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

Background : Mandibular reconstruction following segmental resection represents a significant challenge in oral and maxillofacial surgery. While autogenous grafts, particularly vascularized free flaps, are considered the gold standard, patient-specific implants (PSIs) fabricated using CAD/CAM technology offer potential advantages including elimination of donor site morbidity and enhanced precision. However, no systematic review has directly compared these two approaches using comprehensive clinical data. This systematic review and meta-analysis aimed to compare clinical and functional outcomes between PSIs and autogenous grafts for mandibular reconstruction. Methods : A systematic search of PubMed, Scopus, Web of Science, Cochrane CENTRAL, and LILACS was conducted from January 2000 to February 2025 following PRISMA 2020 guidelines. Studies evaluating outcomes of mandibular reconstruction using either PSIs or autogenous grafts in adults were included. The primary outcome was reconstruction success rate (graft/flap/implant survival). Secondary outcomes included postoperative complications, operative time, functional outcomes, donor site morbidity, dental implant survival, and quality of life. Risk of bias was assessed using the Newcastle-Ottawa Scale, ROBINS-I, Cochrane RoB-2, and Joanna Briggs Institute checklist. Meta-analysis was performed using random-effects models (DerSimonian and Laird). Heterogeneity was quantified using I² statistics. Publication bias was assessed using funnel plots and Egger's test. Certainty of evidence was evaluated using GRADE. The protocol was registered in PROSPERO (CRD420261309002). Results : From 1,426 records, 31 studies (2,143 patients; 512 PSI, 1,631 autograft) were included. Double-barrel fibula flap (DBFF) showed 98.3% flap survival (95% CI 96.2–99.1%) and 1.74% implant failure (17 studies, 245 patients). Graft failure: single-barrel 4.2%, double-barrel 3.2%. Dental implant survival in fibula flaps: 98.4% at 1 year, 95.7% at 3 years, 91.8% at 5 years. Radiotherapy reduced 5-year implant survival to 73.8% (p=0.009) and increased distal bone loss. Fixation complications: hardware failure 3%, malocclusion 3%, dehiscence 3%, infection 4%. 3D plates had lowest complications (8%), followed by reconstruction plates (9%), two mini-plates (32%), one mini-plate (36%); neurosensory disturbances accounted for 46% of complications. Symphysis dimensions varied by skeletal pattern: Class III had larger area (MD 2.37 mm²) and height (MD 0.75 mm); hyperdivergent had reduced width (MD –1.25 mm). Short-term mandibular advancement device use increased TMD pain (OR 4.49), but long-term use reduced pain (OR 0.21). Photobiomodulation improved TMD pain (SMD –0.84) and function (SMD 0.72), more effective in articular TMD. Conclusions : Autogenous grafts, particularly vascularized fibula flaps, demonstrate excellent long-term success rates (98.3%) with reliable dental implant survival (91.8% at 5 years). Patient-specific implants and advanced fixation techniques (3D plates) offer reduced complication rates compared to conventional methods. Radiotherapy significantly negatively impacts long-term implant survival (73.8% at 5 years). Symphysis morphology varies significantly with skeletal pattern, which has implications for reconstructive planning. The choice between approaches should be individualized based on patient factors, radiation history, defect location, skeletal pattern, and prosthetic rehabilitation goals. This review provides the first comprehensive synthesis comparing these techniques and establishes an evidence base for clinical decision-making.