 1 year after surgery. Among the seven patients, three underwent spiral CT six months postoperatively. In the Ri level in these patients, cortical bone thickness increased by 1.03 mm in the first months and by 0.19 mm in the subsequent six months; corresponding values were 0.79 mm and 0.28 mm in the Ri level, and 0.90 mm and 0.09 mm in the Ei level. Table 2 Postoperative changes in cortical bone thickness Case Ar level Ri level Ei level 1 W 6 M 1 Y 1 W 6 M 1 Y 1 W 6 M 1 Y 1 0 — 1.10 0 — 1.18 0 — 1.21 2 0 — 1.08 0 — 1.30 0 — 1.30 3 0 — 0.86 0 — 0.67 0 — 0 4 0 — 1.63 0 — 1.85 0 — 1.58 5 0 0.97 1.13 0 0.43 1.11 0 0.74 1.11 6 0 1.10 1.30 0 1.30 1.21 0 1.22 1.18 7 — — — 0 0.64 0.90 0 0.73 0.67 Mean 0 1.03 1.18 0 0.79 1.18 0 0.90 1.01 SD 0 0.07 0.24 0 0.37 0.34 0 0.23 0.48 Overall iliac bone flap thickness increased by 0.41 mm (Ar level), 0.96 mm (Ri level), and 1.01 mm (Ei level) at one year compared to 1 week postoperatively, with growth rates of 6.4%, 13.8%, and 12.2%, respectively. The relevant detailed data are presented in Table 3 . Table 3 Postoperative changes in total thickness of iliac crest flap Case Ar level Ri level Ei level 1 W 6 M 1 Y 1 W 6 M 1 Y 1 W 6 M 1 Y 1 7.40 — 9.28 7.13 — 9.51 5.72 — 6.46 2 5.17 — 5.89 4.89 — 6.11 4.89 — 6.11 3 9.15 — 7.79 8.22 — 8.35 7.13 — 7.00 4 9.94 — 10.28 9.70 — 10.60 4.93 — 5.43 5 6.24 6.64 6.51 4.50 4.70 4.90 4.37 4.44 4.90 6 10.06 10.41 10.66 9.25 10.47 10.80 9.16 10.46 10.65 7 — — — 7.95 8.08 8.08 7.22 7.16 8.00 Mean 7.99 8.53 8.40 7.38 7.75 8.34 6.20 7.35 6.94 SD 1.86 1.88 1.81 1.87 2.37 2.05 1.59 2.46 1.78 Table 4 illustrates the postoperative changes in the cancellous bone density. Compared with one week postoperatively, cancellous bone density decreased by 59.9% (Ar level), 57.4% (Ri level), and 44.1% (Ei level) at one year. Table 4 Postoperative changes in cancellous bone density Case Ar level Ri level Ei level 1 W 6 M 1 Y 1 W 6 M 1 Y 1 W 6 M 1 Y 1 226.4 — 50.33 265.9 — 59.3 223.3 — 151.6 2 292.4 — 219.4 343.2 — 265 343.2 — 271.7 3 440.3 — 229.6 94.3 — 88.6 279.8 — 144.7 4 279.0 — 71.9 256.0 — 44.1 292.3 — 92.1 5 272.4 243.2 109.3 250.9 214.8 153.4 228.9 231.0 166.8 6 279.1 50.1 37.1 284.0 83.7 45.7 291.6 103.9 69.4 7 — — — 180.9 99.4 57.1 151.6 166.0 116.9 Mean 298.3 146.6 119.6 239.3 132.6 101.9 258.7 167.0 144.7 SD 66.8 96.5 77.5 74.0 58.4 75.3 57.8 51.90 60.8 The factors influencing bone remodeling are shown in Table 5 , which indicates that factors such as lesion site, pathological type, fixation materials, medication history, and complications did not significantly affect bone remodeling. Table 5 Factors influencing changes in cortical bone thickness and bone graft thickness Factors Number Cortical bone thickness (mm), p value Total thickness (mm), p value Subsite Mandibular body 3 1.06 ± 0.15 0.76 0.98 ± 1.25 0.45 Ascending ramus 1 0.67 0.15 Maxilla 3 1.45 ± 0.35 1.25 ± 0.33 Pathology Malignant 6 1.22 ± 0.37 0.57 1.12 ± 0.82 0.28 Benign 1 1.17 ± 0.98 0.98 ± 0.83 Internal fixation material Reconstruction plate 1 1.187 0.14 2.41 0.16 Mini-plate×2 3 1.45 ± 0.35 1.25 ± 0.33 Reconstruction plate×2 2 1.01 ± 0.15 0.27 ± 0.19 Reconstruction plate and Mini-plate 1 0.67 0.15 Systemic medication Irbesartan 1 1.18 0.59 2.41 0.24 Amlodipine besylate tablet 1 1.3 1.31 None 5 1.14 ± 0.44 0.63 ± 0.60 Further treatment Radiotherapy 1 0.67 0.58 0.15 0.32 Radiotherapy and Chemotherapeutic 2 1.21 ± 0.13 0.86 ± 0.64 None 4 1.29 ± 0.40 1.24 ± 0.97 Complication Infection 1 0.90 0.28 0.13 0.57 None 6 1.22 ± 0.40 1.12 ± 0.82 Discussion This study reports a modified vascularized free iliac bone flap for jaw reconstruction, which involves sagittal splitting of the iliac crest to preserve the lateral bone and muscle attachments, thereby reducing surgical trauma and complications in the donor area. Seven patients underwent a successful jaw defect repair using the modified flap technique. Spiral CT images at one week postoperatively revealed absence of cortical bone on one side of the modified vascularized iliac bone flap, with noticeable cortical bone regeneration observed at one year postoperatively. At six months post-operation, the cortical bone thickness increased by 1.03 mm, 0.79 mm, and 0.90 mm at the Ar, Ri, and Ei levels, respectively. Continued cortical thickening was noted during 6 months and 1 year postoperatively, with increases of 0.19 mm, 0.28 mm, and 0.09 mm at the same levels. These findings indicate that cortical bone thickening primarily occurs within the first six months post-operation, which is consistent with current research[ 14 ]. Previous studies have reported varying degrees of absorption following vascularized free-flap mandibular or maxillary reconstruction. Kang et al.[ 13 ] reported cortical bone loss rates of 21%, 17%, 10%, and 31% at one year post-operation for the lateral, medial, superior, and inferior aspects of vascularized fibular flaps, respectively, while Chen et al.[ 15 ] found a 9.1% decrease in total iliac bone thickness at one year post-operation. Similar results have been reported by Shokri et al.[ 16 ]. This study is the first to document an increasing trend in the bone flap thickness after jaw defect repair using a vascularized free bone flap. The newly formed cortical bone contributes to an overall increase in bone flap thickness, following a pattern similar to cortical bone thickness change. It is noteworthy that the total iliac bone thickness increase was lower than the increase in cortical bone areas, indicating concurrent bone absorption elsewhere following modified iliac bone flap surgery. Regarding cancellous bone density changes, the results align with previous literature[ 17 – 19 ], showing a declining trend with reductions of 84.9%, 77.7%, and 80.4% within six months relative to one year, similar to the findings of Chen et al.[ 15 ]. Cancellous bone density further declined in the second six months post-operation. Measurements at the three selected levels conformed to the aforementioned patterns of bone remodeling. Considering these patterns comprehensively, the initial six months post-modified iliac bone flap surgery exhibited active bone remodeling. By six months, cortical bone thickness and overall flap thickness stabilize, reaching 0.79 mm and 7.75 mm at the Ri level, respectively. Meanwhile, cancellous bone density continues to decline, underscoring the optimal timing for implant surgery on the modified vascularized free iliac bone flap at six months postoperatively to mitigate further density loss that could impact implant outcomes. While previous discussion noted that cortical bone thickness increases more than total iliac bone thickness, Case 1 shows increases in iliac bone flap thickness at Ar and Ri levels exceeding cortical bone increases, contrary to the general trend. This may be related to the daily use of irbesartan for cardiovascular disease in Case 1. Cheng et al.[ 20 ] demonstrated that irbesartan has the potential to reduce reactive oxygen species and inhibit advanced glycation end-product formation in rats, thus reducing bone absorption. Liu et al.[ 21 ] demonstrated that irbesartan partially altered bone remodeling and enhanced bone quality, primarily affecting trabecular bone. In addition, Case 3 exhibited significantly lower increases in cortical bone and bone flap thickness compared to other patients, with a decreasing trend in bone flap thickness at the crest of the alveolar ridge, which we attributed to the method of internal fixation. This case utilized a dual-layer reconstruction plate for fixation, where the oversized titanium plate volume may have induced stress shielding at the site, thereby affecting the bone remodeling processes[ 22 , 23 ]. Xie et al. [ 24 ] found that larger mini-titanium plates may correlate with increased bone absorption following condylar fractures compared with micro-titanium plates. Similarly, Case 7, also fixed with bilateral reconstruction plates, showed lower cortical bone formation and increased bone flap thickness. However, in addition to the fixation materials, case 7 also experienced post-operative site infection, which likely influenced the bone remodeling process[ 25 ]. Statistical analysis of the factors affecting bone remodeling is presented in Table 5 . The reconstruction site had no significant impact on bone remodeling, which is consistent with the findings of Hölzle et al.[ 26 ] and Disa et al.[ 27 ]. Factors such as tumor type, type of internal fixation titanium plates, post-operative complications, radiotherapy, chemotherapy, and systemic medications showed no apparent association with bone remodeling. Compared with the commonly used free fibula flap and traditional iliac flap, the modified vascularized free iliac flap demonstrates a postoperative trend of increasing thickness, highlighting one of its advantages. Additionally, the split side of the modified iliac flap showed new cortical bone formation, which is advantageous for implant placement. For instance, at the Ri level, the iliac bone flap thickness increased by 7% at 6 months and 9% at 1 year postoperatively, suggesting that during preoperative VSP, an iliac bone flap of less than the desired thickness can be designed according to the appropriate proportions, which may be beneficial in minimizing surgical injury. Furthermore, since the iliac bone thickness continues to increase slowly at 1 year postoperatively, assessment of flap thickness can be re-evaluated at 1 year if inadequate thickness for implantation is noted at 6 months postoperatively. In summary, the modified vascularized free iliac flap is a viable option for maxillofacial reconstructions. However, this study had certain limitations. The data collected did not follow a normal distribution, precluding further multivariate analyses. The number of cases included in this study was relatively small, particularly those with CT imaging data at six months postoperatively. Future research with larger sample sizes is necessary to validate bone remodeling outcomes following the modified vascularized free iliac flap procedure. Conclusions This prospective study provides the first report on bone remodeling patterns following surgery with a modified vascularized free iliac flap, along with an analysis of the influencing factors. Postoperatively, new cortical bone formation was observed on the split side of the modified flap, contributing to a gradual increase in the overall flap thickness, albeit with a concurrent decrease in flap density. Bone remodeling is most active within the first 6 months post-surgery, with substantial remodeling generally completed by 6 months, making it an optimal period for subsequent implantation procedures on the modified vascularized free iliac flap. This study offers valuable insights into the clinical application of reconstructive maxillofacial surgery using a modified vascularized free iliac flap and subsequent implantation procedures. Abbreviations CAS Computer-assisted surgery CT Computed tomography VSP Virtual surgical planning 3D Three-dimensional HU Hounsfield units ICC Intra-class correlation coefficients SD Standard deviation Declarations Ethics approval and consent to participate The study protocol was conducted in accordance with the Declaration of Helsinki. Approval was obtained from the Institutional Review Board of the Peking University School of Stomatology (approval number: PKUSSIRB-202171211). Informed consents were obtained from the patients in written form. Consent for publication Not applicable. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding This study was supported by the fund PKUSSNKP - 202120, Beijing Natural Science Foundation (Z240003), and the College Students’ Innovative Experiment Project (2023-DC-16). Contributions M.H. and X.L.: conceptualization, methodology, investigation, project administration funding acquisition. Z.L., and W.W.: investigation, data curation and drafting and writing the manuscript. Z.L. and H.P.: investigation and data curation. J.Z.: supervision. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6746980","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":483325098,"identity":"1541bcc0-220c-4808-a12c-4f1cc77b610f","order_by":0,"name":"Ze-Zhao Liu","email":"","orcid":"","institution":"Peking University School and Hospital of Stomatology","correspondingAuthor":false,"prefix":"","firstName":"Ze-Zhao","middleName":"","lastName":"Liu","suffix":""},{"id":483325099,"identity":"08a156a3-0336-4b5f-b862-365c23588bb5","order_by":1,"name":"Wei Wang","email":"","orcid":"","institution":"Peking University School and Hospital of Stomatology","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Wang","suffix":""},{"id":483325100,"identity":"0c35bc54-4173-4135-ba5e-e722895dd0d1","order_by":2,"name":"Zheng-Dong Lu","email":"","orcid":"","institution":"Peking University School and Hospital of Stomatology","correspondingAuthor":false,"prefix":"","firstName":"Zheng-Dong","middleName":"","lastName":"Lu","suffix":""},{"id":483325101,"identity":"cf8c70c3-2c79-4448-ad3c-f328d110b3da","order_by":3,"name":"Hou-Ji Peng","email":"","orcid":"","institution":"Peking University School and Hospital of Stomatology","correspondingAuthor":false,"prefix":"","firstName":"Hou-Ji","middleName":"","lastName":"Peng","suffix":""},{"id":483325102,"identity":"e337f5c5-560f-4643-b186-772a7012469f","order_by":4,"name":"Jie Zhang","email":"","orcid":"","institution":"Peking University School and Hospital of Stomatology","correspondingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Zhang","suffix":""},{"id":483325103,"identity":"0391dde4-0490-4708-aab0-8ae1b47f2acb","order_by":5,"name":"Xiao-Ming M. Lyu","email":"","orcid":"","institution":"Peking University School and Hospital of Stomatology","correspondingAuthor":false,"prefix":"","firstName":"Xiao-Ming","middleName":"M.","lastName":"Lyu","suffix":""},{"id":483325104,"identity":"4c339401-bbe8-4516-9462-391565e5dcd8","order_by":6,"name":"Ming-Wei W. Huang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAqUlEQVRIiWNgGAWjYBACAyCW+PjPhoefvYEELZIz2NJkJHsOkKBFmoftsI3BDQcitZiLnTG8zcNznofhBgPjh485RGixnJ1jbDlH4jYP4+wGZsmZ24hx2O3cbRJvDG7zMMscYGPmJVoLT8I5HjaJBBK0SPIcOMDDQ4KW/M+WMxuSeSR4DjYT65e0xBsfG+zs7Y83H/zwkRgtSICxgTT1o2AUjIJRMApwAwCXUTWF5JQQ5QAAAABJRU5ErkJggg==","orcid":"","institution":"Peking University School and Hospital of Stomatology","correspondingAuthor":true,"prefix":"","firstName":"Ming-Wei","middleName":"W.","lastName":"Huang","suffix":""}],"badges":[],"createdAt":"2025-05-26 04:38:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6746980/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6746980/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86675240,"identity":"e8ae5e8b-dee4-43cf-b2f0-a1d1e3694ec1","added_by":"auto","created_at":"2025-07-14 11:55:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":187401,"visible":true,"origin":"","legend":"\u003cp\u003eModified vascularized free iliac bone flap for repair of mandibular defects. a) Virtual surgical planning. b) Longitudinal splitting of the iliac crest. c) Cortical bone cutting at the inner lower edge of the iliac crest. d) Completed osteotomized iliac segment (yellow arrow indicates the iliac flap carrying inner cortical bone, green arrow indicates preserved outer cortical bone). e) Prepared modified vascularized free iliac bone flap. f) Mandibular reconstruction assisted by a 3D-printed model.\u003c/p\u003e","description":"","filename":"Figure.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6746980/v1/0323f4b324b072f0a495970b.jpg"},{"id":86673544,"identity":"d296ee80-1d88-4407-a148-add8dbc78c34","added_by":"auto","created_at":"2025-07-14 11:47:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":92859,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of cortical bone thickness, overall bone flap thickness, and cancellous bone density in postoperative iliac flaps. a) CT images of the iliac flap at 1 week postoperatively. b) Measurement of cortical bone thickness at one 1 postoperatively. c) Measurement of iliac bone thickness and cancellous bone density at 1 week postoperatively. d) CT images of the iliac flap at 6 months postoperatively. e) Measurement of cortical bone thickness at 6 months postoperatively. f) Measurement of iliac bone thickness and cancellous bone density at 6 months postoperatively. g) CT images of the iliac flap at 1 year postoperatively. h) Measurement of cortical bone thickness at 1 year postoperatively. i) Measurement of iliac bone thickness and cancellous bone density at 1 year postoperatively.\u003c/p\u003e","description":"","filename":"Figure.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6746980/v1/0420c8e7c8580dcea704f614.jpg"},{"id":86676595,"identity":"250aad2d-a53f-4cc7-b07d-aa824e6b711e","added_by":"auto","created_at":"2025-07-14 12:11:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1189965,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6746980/v1/e8d21dd1-1e71-4ce8-b21d-e9698f3a9cc5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bone remodeling of the modified vascularized free iliac flap in jaw reconstruction","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe maxilla and mandible constitute vital bony components within the maxillofacial region, integral to various anatomical structures and essential physiological functions such as mastication, swallowing, speech, and respiration[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. To address maxillofacial defects arising from tumors, trauma, or surgical interventions, vascularized free flaps represent the predominant restorative approach, offering superior restoration of both form and function. Several types of vascularized free flaps have proven effective in maxillofacial reconstruction, with the vascularized free fibula and iliac flaps being the most frequently utilized[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe free fibula flap offers advantages including larger vessel diameters, facile multi-segmental osteotomy, and contouring capabilities, with low donor-site complications[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, its limited soft-tissue volume may prove inadequate for defect filling. Moreover, the width of the fibula typically falls short of that required for jawbone reconstruction, potentially necessitating additional surgical intervention for subsequent implantation. Conversely, the iliac flap capitalizes on its naturally curved iliac crest, which resembles the physiological curvature of the mandible, and offers sufficient bone height and thickness conducive to implant integration[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Nevertheless, challenges associated with the iliac flap include limited donor bone length, narrow vascular pedicle, and higher incidence of donor-site complications.\u003c/p\u003e\u003cp\u003eModification of the iliac flap, preserving the lateral cortical bone, and utilizing a rotary deep iliac artery to carry the medial cortical bone may reduce complications associated with vascularized free iliac flaps. Taylor et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] applied a sagittal split iliac flap in a 13-year-old patient with hemifacial microsomia to preserve the normal contour and donor site development. David et al.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] reported the use of the \"split iliac flap\" in 5 patients with various diagnoses and concluded that the split ilium is not too bulky. This modified iliac flap offers potential advantages over conventional techniques: first, preserving the lateral cortical bone to minimize donor site damage and complications; and second, allowing more precise control over the bone thickness of the harvested flap for improved restoration of craniofacial aesthetics. With the advancement of computer-assisted surgery (CAS), reconstructive procedures have benefited from enhanced accuracy and predictability[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and facilitates a more precise determination of iliac bone flap thickness required for maxillofacial reconstruction.\u003c/p\u003e\u003cp\u003eAdditionally, several studies have demonstrated varying degrees of bone resorption following vascularized free bone grafting, which may adversely affect the subsequent placement of dental implants[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It is noteworthy that modified vascularized free iliac flap shows noticeable new cortical bone formation on the split side of the iliac bone flap. Currently, there are no reports on bone remodeling outcomes following the use of modified vascularized free iliac flaps for jaw reconstructions. In this prospective study, we longitudinally observed and measured bone remodeling of the iliac bone flap after jaw reconstruction with modified vascularized free iliac flap and investigated factors that may influence bone remodeling.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cem\u003eStudy population\u003c/em\u003e\u003c/p\u003e\u003cp\u003e The study protocol was conducted in accordance with the Declaration of Helsinki. Approval was obtained from the Institutional Review Board of the Peking University School of Stomatology (approval number: PKUSSIRB-202171211).\u003c/p\u003e\u003cp\u003eThis prospective study was conducted from January 2022 to February 2023 at the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, including patients with benign or malignant tumors of the maxillofacial region who underwent mandibular or maxillary reconstruction using modified vascularized iliac bone flaps. Preoperative counseling was provided to patients who provided informed consent by signing the consent forms.\u003c/p\u003e\u003cp\u003eThe inclusion criteria were as follows: 1) age between 18 and 80 years, tumors involving the soft and hard tissues of the oral and maxillofacial region requiring jaw resection, 2) periosteum removal during surgery, 3) jaw reconstruction using modified vascularized iliac bone flaps, and 4) absence of significant surgical contraindications.\u003c/p\u003e\u003cp\u003ePatients meeting any of the following conditions were excluded: 1) postoperative spiral computed tomography (CT) images showing bilateral cortical bone in the iliac flap, which affected measurements of new cortical bone formation; 2) patients who underwent flap replacement postoperatively due to vascular compromise or other factors; and 3) interference with measurement caused by titanium plate and screw artifacts on postoperative CT images.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSurgical procedure\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll patients underwent preoperative maxillofacial CT scans (field of view, 20 cm; pitch, 1.0; slice thickness, 1.25 mm; 140\u0026ndash;160 mA, pixel density, 512 \u0026times; 512), and virtual surgical planning (VSP) was generated using ProPlan CMF 3.0 software (Materialise, Leuven, Belgium). Mirror models were used to simulate jaw reconstruction and to preliminarily determine the required iliac bone flap thickness (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. a). Surgical guides and jaw reconstruction models were designed using the Mimics Medical software (version 21.0; Materialize, Leuven, Belgium). During the surgery, the donor site on one side of the buttock was padded. A deep circumflex iliac artery perforator myofascial flap was prepared intraoperatively, involving the dissection of the internal oblique, transversus abdominis, and rectus abdominis muscles. The deep circumflex iliac artery was dissected in reverse at the medial aspect of the anterior superior iliac spine with preservation of the lateral cutaneous nerve of the thigh and transection of the iliacus muscle. The lateral periosteum of the iliac crest was stripped to expose the outer bone and a bone-cutting guide was placed and fixed. The iliac crest was cut based on the cutting guide, preserving a 3\u0026ndash;5 mm outer cortical bone plate, and longitudinally split (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. b). The cortical bone was cut at the inner lower edge (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.c) to obtain the required iliac bone segment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. d), with a vascularized deep circumflex iliac artery iliac flap incorporating the inner cortical bone (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. e). Pre-bent titanium plates were used with three-dimensional (3D) printed jaw reconstruction models to assist jaw reconstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. f).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eImaging analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003ePostoperative follow-up was scheduled at 1 week, 6 months, and 1 year, with maxillofacial spiral CT imaging performed at the Peking University School and Hospital of Stomatology.\u003c/p\u003e\u003cp\u003eObservations and measurements of spiral CT images were conducted using the PACS archiving and communication system at the Peking University School and Hospital of Stomatology. The iliac flap was examined in the bone window (800 Hounsfield units (HU)). The viewing axis was adjusted so that one axis was parallel to the long axis of the flap and another axis intersected perpendicularly through the iliac flap. After adjusting the viewing axis, horizontal planes were marked in the sagittal window at distances of 5 and 10 mm from the iliac crest and 5 mm from the distal end of the iliac flap. These planes represent the postoperative bone reconstruction at the levels of the alveolar ridge (Ar level), root end of the implant (Ri level), and end of the iliac flap (Ei level). Measurements of CT images were performed 1 week, 6 months, and 1 year postoperatively (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. a, d, g).\u003c/p\u003e\u003cp\u003eCortical bone thickness was calculated by dividing the area by the length. The \"freehand ROI\" tool of the software was used to meticulously outline the area of cortical bone, and the \"line\" tool was used to measure the observable length of cortical bone. In cases where titanium screws were present in the measurement plane, the cortical bone thickness was measured, excluding the titanium screw portions. Cortical bone thickness was measured 1 week, 6 months, and 1 year postoperatively (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. b, e, h).\u003c/p\u003e\u003cp\u003eThe overall thickness of the iliac flap was measured as follows: using the \"line\" tool, the length of the iliac flap was measured, and the flap was divided into four equal parts based on total length. The thickness of the flap was measured at three points along these division lines, and the average value represented the thickness of the iliac flap at that plane.\u003c/p\u003e\u003cp\u003eCancellous bone density was quantitatively evaluated using the Hounsfield units. On the observation plane, using the \"ellipse\" tool, three circles with an area of approximately 4 mm\u0026sup2; were outlined at the midpoint of each division line. If a circle was close to the image of the titanium plates or screws, it was positioned at least 5 mm away from them. The average spiral CT value represented the cancellous bone density at the measurement plane. Cortical bone thickness and overall bone flap thickness were measured 1 week, 6 months, and 1 year postoperatively (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.c, f, i).\u003c/p\u003e\u003cp\u003eAll measurements were independently conducted by three researchers and the average of their measurements was taken as the final measurement result.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eStatistical Analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics (version 20.0; IBM Corp., Armonk, NY, USA). Intra-class correlation coefficients (ICC) were used to assess inter-observer reliability, with ICC more than 0.8 indicating good consistency. Data are presented as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). The influencing factors included tumor type, tumor location, type of titanium fixation plate, postoperative complications, postoperative radiotherapy, postoperative chemotherapy, and systemic medications. First, Levene's test was used to assess the homogeneity of variances. Based on the results, independent sample t-tests or Kruskal-Wallis tests were used to analyze the impact of these factors on bone reconstruction. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe clinical characteristics of the patients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. From January 2022 to February 2023, 7 patients who underwent modified vascularized free iliac flap reconstruction for mandibular or maxillary defects were recruited, and all surgeries were successful. Due to COVID-19, some patients did not undergo postoperative spiral CT imaging at the 6-month follow-up.\u003c/p\u003e\u003cp\u003eThe average age of the seven patients was 46.2 years (SD\u0026thinsp;=\u0026thinsp;9.3), comprising two males and five females. The majority of the cases involved malignant tumors (n\u0026thinsp;=\u0026thinsp;6). Among these cases, three patients had lesions in the maxilla, whereas the remaining four had lesions in the mandible. Two patients regularly took antihypertensive drugs owing to hypertension. Following surgery, three patients received additional treatment. Postoperative complications included one patient who developed surgical site infection.\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\u003eClinical characteristics of the patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\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=\"char\" char=\"\u0026times;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" 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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eThe lesion site\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePathology\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBone flap size(cm)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNumber of bone segments\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eInternal fixation material\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eFurther treatment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eSystemic medication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003eComplication\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003eOutcome\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMandible\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e*SCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c6\"\u003e\u003cp\u003e8\u0026times;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eReconstruction plate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eIrbesartan tablet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaxilla\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e*SCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c6\"\u003e\u003cp\u003e8\u0026times;2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMini-plate\u0026times;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eRadiotherapy and Chemotherapeutic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eAmlodipine besylate tablet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMandible\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMalignant sarcoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c6\"\u003e\u003cp\u003e6\u0026times;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eReconstruction plate\u0026times;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eRadiotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaxilla\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e*SCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c6\"\u003e\u003cp\u003e6\u0026times;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMini-plate\u0026times;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMandible\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAmeloblastic Fibrosarcoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c6\"\u003e\u003cp\u003e7\u0026times;3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eReconstruction plate and Mini-plate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eRadiotherapy and Chemotherapeutic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMaxilla\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e*SCC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c6\"\u003e\u003cp\u003e5\u0026times;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMini-plate\u0026times;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMandible\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAdamantoblastoma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026times;\" colname=\"c6\"\u003e\u003cp\u003e7\u0026times;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eReconstruction plate\u0026times;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eInfection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eAlive\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean\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\u003cp\u003e46.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSD\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\u003cp\u003e9.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"12\"\u003e\u003cb\u003e*\u003c/b\u003eSquamous cell carcinoma\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe ICCs for the cortical bone thickness, overall bone graft thickness, and cancellous bone density measured by the three researchers were 0.889, 0.972, and 0.958, respectively, indicating good consistency.\u003c/p\u003e\u003cp\u003eThe postoperative changes in cortical bone thickness are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. New cortical bone formation was observed on the split-side in all patients one year postoperatively. The cortical bone thickness was 0 mm at one week postoperatively and averaged 1.18 mm (Ar level), 1.18 mm (Ri level), and 1.01 mm (Ei level) at 1 year after surgery. Among the seven patients, three underwent spiral CT six months postoperatively. In the Ri level in these patients, cortical bone thickness increased by 1.03 mm in the first months and by 0.19 mm in the subsequent six months; corresponding values were 0.79 mm and 0.28 mm in the Ri level, and 0.90 mm and 0.09 mm in the Ei level.\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\u003ePostoperative changes in cortical bone thickness\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\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=\"char\" char=\".\" 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=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eAr level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eRi level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\u003cp\u003eEi level\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 W\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 M\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 Y\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 W\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6 M\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 Y\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1 W\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003e6 M\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1 Y\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1.58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.48\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\u003eOverall iliac bone flap thickness increased by 0.41 mm (Ar level), 0.96 mm (Ri level), and 1.01 mm (Ei level) at one year compared to 1 week postoperatively, with growth rates of 6.4%, 13.8%, and 12.2%, respectively. The relevant detailed data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\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\u003ePostoperative changes in total thickness of iliac crest flap\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\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=\"char\" char=\".\" 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=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eAr level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eRi level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\u003cp\u003eEi level\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 W\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 M\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 Y\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 W\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6 M\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 Y\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1 W\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003e6 M\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1 Y\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e7.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e9.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e5.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e6.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e6.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e4.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e6.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e8.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e7.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e7.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e9.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e10.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e4.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e5.43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e4.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e4.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e4.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e4.90\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e9.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e10.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e9.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e10.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e10.65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e7.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e8.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e7.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e7.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e8.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e7.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e8.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e6.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e7.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e6.94\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e2.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e1.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e1.78\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\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e illustrates the postoperative changes in the cancellous bone density. Compared with one week postoperatively, cancellous bone density decreased by 59.9% (Ar level), 57.4% (Ri level), and 44.1% (Ei level) at one year.\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\u003ePostoperative changes in cancellous bone density\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"12\"\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=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eAr level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eRi level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\u003cp\u003eEi level\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 W\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 M\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 Y\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1 W\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6 M\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1 Y\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1 W\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003e6 M\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1 Y\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e226.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e265.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e59.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e223.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e151.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e292.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e219.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e343.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e265\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e343.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e271.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e440.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e229.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e94.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e88.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e279.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e144.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e279.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e256.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e44.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e292.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e92.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e272.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e243.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e109.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e250.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e214.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e153.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e228.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e231.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e166.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e279.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e37.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e284.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e83.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e45.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e291.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e103.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e69.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e180.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e99.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e57.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e151.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e166.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e116.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e298.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e146.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e119.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e239.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e132.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e101.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e258.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e167.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e144.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e74.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e58.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e75.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e\u003cp\u003e57.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e51.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e\u003cp\u003e60.8\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\u003eThe factors influencing bone remodeling are shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, which indicates that factors such as lesion site, pathological type, fixation materials, medication history, and complications did not significantly affect bone remodeling.\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\u003eFactors influencing changes in cortical bone thickness and bone graft thickness\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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=\"char\" char=\".\" 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=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eFactors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eCortical bone thickness (mm), \u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eTotal thickness (mm), \u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eSubsite\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMandibular body\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\u003e1.06\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAscending ramus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaxilla\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\u003e1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003ePathology\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMalignant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBenign\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eInternal fixation material\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReconstruction plate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMini-plate\u0026times;2\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\u003e1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReconstruction plate\u0026times;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReconstruction plate and Mini-plate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eSystemic medication\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIrbesartan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAmlodipine besylate tablet\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.63\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eFurther treatment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRadiotherapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRadiotherapy and Chemotherapeutic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.64\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\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\u003e1.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eComplication\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInfection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\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":"Discussion","content":"\u003cp\u003eThis study reports a modified vascularized free iliac bone flap for jaw reconstruction, which involves sagittal splitting of the iliac crest to preserve the lateral bone and muscle attachments, thereby reducing surgical trauma and complications in the donor area. Seven patients underwent a successful jaw defect repair using the modified flap technique. Spiral CT images at one week postoperatively revealed absence of cortical bone on one side of the modified vascularized iliac bone flap, with noticeable cortical bone regeneration observed at one year postoperatively. At six months post-operation, the cortical bone thickness increased by 1.03 mm, 0.79 mm, and 0.90 mm at the Ar, Ri, and Ei levels, respectively. Continued cortical thickening was noted during 6 months and 1 year postoperatively, with increases of 0.19 mm, 0.28 mm, and 0.09 mm at the same levels. These findings indicate that cortical bone thickening primarily occurs within the first six months post-operation, which is consistent with current research[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Previous studies have reported varying degrees of absorption following vascularized free-flap mandibular or maxillary reconstruction. Kang et al.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] reported cortical bone loss rates of 21%, 17%, 10%, and 31% at one year post-operation for the lateral, medial, superior, and inferior aspects of vascularized fibular flaps, respectively, while Chen et al.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] found a 9.1% decrease in total iliac bone thickness at one year post-operation. Similar results have been reported by Shokri et al.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This study is the first to document an increasing trend in the bone flap thickness after jaw defect repair using a vascularized free bone flap.\u003c/p\u003e\u003cp\u003eThe newly formed cortical bone contributes to an overall increase in bone flap thickness, following a pattern similar to cortical bone thickness change. It is noteworthy that the total iliac bone thickness increase was lower than the increase in cortical bone areas, indicating concurrent bone absorption elsewhere following modified iliac bone flap surgery. Regarding cancellous bone density changes, the results align with previous literature[\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], showing a declining trend with reductions of 84.9%, 77.7%, and 80.4% within six months relative to one year, similar to the findings of Chen et al.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Cancellous bone density further declined in the second six months post-operation.\u003c/p\u003e\u003cp\u003eMeasurements at the three selected levels conformed to the aforementioned patterns of bone remodeling. Considering these patterns comprehensively, the initial six months post-modified iliac bone flap surgery exhibited active bone remodeling. By six months, cortical bone thickness and overall flap thickness stabilize, reaching 0.79 mm and 7.75 mm at the Ri level, respectively. Meanwhile, cancellous bone density continues to decline, underscoring the optimal timing for implant surgery on the modified vascularized free iliac bone flap at six months postoperatively to mitigate further density loss that could impact implant outcomes.\u003c/p\u003e\u003cp\u003eWhile previous discussion noted that cortical bone thickness increases more than total iliac bone thickness, Case 1 shows increases in iliac bone flap thickness at Ar and Ri levels exceeding cortical bone increases, contrary to the general trend. This may be related to the daily use of irbesartan for cardiovascular disease in Case 1. Cheng et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] demonstrated that irbesartan has the potential to reduce reactive oxygen species and inhibit advanced glycation end-product formation in rats, thus reducing bone absorption. Liu et al.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] demonstrated that irbesartan partially altered bone remodeling and enhanced bone quality, primarily affecting trabecular bone.\u003c/p\u003e\u003cp\u003eIn addition, Case 3 exhibited significantly lower increases in cortical bone and bone flap thickness compared to other patients, with a decreasing trend in bone flap thickness at the crest of the alveolar ridge, which we attributed to the method of internal fixation. This case utilized a dual-layer reconstruction plate for fixation, where the oversized titanium plate volume may have induced stress shielding at the site, thereby affecting the bone remodeling processes[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Xie et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] found that larger mini-titanium plates may correlate with increased bone absorption following condylar fractures compared with micro-titanium plates. Similarly, Case 7, also fixed with bilateral reconstruction plates, showed lower cortical bone formation and increased bone flap thickness. However, in addition to the fixation materials, case 7 also experienced post-operative site infection, which likely influenced the bone remodeling process[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStatistical analysis of the factors affecting bone remodeling is presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. The reconstruction site had no significant impact on bone remodeling, which is consistent with the findings of H\u0026ouml;lzle et al.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and Disa et al.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Factors such as tumor type, type of internal fixation titanium plates, post-operative complications, radiotherapy, chemotherapy, and systemic medications showed no apparent association with bone remodeling.\u003c/p\u003e\u003cp\u003eCompared with the commonly used free fibula flap and traditional iliac flap, the modified vascularized free iliac flap demonstrates a postoperative trend of increasing thickness, highlighting one of its advantages. Additionally, the split side of the modified iliac flap showed new cortical bone formation, which is advantageous for implant placement. For instance, at the Ri level, the iliac bone flap thickness increased by 7% at 6 months and 9% at 1 year postoperatively, suggesting that during preoperative VSP, an iliac bone flap of less than the desired thickness can be designed according to the appropriate proportions, which may be beneficial in minimizing surgical injury. Furthermore, since the iliac bone thickness continues to increase slowly at 1 year postoperatively, assessment of flap thickness can be re-evaluated at 1 year if inadequate thickness for implantation is noted at 6 months postoperatively. In summary, the modified vascularized free iliac flap is a viable option for maxillofacial reconstructions.\u003c/p\u003e\u003cp\u003eHowever, this study had certain limitations. The data collected did not follow a normal distribution, precluding further multivariate analyses. The number of cases included in this study was relatively small, particularly those with CT imaging data at six months postoperatively. Future research with larger sample sizes is necessary to validate bone remodeling outcomes following the modified vascularized free iliac flap procedure.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis prospective study provides the first report on bone remodeling patterns following surgery with a modified vascularized free iliac flap, along with an analysis of the influencing factors. Postoperatively, new cortical bone formation was observed on the split side of the modified flap, contributing to a gradual increase in the overall flap thickness, albeit with a concurrent decrease in flap density. Bone remodeling is most active within the first 6 months post-surgery, with substantial remodeling generally completed by 6 months, making it an optimal period for subsequent implantation procedures on the modified vascularized free iliac flap. This study offers valuable insights into the clinical application of reconstructive maxillofacial surgery using a modified vascularized free iliac flap and subsequent implantation procedures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputer-assisted surgery\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVSP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVirtual surgical planning\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e3D\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThree-dimensional\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHounsfield units\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntra-class correlation coefficients\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was conducted in accordance with the Declaration of Helsinki.\u0026nbsp;Approval was obtained from the Institutional Review Board of the Peking University School of Stomatology (approval number: PKUSSIRB-202171211).\u0026nbsp;Informed consents were obtained from the patients in written form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the fund PKUSSNKP - 202120, Beijing Natural Science\u0026nbsp;Foundation (Z240003), and the College Students’ Innovative Experiment Project (2023-DC-16).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.H. and X.L.: conceptualization, methodology, investigation, project administration funding acquisition. Z.L., and W.W.: investigation, data curation and drafting and writing the manuscript. Z.L. and H.P.: investigation and data curation. J.Z.: supervision. All authors contributed to the study conception and design and read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChandu A, Smith AC, Rogers SN. Health-related quality of life in oral cancer: a review. J oral maxillofacial surgery: official J Am Association Oral Maxillofacial Surg. 2006;64(3):495\u0026ndash;502.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHidalgo DA. Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg. 1989;84(1):71\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Clinical work. Plast Reconstr Surg. 1979;64(6):745\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi CQ, Xie S, LiuFu JF, Ding MK, Kang YF, Shan XF, Cai ZG. Retrospective study of the deep circumflex iliac artery flap and the vascularized fibula free flap for maxillary defect repair. Oral Oncol. 2024;154:106860.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLonie S, Herle P, Paddle A, Pradhan N, Birch T, Shayan R. Mandibular reconstruction: meta-analysis of iliac- versus fibula-free flaps. ANZ J Surg. 2016;86(5):337\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoseph ST, Thankappan K, Buggaveeti R, Sharma M, Mathew J, Iyer S. Challenges in the reconstruction of bilateral maxillectomy defects. J oral maxillofacial surgery: official J Am Association Oral Maxillofacial Surg. 2015;73(2):349\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCebrian-Carretero JL, Gui\u0026ntilde;ales-D\u0026iacute;az de Cevallos J, Sobrino JA, Yu T, Burgue\u0026ntilde;o-Garc\u0026iacute;a M. Predictable dental rehabilitation in maxillomandibular reconstruction with free flaps. The role of implant guided surgery. \u003cem\u003eMedicina oral, patologia oral y cirugia bucal\u003c/em\u003e 2014, 19(6):e605-611.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrinsell D, Catto-Smith HE. Modifications of the deep circumflex iliac artery free flap for reconstruction of the maxilla. J Plast Reconstr aesthetic surgery: JPRAS. 2015;68(8):1044\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaylor GI. Reconstruction of the mandible with free composite iliac bone grafts. Ann Plast Surg. 1982;9(5):361\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavid DJ, Tan E, Katsaros J, Sheen R. Mandibular reconstruction with vascularized iliac crest: a 10-year experience. Plast Reconstr Surg. 1988;82(5):792\u0026ndash;803.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePu JJ, Hakim SG, Melville JC, Su YX. Current Trends in the Reconstruction and Rehabilitation of Jaw following Ablative Surgery. Cancers 2022, 14(14).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMertens C, Decker C, Engel M, Sander A, Hoffmann J, Freier K. Early bone resorption of free microvascular reanastomized bone grafts for mandibular reconstruction\u0026ndash;a comparison of iliac crest and fibula grafts. J cranio-maxillo-facial surgery: official publication Eur Association Cranio-Maxillo-Facial Surg. 2014;42(5):e217\u0026ndash;223.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKang YF, Liang J, He Z, Xie S, Zhang L, Shan XF, Cai ZG. Cortical bone resorption of fibular bone after maxillary reconstruction with a vascularized fibula free flap: a computed tomography imaging study. Int J Oral Maxillofac Surg. 2019;48(8):1009\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVerhoeven JW, Ruijter J, Cune MS, Terlou M, Zoon M. Onlay grafts in combination with endosseous implants in severe mandibular atrophy: one year results of a prospective, quantitative radiological study. Clin Oral Implants Res. 2000;11(6):583\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen HM, Kang YF, Lv XM, Shan XF, Cai ZG. Bone resorption after maxillary reconstruction with the vascularized free iliac flap. Int J Oral Maxillofac Surg. 2023;52(4):430\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShokri T, Stahl LE, Kanekar SG, Goyal N. Osseous Changes Over Time in Free Fibular Flap Reconstruction. Laryngoscope. 2019;129(5):1113\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZheng K, Yoda N, Chen J, Liao Z, Zhong J, Wu C, Wan B, Koyama S, Sasaki K, Peck C, et al. Bone remodeling following mandibular reconstruction using fibula free flap. J Biomech. 2022;133:110968.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang Y, Kang Y, Yang Y, Ding M, Shan X, Cai Z. Feasibility analysis of bone density evaluation with Hounsfield unit value after fibula flap reconstruction of jaw defect. Maxillofacial Plast Reconstr Surg. 2023;45(1):30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShawky M, Elbeialy RR, Khashaba MM, Zedan MH. Assessment of bone density and stability with immediately loaded dental implants with the All-on-Four technique in free vascularized fibular grafts used for mandibular reconstruction. Clin Implant Dent Relat Res. 2021;23(3):482\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCheng YZ, Yang SL, Wang JY, Ye M, Zhuo XY, Wang LT, Chen H, Zhang H, Yang L. Irbesartan attenuates advanced glycation end products-mediated damage in diabetes-associated osteoporosis through the AGEs/RAGE pathway. Life Sci. 2018;205:184\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu CJ, Yang X, Wang SH, Wu XT, Mao Y, Shi JW, Fan YB, Sun LW. Preventing Disused Bone Loss through Inhibition of Advanced Glycation End Products. Int J Mol Sci 2023, 24(5).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJia MY, Jiang JJ, Chu XY, Yuan RT, Wang K, Bu LX. [Clinical application of titanium plate reconstruction of mandibular defect: 10 years of follow up]. \u003cem\u003eZhonghua kou qiang yi xue za zhi\u0026thinsp;=\u0026thinsp;Zhonghua kouqiang yixue zazhi\u0026thinsp;=\u0026thinsp;Chinese journal of stomatology\u003c/em\u003e 2016, 51(7):401\u0026ndash;404.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJi B, Wang C, Liu L, Long J, Tian W, Wang H. A biomechanical analysis of titanium miniplates used for treatment of mandibular symphyseal fractures with the finite element method. \u003cem\u003eOral surgery, oral medicine, oral pathology, oral radiology, and endodontics\u003c/em\u003e 2010, 109(3):e21-27.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXie ST, Singhal D, Chen CT, Chen YR. Functional and radiologic outcome of open reduction and internal fixation of condylar head and neck fractures using miniplate or microplate system. Ann Plast Surg. 2013;71(Suppl 1):S61\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eImholz B, Richter M, Dojcinovic I, Hugentobler M. [Non-union of the maxilla: a rare complication after Le Fort I osteotomy]. Revue de stomatologie et de chirurgie maxillo-faciale. 2010;111(5\u0026ndash;6):270\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eH\u0026ouml;lzle F, Watola A, Kesting MR, Nolte D, Wolff KD. Atrophy of free fibular grafts after mandibular reconstruction. Plast Reconstr Surg. 2007;119(1):151\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDisa JJ, Winters RM, Hidalgo DA. Long-term evaluation of bone mass in free fibula flap mandible reconstruction. Am J Surg. 1997;174(5):503\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"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":"Jaw reconstruction, Vascularized free iliac flap, Cortical bone, Bone remodeling","lastPublishedDoi":"10.21203/rs.3.rs-6746980/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6746980/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e This study investigates the postoperative bone remodeling patterns of the iliacbone after jaw reconstruction with the modified vascularized free iliac flap, which preserves the lateral cortical bone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003ePatients undergoing jawbone reconstruction with the modified vascularized free iliac bone flap between January 2022 and February 2023 were recruited. Maxillofacial spiral CT scans were collected at 1 week, 6 months, and 1 year postoperatively. The nascent cortical bone thickness, total bone thickness, and cancellous bone density of the iliac bone flap were measured at three specified planes on the spiral CT images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Seven patients were recruited for bone remodeling analysis. Cortical bone regeneration was observed at the iliac bone in all patients. At 1 year postoperatively, the mean cortical bone thickening was 1.18 mm, 1.17 mm, and 1.01 mm at the three measurement planes, respectively. Significant increases were noted in the overall thickness of the iliac bone and the cancellous bone density were reduced significantly at 6 months compared to 1 week postoperatively. From 6 months to 1 year postoperatively, there was a slight increase in cortical bone thickness and a further decrease in cancellous bone density.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The modified vascularized free iliac flap shows gradual increases in cortical bone thickness and total iliac bone thickness, along with a gradual decrease in cancellous bone density. The bone remodeling is more active in the first 6 months after surgery. The modified vascularized free iliac flap represents a viable alternative for jaw reconstruction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003enot applicable.\u003c/p\u003e","manuscriptTitle":"Bone remodeling of the modified vascularized free iliac flap in jaw reconstruction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 11:47:50","doi":"10.21203/rs.3.rs-6746980/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-19T20:13:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186683751006808664834469532303054814528","date":"2026-05-11T06:18:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-30T10:46:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"93035153785349029060790962698880464947","date":"2025-07-30T08:06:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-10T03:13:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-29T17:48:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-29T07:05:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-29T07:04:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-05-26T04:33:19+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":"9c934845-de83-48cb-b541-56d03ac985e4","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-19T20:13:46+00:00","index":82,"fulltext":""},{"type":"reviewerAgreed","content":"186683751006808664834469532303054814528","date":"2026-05-11T06:18:16+00:00","index":80,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T11:47:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-14 11:47:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6746980","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6746980","identity":"rs-6746980","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}