Consensus on the terminologies and methodologies for masticatory assessment.

A large number of methodological procedures and experimental conditions are reported to describe the masticatory process. However, similar terms are sometimes employed to describe different methodologies. Standardisation of terms is essential to allow comparisons among different studies. This article was aimed to provide a consensus concerning the terms, definitions and technical methods generally reported when evaluating masticatory function objectively and subjectively. The consensus is based on the results from discussions and consultations among world-leading researchers in the related research areas. Advantages, limitations and relevance of each method are also discussed. The present consensus provides a revised framework of standardised terms to improve the consistent use of masticatory terminology and facilitate further investigations on masticatory function analysis. In addition, this article also outlines various methods used to evaluate the masticatory process and their advantages and disadvantages in order to help researchers to design their experiments.

The association between a mixing ability test and patient reported chewing ability in patients treated for oral malignancies.

INTRODUCTION: Mastication has been assessed in several ways in the past. Both patients reported and objective assessment methods have been developed. The University Medical Center (UMC) Utrecht has developed a mixing ability test (MAT) using a two-coloured wax tablet. The present study investigates the association between the mixing ability test and a chewing related questionnaire in patients treated for oral malignancies. PATIENTS AND METHODS: In a cohort study, patients treated for oral malignancies were assessed 4-6 weeks before and 4-6 weeks after treatment, as well as 6 months, 1 year and 5 years after treatment. The mixing ability test was assessed using 10 and 20 chewing strokes and was compared to seven questions about several aspects of mastication. Regression analysis was performed and density plots were drawn for statistical analysis. RESULTS: One hundred and twenty-three patients were included in this study. The questionnaire was less predictive for the 10-chewing stroke test and the test was less discriminatory for different food types than the 20-chewing stroke mixing ability test. Three questions about the ability to chew solid, soft and thickened liquid food types were found to be significantly predictive for the 20-chewing stroke test. Threshold values on the mixing ability index were around 20 for the ability to chew solid food types and 24 for soft food types. CONCLUSION: The 10-chewing stroke mixing ability test is less suitable than 20-chewing strokes for patients with and treated for oral cancer. The 20-chewing stroke mixing ability test has a fair association with self-reported outcomes.

Free vascularized flaps for reconstruction of the mandible: complications, success, and dental rehabilitation.

PURPOSE: To evaluate complications and success of mandibular reconstruction with free fibula flaps, iliac crest flaps, and forearm flaps with reconstruction plates and to evaluate dental rehabilitation after these reconstructions. PATIENTS AND METHODS: Eighty-three patients with segmental mandibular defects were included. Correlation analyses were used to determine the relationship between reconstruction type and clinical parameters with recipient-site complications and success. The dental rehabilitation was evaluated in successfully reconstructed survivors. RESULTS: Multivariate analyses showed significant correlations between flap type and success (P < .0001). Of the patients, 51 (61%) were alive 2 years after the reconstruction. Mandibular reconstruction with a free forearm flap and reconstruction plate was associated with higher complication rates at the recipient site and higher failure rates compared with reconstruction with free vascularized bone flaps. Of the 32 successfully reconstructed survivors, 14 (44%) had a complete dental rehabilitation, of which 10 had dental implants and 4 did not. Only 6 (29%) of the edentulous survivors ultimately had an implant-supported prosthesis. CONCLUSIONS: Reconstruction of the mandible with a free vascularized bone flap is superior to reconstruction with a free forearm flap with a reconstruction plate. Complete dental rehabilitation was reached in fewer than half of the surviving patients.

The influence of auditory and visual information on the neuromuscular control of chewing crispy food.

The influence of auditory and/or visual information on the neuromuscular control of chewing a crispy food was investigated. Participants chewed biscuits of three different levels of crispness under four experimental conditions: no masking, auditory masking, visual masking, and auditory plus visual masking. The order of the four masking condition blocks was randomized. The sound of chewing was masked by loud sounds on a headphone, and visual masking of the food was achieved by closing the eyes. Mechanical tests were performed on the biscuits to determine their characteristics, yield force, and sound production. Skull vibration, jaw-muscle activity, and jaw movement were measured while the subjects chewed and swallowed the food. Auditory and/or visual masking did not have a significant effect on skull vibration, muscle activity, and number of chewing cycles until swallowing. However, auditory and/or visual masking significantly increased the chewing cycle duration, but only for the participants who started the experiments with auditory and/or visual masking. The other participants were not influenced by masking. The memory of the unmodified stimuli helped these subjects to maintain their habitual chewing rate in later trials.

Assessment of mastication with implications for oral rehabilitation: a review.

During chewing, food is reduced in size, while saliva moistens the food and binds the masticated food into a bolus that can be easily swallowed. Characteristics of the oral system, like number of teeth, bite force and salivary flow, will influence the masticatory process. Masticatory function of healthy persons has been studied extensively the last decades. These results were used as a comparison for outcomes of various patient groups. In this review, findings from literature on masticatory function for both healthy persons and patient groups are presented. Masticatory function of patients with compromised dentition appeared to be significantly reduced when compared with the function of healthy controls. The influence of oral rehabilitation, e.g. dental restorations, implant treatment and temporomandibular disorder treatment, on masticatory function will be discussed. For instance, implant treatment was shown to have a significant positive effect on both bite force and masticatory performance. Also, patient satisfaction with an implant-retained prosthesis was high in comparison with the situation before implant treatment. The article also reviews the neuromuscular control of chewing. The jaw muscle activity needed to break solid food is largely reflexly induced. Immediate muscle response is necessary to maintain a constant chewing rhythm under varying food resistance conditions. Finally, the influence of food characteristics on the masticatory process is discussed. Dry and hard products require more chewing cycles before swallowing than moist and soft foods. More time is needed to break the food and to add enough saliva to form a cohesive bolus suitable for swallowing.

ß-TCP versus autologous bone for repair of alveolar clefts in a goat model.

OBJECTIVE: The aim of this study in goats was to test the hypothesis that a novel synthetic bone substitute beta tricalcium phosphate (ß-TCP) can work as well as autologous bone harvested from the iliac crest for grafting and repair of alveolar clefts. DESIGN: Ten adult Dutch milk goats (Capra hircus) were used in a split-mouth study design. MAIN OUTCOME MEASURES: Volumetric histologic assessment of new bone formation and radiographic measurement of orthodontic movement of teeth in a formerly created alveolar cleft. CONCLUSIONS: The synthetic bone substitute ß-TCP was shown to result in bone healing similar to that of iliac crest bone. The surgical, orthodontic, and histologic results now warrant the testing of ß-TCP in the human cleft situation.

Do implant-supported prostheses affect bioavailability of nutrients of complete and partially edentulous patients? A systematic review with meta-analysis.

BACKGROUND & AIMS: Debate still exists about the impact of dental implant-supported prostheses on nutritional status of partially and complete edentulous patients. This review aims to answer the focused question: "Do complete and partial edentulous patients, using implant-supported prostheses, present better nutritional and masticatory functions when compared to those using conventional rehabilitations?". A possible cause-effect relationship between masticatory improvements and nutritional gain was also evaluated. METHODS: Literature search included 6 databases (PubMed/Medline, Embase, LILACS, Scopus, Web of Science, and The Cochrane Library - CENTRAL), grey literature (Google Scholar, Proquest Dissertations and Thesis and Open Grey databases) and manual search (last update June 2020), without language, publication time and follow-up restrictions. We included only studies evaluating both masticatory and nutritional outcomes. The PICO question comprised complete and partial edentulous patients (Population), submitted to implant-supported prostheses (Intervention), in comparison to conventional dental prosthetic rehabilitation, evaluating masticatory function and nutrition parameters (outcomes). Risk of bias was assessed by using Cochrane Collaboration's tool (randomized clinical trials), Joanna Briggs Institute critical appraisal checklist (paired clinical trials), and Meta-Analysis of Statistics Assessment and Review Instrument" (JBI - MAStARI) critical appraisal tools (cohort studies). All meta-analyses were conducted at 5% level of significance. This report followed the PRISMA guidelines. (Review registration PROSPERO - CRD42019135744). RESULTS: We identified 1199 articles while searching databases. Fourteen articles met eligibility criteria, including 817 prostheses installed in 660 patients (mean age = 66.8 years-old). Patients wearing implant overdentures (IOD) presented better masticatory function in comparison to conventional complete denture (CD) wearers (p < 0.05). However, bioavailability of several nutrients remained within the same range, except for serum folate that was lower in IOD patients after 6 (mean difference 3.51 nmol/L; p = 0.01) and 12 months of rehabilitation (mean difference 3.69 nmol/L; p = 0.003). When comparing the effects of CD and IOD rehabilitations along time (for the same patient), serum albumin and vitamin B12 levels also decreased for both groups after 12 months-follow-up, but still within the reference range. The additional retention of the implants did not interfere in body weight, but reduced the risk of malnutrition (using the Mini Nutritional Assessment). Implant-supported partial prostheses also improved mastication in comparison to the conventional ones, increasing short-term daily intake of carbohydrates, protein, calcium, fiber, and iron, whereas decreasing the consumption of cholesterol. However, no long-term changes on bioavailability of most nutrients were observed, expect for a slight increase in ferritin and cholinesterase, and a small reduction in folate and Vitamin A. CONCLUSION: Current evidence indicates significant masticatory improvements for dental fixed implant-supported prostheses in comparison to conventional removable prostheses. However, bioavailability remained stable for most of the nutrients, especially for complete edentulous patients. These results indicate the importance of a multidisciplinary approach during oral rehabilitation (nutrient specialist), in order to enhance food choices and promote health benefits to the patients.

Mandibular implant-supported overdentures and oral function.

OBJECTIVES: Oral rehabilitation by means of implant-retained mandibular overdentures is known to improve oral function. The aim of this study was to evaluate the long-term effects of mandibular implant treatment on oral function. We quantified maximum bite force and masticatory performance 10 years after implant treatment. It was hypothesized that these outcome measures would not change in this period. MATERIALS AND METHODS: Eighteen edentulous patients were scheduled for re-evaluation of their oral function 10 years after they had participated in a randomized cross-over clinical trial. In that trial, they had received two mandibular implants and a new denture with successively magnet-, ball-socket, and bar-clip attachments. RESULTS: At the 10-year follow-up, 14 of the initial 18 patients participated in the evaluation. As a result of the implant treatment, the average maximum bite force more than doubled, from 162 to 341 N, whereas the average number of chewing cycles to halve the initial particle size decreased from 55 to 27 cycles. No significant changes in maximum bite force and masticatory performance were observed after 10 years. However, the average maximum bite force obtained with implant-retained overdentures is still significantly lower than that of dentate subjects (569 N). CONCLUSION: Maximum bite force and masticatory performance significantly increased after implant treatment and remained unaltered during the following 10-year period. Thus, implant treatment greatly improves oral function for a long period of time.

Oral function after oncological intervention in the oral cavity: a retrospective study.

PURPOSE: To assess self-perceived oral function of patients with oral cavity cancer at different stages of treatment, ie, before oncologic intervention, 5 weeks after intervention, and 5 years after intervention. PATIENTS AND METHODS: A cohort of 158 patients with malignancy in the oral cavity treated by surgery in 1999 or 2000 was included. From this cohort we interviewed 69 patients by telephone in 2005 and collected data on dental status, disorders of chewing and swallowing, xerostomia, preference of food consistency, tube nutrition, weight loss, and speech for different stages of treatment. RESULTS: For patients treated in the maxilla region we observed a significant (P < .05) recovery of perceived chewing ability after 5 years to the level experienced before oncologic intervention. Patients treated in the mandible region reported a deteriorated dental state, chewing ability, lip competence, and xerostomia after 5 years. Patients treated in the tongue and mouth-floor region experienced deterioration for dental state, chewing ability, and xerostomia after 5 years compared with the level before the oncologic intervention. CONCLUSIONS: Our telephone interview on oral function provided supplementary information on how patients experienced their problems with oral function during various phases of oncologic treatment. A retrospective interview may thus help to add information to incomplete retrospective data.

Orthodontic treatment results following grafting autologous mandibular bone to the alveolar cleft in patients with a complete unilateral cleft.

OBJECTIVE: To analyze orthodontic treatment results following mandibular symphysis bone grafting and postoperative orthodontic treatment. DESIGN: Randomized selection of 75 patients out of 308 with unilateral cleft of lip, alveolus, and palate, operated upon according to protocol between 1990 and 2008 in the Wilhelmina Children's Hospital, Utrecht, The Netherlands. MAIN OUTCOME MEASURE: Goslon Yardstick rating changes of dental arch relationship. Significant agreement (p < .001) was observed between the two assessments carried out with an interval of 3 months (Cohen's kappa = .963, p < .001). RESULTS: Following mandibular bone grafting and orthodontic treatment in 65.3% of the patients, the aim of treatment (Goslon Yardstick groups 1 and 2) had been achieved. The applied before/after Goslon allocations showed high improvement significance (p < .001). CONCLUSIONS: Postoperative orthodontic treatment in patients following grafting with mandibular symphysis bone showed excellent results.

Masticatory function and related factors after oral oncological treatment: A 5-year prospective study.

BACKGROUND: Chewing ability is often compromised in patients with oral cancer. The aim of this study was to identify which factors affect masticatory performance in these patients. METHODS: Patients with primary oral cancer were assessed for up to 5 years after primary treatment. Healthy controls were assessed once. A mixed-model analysis was performed, with masticatory performance as outcome measure. RESULTS: A total of 123 patients were included in the study. Factors positively associated with masticatory performance were number of occlusal units (OU), having functional dentures, and maximum mouth opening (MMO). The impact of tumor location and maximum bite force (MBF) differed per assessment moment. Masticatory performance declined for up to 1 year but recovered at 5 years after treatment. CONCLUSION: Masticatory performance in patients treated for oral cancer is affected by MBF, MMO, number of OU, and dental status. These should be the focus of posttreatment therapy.

Smartphone use while eating increases caloric ingestion.

The use of smartphones during meals may possibly influence the number of ingested calories. We evaluated the influence of smartphones' distraction during eating on caloric intake. Physical (masticatory parameters, sex and body mass index - BMI); environmental (with or without distraction) and psychological (stress levels) variables were evaluated as confounding factors. Sixty-two adults were recruited for experimental snack tests performed on four different days. At baseline, we evaluated masticatory performance, swallowing threshold, masticatory frequency and body mass index (BMI). In the following three sessions, volunteers were presented a snack test in which participants ate under three experimental conditions: no distraction, using their smartphones, or reading a printed text. At the end of each session, total and nutritional compound stratified caloric intake was measured. Three-way mixed model ANOVA was used to test the effect of experimental condition on the total, carbohydrate and lipid caloric intakes. Hierarchical multiple linear regression models were used to estimate the influence of confounding factors on the total caloric intake. We found an effect of the condition (no distraction, smartphone or reading) on the total caloric (p = .007) and lipid intake (p = .002). When eating without distraction, the mean caloric intake was 535 (±164) kcal, in comparison to 591 (±203) kcal using smartphone (p = .05) and 622 (±226) kcal (p = .002) reading a text (no significant difference between distracters). Eating with distracters increased approximately 15% caloric ingestion. An interaction condition*sex effect was observed on lipid intake (p = .020). Energy intake was found to be dependent on sex and age, in which older men ingested more calories. Smartphone use during a meal increased caloric and lipid intake, depending on sex and age in young adults with complete dentition.

Bite force and electromyograpy during maximum unilateral and bilateral clenching.

Maximum voluntary bite force has often been studied as an indicator of the functional state of the masticatory system. Bilateral, as well as unilateral, methods have been used to determine bite force. Only a few studies have compared the outcomes of both methods. The aim of this study was to measure bite force and jaw-muscle activity during bilateral as well as unilateral maximum clenching in a large number of healthy subjects, so that the results could be compared. In a group of 81 dentate subjects we observed an average bilateral bite force of 569 N. The average unilateral bite force was significantly lower, being 430 N (right) and 429 N (left). Masseter and anterior temporal muscle activities were also significantly lower during unilateral clenching as compared with bilateral clenching. The masseter muscles showed no difference in activity between the ipsilateral side and the contralateral side during unilateral clenching. In contrast, the activity of the anterior temporal muscle on the ipsilateral side was significantly higher than on the contralateral side. Thus, the change in the forces acting on the jaw during unilateral clenching compared with bilateral clenching leads to a different response in the temporal muscles than in the masseter muscles.

Long-term reliable change of pain scores in individual myogenous TMD patients.

A within-patient change in pain score after treatment is statistically 'reliable' when it exceeds the smallest detectable difference (SDD). The aims of the present study were to: (i) determine SDDs for VAS-scores of pain intensity, for sufficiently long test-retest intervals to include most biological fluctuations, (ii) examine whether SDD is invariant to baseline score, and (iii) discuss the value of reliable change (RC) for detecting clinically important difference (CID) or as a possible indicator of successful treatment. SDDs were determined using duplicate data from 118 patients with myogenous Temporomandibular disorders: (1) VAS-scores of pain intensity from the masticatory system in a pre-treatment diary, and (2) VAS-scores of pain intensity from the hand (cold-pressor test). RC was determined in VAS-scores from a pre- and post-treatment questionnaire. The long-term SDD was 49mm. A regression analysis on duplicate VAS-scores showed that SDD was largely invariant to the baseline level. Because RC (change>SDD) exceeded CID, it might serve as an indicator of successful treatment. However, only 17% of the patients showed RC after treatment, mainly because the baseline was smaller than SDD in 67% of the patients thus making detection of any treatment effect impossible. For patients with possible detection (33%), the frequency of RC was 51%. If the detection threshold would be avoided by provoking pain in patients with a low baseline, a long-term RC in VAS-scores might occur in about half of all myogenous TMD patients and might then serve as an indicator of cases of treatment success.

Functional roles of oral reflexes in chewing and biting: phase-, task- and site-dependent reflex sensitivity.

Because loading during chewing is not totally predictable and jaw-closing muscles are strong and act over short distances, feedback from oral receptors is important in the control of mastication. Information on such feedback can be obtained by studying reflexes in jaw muscle EMGs. This review will deal with the contribution of reflex mechanisms to modifying motor neuron activity during chewing, and the dependency of reflex sensitivity on motor task, phase of movement, and site of stimulation.

The effect of saliva composition on texture perception of semi-solids.

Saliva is expected to be of significance for the perception of food stimuli in the mouth. Mixing the food with saliva, including breakdown and dilution, is considered to be of large importance for semi-solids as these products are masticated without chewing. It is known that there are large variations in composition of saliva originating from different glands and different subjects. In this study we investigated how variations in salivary characteristics affect sensory perception. Eighteen trained subjects participated in the study. Saliva was collected at rest and during three types of stimulation (odour, parafilm chewing and citric acid), and flow rates were determined. The collected saliva was analyzed for protein concentration, buffer capacity, mucin level and alpha-amylase activity. The salivary components measured in this study varied considerably among subjects, but also within subjects as a result of different means of stimulation. Variations in salivary components were correlated with sensory perception of a number of flavour, mouth feel and after feel attributes in the semi-solids mayonnaise and custard dessert. Total protein concentration and alpha-amylase activity were observed to correlate most strongly with texture perception.

Effects of added fluids on the perception of solid food.

The production of sufficient saliva is indispensable for good chewing. Recent research has demonstrated that salivary flow rate has little influence on the swallowing threshold. We examined the hypothesis that adding fluid to a food will influence the chewing process. Twenty healthy subjects chewed on melba toast, breakfast cake, carrot, peanut and Gouda cheese. In addition they chewed on these foods after we added different volumes of tap water or a solution of alpha-amylase. We measured jaw muscle activity and the number of cycles until swallowing. Furthermore, we obtained visual analogue scale (VAS) scores for texture and sound attributes for all foods and fluid conditions. The additional fluids significantly lowered muscle activity and swallowing threshold for melba, cake and peanut. The effect of alpha-amylase in the solutions was rather limited. Doubling the volume of tap water had a larger effect. Several texture and sound attributes of melba, cake and peanut were also significantly affected by the additional fluids. For melba, cake, and peanut we observed significant correlations between the physiology parameters and several attributes for the various fluid conditions. This indicates that the added fluid affects both the physiology (muscle activity and number of cycles) and the sensory perception of a number of texture and sound attributes. Adding fluid facilitates the chewing of dry foods (melba, cake), but does not influence the chewing of fatty (cheese) and wet products (carrot).

Relating particles and texture perception.

Practically all foods contain particles. It has been suggested that the presence of particles in food may affect the perception of sensory attributes. In the present study we investigated the effect of size and type (hardness and shape) of particles added to a CMC based vanilla custard dessert. The two types of particles included in the study were silica dioxide and polystyrene spheres, varying in size from 2 to 230 microm. Eighteen trained adults participated in the study. They rated the sensation of 17 sensory flavour and texture attributes on a 100-point visual analogue scale (VAS). The results indicate that the addition of particles increased the sensation of roughness attributes and decreased the ratings of a number of presumably favorable texture attributes (smoothness, creamy, fatty and slippery) significantly. These effects increased with increasing particle size up to 80 microm. Roughness ratings deceased for larger particles sizes. Surprisingly, even particles of 2 microm had significant effects: they increased perceived rough lip-tooth feel, and decreased slippery lip-tooth feel and smoothness of the product. The affected attributes had previously been related to lubricative properties of foods. Particles added to semi-solid foods with relatively low levels of fat seem to counteract the lubricating effects of the fat resulting in increased oral friction. In a separate study on size perception the silica dioxide particles were used. By sampling the stimuli between the tongue and palate, subjects rated the size of the particles on a 100-point scale in comparison to anchor stimuli containing no particles and particles of 250 microm. The perceived particle size significantly increased for larger particles. Furthermore, perceived particle size was negatively correlated with roughness ratings. Thus, subjects who were sensitive and perceived the particles as being relatively large reported the same stimuli to have less rough after-feel. In conclusion, particles added to a product induce large effects on texture sensations, and texture sensation is related to individual size perception.

The influence of product and oral characteristics on swallowing.

The urge to swallow food could be triggered by a threshold level in both food particle size and lubrication of the food bolus. Thus, both oral physiology and product characteristics may influence the swallowing threshold. We quantified the swallowing threshold in a group of 266 healthy adult subjects (age 42 +/- 12 years) by counting the number of chewing cycles needed to prepare food for swallowing. The influence of oral physiology on the swallowing threshold was determined by measuring salivary flow rate, maximum bite force and masticatory performance. We used about 10 cm(3) of bread, toast, melba toast, breakfast cake, peanuts and cheese to determine the influence on the swallowing threshold of various food characteristics, e.g. hardness, moisture and fat. Furthermore, we tested the effect of buttering the bread, toast, melba toast and breakfast cake on the swallowing threshold. Salivary flow rates were significantly and negatively correlated with the number of chewing cycles of melba toast and breakfast cake. Hence, subjects with more saliva needed less chewing cycles for these dry products. Maximum bite force and masticatory performance had an influence on the swallowing threshold for the hard products only (carrot and peanut). Although significant, the correlation coefficients were less than 0.28. Thus, the oral physiology parameters explained less than 10% of the variance in the swallowing threshold. We found significantly different numbers of chewing cycles for the various foods, ranging from 17 for cake to 63 for carrot. Hard and dry products needed more chewing cycles until swallowing. Buttering the food significantly reduced the number of chewing cycles needed before swallowing. This was especially true for the dry products cake, melba toast and toast. Hard and dry products require more chewing cycles and longer time in mouth until swallowing for sufficient breakdown to take place and for enough saliva to be added to form a coherent bolus safe for swallowing. In spite of this, more saliva, higher maximum bite force and better masticatory performance were only weakly correlated with a smaller number of chewing cycles. Butter enhanced lubrication and bolus formation of dry products, thus reducing the number of chewing cycles until swallowing. In conclusion, product characteristics and to a lesser extent oral physiology significantly affect swallowing threshold.

Health-related quality of life after segmental resection of the lateral mandible: Free fibula flap versus plate reconstruction.

OBJECTIVES: Segmental resection of the mandible causes functional, aesthetic and social problems affecting health-related quality of life (HRQoL). It is often assumed that reconstruction with composite free flaps guarantees better function and aesthetics than bridging the defect with reconstruction plates. METHODS: Using the European Organization for Research and Treatment of Cancer questionnaires (EORTC QLQ-C30 version 3.0 and EORTC QLQ-H&N35), we compared HRQoL in patients who received free fibula flaps versus reconstruction plates after segmental resection of the lateral mandible. RESULTS: Thirty-seven completed questionnaires (18 fibula reconstructions and 19 patients with reconstruction plates) were available. Reconstruction with a free fibula flap did not provide clear additional benefit to bridging the defect with a reconstruction plate after segmental resection of the lateral mandible. In particular aspects known to have the most impact on HRQoL like swallowing, speech and chewing were not influenced by the type of reconstruction. CONCLUSIONS: Reconstruction of segmental defects of the lateral mandible with free fibula flap and reconstruction plate resulted in comparable HRQoL. If dental rehabilitation by means of dental implants is not anticipated in the fibula, then plate reconstruction with adequate soft tissue remains a suitable technique for the reconstruction of segmental defects of the lateral mandible.