Minimally Invasive Mandibular Microsurgery: A Systematic Review and Meta-analysis

Background:

Microsurgical advances have led to minimally invasive approaches for mandibular reconstruction. Currently, no resource compares all minimally invasive microvascular mandibular reconstruction (MIMMR) treatment options.

Methods:

All known cases of MIMMR were identified following the Preferred Reporting Items for Systematic Reviews, Meta-Analyses guidelines, and our own surgical experience. Patient demographics, MIMMR type [submandibular (SM), modified facelift/retroauricular (MFL/RA), or intraoral (IO)], methodology, and clinical outcomes were analyzed with the Fisher exact and Kruskal-Wallis tests.

Results:

Forty-seven patients underwent MIMMR. Ameloblastoma was the most common pathology treated using all approaches, and MFL/RA was the only approach used to treat squamous cell carcinoma (P = 0.0103). Reconstruction was reported for large, bilateral defects only via the SM or IO approach (P = 0.0216). The iliac crest or fibula was used as a donor site. The facial artery was the most common recipient vessel using the IO and SM approaches, whereas the superior thyroid and external carotid vessels were the most common in the MFL/RA approach (P < 0.0001). Virtual planning was used in all cases performed via an IO approach, 80.0% of cases using an SM approach, and no MFL/RA cases (P < 0.0001). Good aesthetic and functional outcomes were reported for every patient, and there was no difference in complication rates (P = 0.2880).

Conclusions:

Minimally invasive approaches are safe and effective treatment options for patients requiring mandibular microsurgery, usually in the setting of benign pathology. The IO and SM approaches usually rely on the facial vessels, whereas the MFL/RA approach permits access to the superior thyroid and external carotid vessels and cervical lymphadenectomy.

Takeaways

Question: How do minimally invasive microvascular mandibular reconstruction treatment options compare to each other?

Findings: A systemic review identified three minimally invasive approaches that have been utilized for microvascular mandibular reconstruction. The intraoral and submandibular approaches usually rely on the facial vessels, while the modified face lift/retroauricular approach permits access to the superior thyroid and external carotid vessels in addition to cervical lymphadenectomy.

Meaning: Minimally invasive approaches are safe and effective treatment options for patients requiring mandibular microsurgery, usually in the setting of benign pathology.

INTRODUCTION

Traditionally, free vascularized tissue grafts have been inset into mandibular defects using a large transcervical incision, possibly including a lip split.^1–3 The utility of this approach has consistently been demonstrated for benign and malignant conditions necessitating a segmental mandibulectomy, enabling functional and aesthetic restoration of the jaw.^1,4 Recently, microvascular reconstruction of the mandible has been described using a small access neck incision or no skin incision at all. This development is consistent with trends toward minimally invasive surgery in multiple fields, with potential benefits including reduced pain, shorter hospitalizations, and improved cosmesis.⁵ The indications and outcomes associated with minimally invasive microvascular reconstruction of the mandible have not been comprehensively assessed.

Here, we systematically assess three minimal access approaches that have been described in the literature. All involve intraoral (IO) delivery of the vascularized bone graft with microvascular anastomosis performed via a submandibular (SM) incision, a modified facelift/retroauricular (MFL/RA) incision, or an IO incision in the buccal mucosa.^2,3,6–15 By investigating the outcomes of each approach, we aim to assess their safety and value.

METHODS

Literature Review

A literature search was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines (Fig. 1).¹⁶ PubMed was used to search all available literature from inception to September 2022 utilizing permutations of the key terms “minimally invasive,” “stereolithographic,” “intraoral,” “transoral,” “endoscopic,” “microvascular,” “mandible,” “face,” “alveolar ridge,” “midface,” “flap,” and “reconstruction.” Additional articles were identified through a review of citations from articles captured in the primary search. All studies included in this review were reported in the English language, reported minimally invasive mandibular reconstruction with vascularized bone grafts on humans, and had clearly defined surgical techniques. Three surgical cases from our institution fitting the above criteria were also included in the analysis.

Fig. 1.

Preferred Reporting Items for Systemic Reviews and Meta-Analyses 2020 flow diagram detailing the systemic literature review performed to identify cases of MIMMR.

Data Abstraction and Statistical Analysis

Data extracted included patient demographics, diagnosis, location of defect, donor site, use of virtual planning, complications, and functional and aesthetic outcomes. The location of defects was then classified per the Jewer classification system. In this system, H represents a lateral defect of any length including the condyle without significantly crossing the midline.¹⁷ L defects are lateral defects without condylar involvement, while central mandibular segment defects are represented by C.¹⁷ These letters may be combined (such as LCL—an angle-to-angle defect) to represent all possible mandibular defects.¹⁷ Outcomes were classified as “good” or “poor” based on author’s interpretations of descriptors used in original articles. Data management and statistical analyses were performed using SAS software (version 9.4) (Copyright (c) 2002-2012 by SAS Institute Inc., Cary, NC, USA. All Rights Reserved). Categorical variables were summarized with percentages, and continuous variables were summarized by median, mean, and SD. The Fisher exact test was used to test associations for categorical variables due to cells with expected counts of less than five. Similarly, the Kruskal-Wallis test was used to make global comparisons of the medians across the three groups. Statistical significance was set at 0.05.

Operative Technique: Submandibular Approach

The following technique was utilized on the three patients at our institution included in this study. A 3-cm incision is designed in a neck crease at least two fingerbreadths below the mandible. A subplatysmal flap is elevated keeping the marginal mandibular nerve protected in the upper cervical flap. The facial vein is reflected inferiorly, and the facial artery is dissected from the posterolateral aspect of the SM gland. In some cases, the SM gland is removed to create space for the flap pedicle. A transoral incision along the mandibular alveolar ridge enables exposure of the mandible and delivery of a cutting guide. Bilateral mandibular osteotomies are performed. In some instances, the posterior osteotomy is made using the minimal access SM approach. Following removal of the mandibular specimen, the genioglossus and geniohyoid muscles are tagged for future reinsertion. The fibular flap is harvested, and a custom cutting guide is used to create osteotomies to shape the fibula before plate fixation on the leg and pedicle division. The flap pedicle is then drawn into the SM neck as the flap is parachuted into the mouth. Sutures anchored to the genioglossus are passed through drill holes in the central segment of the fibular reconstruction. The bone is then fixated to the predrilled holes in the native mandible. Microvascular anastomosis is performed before closure of oral and neck incisions. (See Video 1 [online], which shows the resection of the mandible utilizing the SM approach; see Video 2 [online], which shows the reconstruction of the mandible utilizing the SM approach.) Patients who underwent this style of minimally invasive approach, performed by Jacobsen et al,² Bianchi et al,¹¹ Diaz-Carandell et al,¹² and Givol et al,¹³ were also included in this study.

Video 1. This video demonstrates the resection of the mandible utilizing the submandibular approach.

Download video file ^{(124.5MB, mp4)}

Video 2. This video demonstrates the reconstruction of the mandible utilizing the submandibular approach.

Download video file ^{(125MB, mp4)}

Operative Technique: Modified Facelift/Retroauricular Approach

The MFL/RA is a technique that utilizes a pretragal rhytidectomy incision with an extension to the retroauricular region.^3,14 Per Garcia-Diez et al,¹⁴ an anterior skin flap is raised, and the parotid gland is exposed. The gland is carefully dissected and retracted superiorly to expose the mandibular ramus and body. Care is taken to preserve superficial temporal vessels, the external carotid artery and external jugular vein, and the occipital vessels as these are potential recipients. The IO incision is developed similar to the SM approach, with a tunnel created between the two incisions. Before osteotomy, a reconstruction plate is placed over the defect and bent to fit the contour of the native mandible. Anterior mandibular osteotomy is subsequently performed using the IO approach, whereas posterior osteotomy is performed through the MFL/RA incision. Flap harvest is performed in a standard fashion, fixed to the reconstruction plate, and introduced to the defect via the transoral approach. The MFL/RA incision is utilized to perform the microvascular anastomosis. Of note, Kim et al³ utilized this approach to perform an endoscopic or robotic neck dissection before mandibular resection and reconstruction.

Operative Technique: Intraoral Approach

Similar to the previous two approaches, an incision is made along the mandibular alveolar ridge, and the mandible is exposed.^6–10,15 Per Lim et al,⁶ preformed cutting guides are placed with predictive drill holes, and the diseased bone is resected. In cases of immediate reconstruction, the facial artery and vein are palpated intraorally or via Doppler before the creation of a vertical buccal mucosa incision. Next, the vessels are dissected, taking care to protect branches of the facial nerve while creating enough length for mobilization. During this dissection, the vascularized bone flap is harvested in standard fashion and shaped with a custom cutting guide to fit the patient-specific reconstructive plate. Authors vary slightly in regard to the next reconstructive step, with successful reports of anastomosis via the vertical buccal incision followed by construct placement,⁹ and placement of construct followed by anastomosis.⁶ Delayed reconstruction with IO microvascular bone graft has also been successfully reported, in which a prebent reconstruction plate was used to stabilize the mandible until definitive reconstruction occurred 6 weeks later.⁸

RESULTS

We identified a total of 47 patients (18 men and 29 women) with a mean age 35.8 years (range, 6–74) who underwent MIMMR (Tables 1–4). There was no significant difference in patient age among the three groups (P = 0.0809). The most common diagnosis was ameloblastoma (59.6%) followed by ossifying fibroma (10.6%), oral cavity squamous cell carcinoma (SCC) (8.5%), and osteonecrosis (4.3%). The MFL/RA approach was the only one utilized to treat SCC. A difference in diagnosis was found between the three approaches (P = 0.0103).

Table 1.

Case Information for All Patients Undergoing MIMMR via Submandibular Approach

Patient	Age/Gender	Diagnosis	Defect Location	Donor Site	Recipient Vessels	Complications	Virtual Planning	Functional Recovery	Aesthetic Outcome	Source
1	12 F	Ameloblastoma	LC	Fibula	Facial artery/facial vein	No	Yes	Good	Good	Self
2	23 M	Mandibular juvenile ossifying fibroma	LCL	Fibula	Facial artery/facial vein	Neck hematoma	Yes	Good	Good	Self
3	74 F	Mandibular osteomyelitis	LC	Fibula	Facial artery/facial vein	Donor site infection	Yes	Good	Good	Self
4	38 M	Ameloblastoma	LC	Fibula	Facial artery/internal jugular vein	No	Yes	Good	Good	Bianchi et al11 2008
5	52 F	Osteonecrosis	LCL	Fibula	Facial artery/internal jugular vein	No	Yes	Good	Good	Bianchi et al11 2008
6	27 M	Ameloblastoma	L	Fibula	Facial artery/ facial vein	No	Yes	Good	Good	Diaz-Carandell et al12 2014
7	17 F	Desmoplastic fibroma	C	Iliac crest	Facial artery/facial vein	No	No	Good	Good	Givol et al13 1998
8	40 M	Osteogenic sarcoma	L	Iliac crest	Facial artery/facial vein	No	No	Good	Good	Givol et al13 1998
9	26 F	Ameloblastoma	LCL	Fibula	Facial artery/facial vein	No	Yes	Good	Good	Jacobsen et al2 2015
10	26 M	Ameloblastoma	L	Fibula	Facial artery/facial vein	No	Yes	Good	Good	Sun et al15 2022

Table 4.

Comparison among Three MIMMR Approaches

	Submandibular, N = 10	RA/MFL, N = 12	Intraoral, N = 25	P
Age	Median, mean ± SD
	26.5, 33.5 ± 18.4	42.5, 42.3 ± 11.0	32.0, 33.6 ± 11.7	0.081
Diagnosis, N (%)
Ameloblastoma	5 (50.0)	6 (50)	17 (68.0)	0.0103
Ossifying fibroma	1 (10.0)	0 (0)	4 (16.0)
SCC	0 (0)	4 (33.3)	0 (0)
Defect location, N (%)
L	3 (30.0)	11 (91.7)	15 (60.0)	0.0216
LCL	3 (30.0)	0 (0)	2 (8.0)
LC	3 (30.3)	1 (8.3)	2 (8.0)
Donor site, N (%)
Fibula	8 (80.0)	6 (50)	19 (76.0)	0.2325
Iliac crest	2 (20.0)	6 (50)	6 (24.0)
Recipient vessels, N (%)
Facial artery/facial vein	8 (80.0)	0 (0)	15 (100)	<0.0001
Superior thyroid artery/branch of IJV	0 (0)	4 (33.3)	0
External carotid artery/EJV	0 (0)	3 (25)	0
Use of virtual planning	8 (80.0)	0 (0)	25 (100)	<0.0001
Good functional outcome	10 (100)	12 (100)	25 (100)	1
Good aesthetic outcome	10 (100)	12 (100)	25 (100)	1
Complications	2 (20.0)	4 (33.3)	3 (12.0)	0.2880

All diagnoses, defect locations, and recipient vessels were incorporated in the statistical analysis to determine whether there was a difference based on MIMMR type. Only the most frequent three results are shown in the table for ease of presentation; the remainder is listed in Tables 1–3. With respect to the recipient vessels for the IO approach, N = 15 instead of 25 as ten articles did not specify vessels used.

P < 0.05 denotes statistical significance.

EJV, external jugular vein; IJV, internal jugular vein.

A variety of defect locations were treated between the three approaches, including L (61.7%), LC (12.8%), LCL (10.6%), H (10.6%), and C (4.3%). The SM approach treated 60% of the total LCL defects, while 91.7% of defects treated by the RA/MFL approach were classified as L. The three approaches were found to differ significantly in regard to defect location (P = 0.0216). The fibula (70.2%) was more frequently used as a donor site than the iliac crest out of all cases, and donor site was not found to differ significantly among approaches (P = 0.2325). Virtual planning was utilized in a majority of cases (70.2%). However, virtual planning was not utilized for the MFL/RA approach (P < 0.0001).

The most common recipient vessels included the facial artery and vein (62.16%), the superficial thyroid artery and branch of the internal jugular vein (10.8%), and the external carotid artery and external jugular vein (8.1%). Ten cases did not specify which vessels were used (21.3%). The facial artery and vein were the most common vessels utilized in the SM (80.0%) and IO (100.0%) approaches, wheres the superior thyroid artery was favored in the MFL approach (33.3%). A difference in recipient vessels was found among the three approaches (P < 0.0001).

Only two articles mentioned operative times. One author detailing the IO approach stated that preparation of vessels intraorally took 30–60 minutes, with no mention of total time to perform resection or reconstruction.¹⁰ The mean operation time for mandibulectomy and neck dissection via the MFL/RA approach by Kim et al was 82 and 156 minutes, respectively. Kim et al went on to state the MFL/RA approach results in longer operation times for the mandibulectomy, neck dissection, and reconstruction; however, operative time could be reduced with further experience.

Nine patients experienced minor complications including anesthesia to the lower lip (6.3%), transient marginal mandibular nerve weakness (4.3%), donor site infection (4.3%), or hematoma (4.3%). Flap loss was only noted in one patient (2.1%). All patients were noted to have a good functional and aesthetic recovery. No difference in complication rate (P = 0.2880) and functional (P = 1.0) and aesthetic outcomes (P = 1.0) was found among the three approaches.

DISCUSSION

To our knowledge, this is the first meta-analysis of patients undergoing MIMMR. The 47 patients identified in this study demonstrate that microvascular reconstruction of the mandible can be safely performed with a low flap loss rate of 2.1%. The one flap loss occurred via the MFL/RA approach and was due to an infected cervical hematoma in the postoperative period.¹⁴ The patient was initially managed with surgical drainage and intravenous antibiotics. Due to recurrent infections over the next 3 months, however, it was elected to substitute the iliac crest flap with a fibular free flap, ultimately resulting in good functional and aesthetic outcomes.¹⁴ In comparison, flap loss rate via traditional methods of mandibular reconstruction has been reported to be twice as high at 5.2% in a 2015 study evaluating more than 1200 free flaps.¹⁸ Minor complications, including infection and hematoma, are comparable to, if not better, than rates using conventional approaches.^18–20 However, the small sample size in this study does not allow for a robust comparison.

Interestingly, we found that MIMMR is being used for a predominantly young patient population. The mean patient age of 35.8 in this study is much younger than the mean age of 58.75 (range, 38–67), for patients undergoing head and neck reconstruction using traditional open approaches.²⁰ This suggests that surgeons are choosing a MIMMR approach for younger patients who potentially have more to gain from a minimal access approach in terms of function, aesthetics, and quality of life. This finding could also be due to the differences in pathology. For example, the average age of patients diagnosed with ameloblastoma is 33.3 years,²¹ whereas the average age of patients diagnosed with oropharyngeal cancer is 63.²² Although there was no statistical significance among the three approaches with respect to patient age, patients who underwent the RA/MFL approach were older. This trend could be due to the malignant pathology addressed in this approach. Future studies that investigate patient-reported experiences with the MIMMR approach would be of value in further defining the indications and value of this technique.

The SM approach was the first MIMMR approach introduced in the literature and perhaps the most practical for benign pathology or malignant pathology such as osteosarcoma that does not mandate neck dissection. Angle-to-angle resection and reconstruction of the mandible have been demonstrated using a 3-cm access in the SM neck, leaving the patient with a largely inconspicuous scar. In the authors’ own experience, we have been able to easily perform a suprahyoid neck dissection or simple SM gland excision through this access point to create space for the flap pedicle, and also have the opportunity to access the superior thyroid vessels if needed. Virtual planning has been an essential development to overcome the obstacle of shaping and delivering the mandibular reconstruction transorally,² as demonstrated by the fact that 80.0% of cases performed using the SM approach involved virtual planning.

Oncologic resection requiring neck dissection was permitted with the MFL/RA approach, making this a unique approach to consider for the head and neck cancer patients. All patients who underwent this approach had the desired oncologic, in addition to functional and aesthetic, outcomes. Additionally, none of the patients developed lymphedema, possibly due to the improved lymphatic drainage through the preserved cervical soft tissues.³ The MFL/RA approach, however, was not described in the context of anterior or midline mandibular masses (P = 0.0216). It is possible that this was due to the fact that the lip or chin soft tissues were involved, precluding a minimal access approach. Alternatively, the authors in these studies did not use virtual planning and were, therefore, limited in shaping the reconstruction through the MFL/RA access point. Nonetheless, the practicality of limiting neck incisions on a cancer patient is questionable, because in many instances, a transcervical incision is hardly the most morbid aspect of their care. For a patient with multiple comorbidities who is anticipating adjuvant radiation treatment and may have a poor prognosis, the extra time required in the operating room to avoid a lengthier incision may not be in his or her interest.^3,14 Further studies would be required to better understand the potential benefits in the oncologic setting. Ultimately, however, these approaches appear to be predominantly beneficial for benign disease and have less utility for malignancy.

The least invasive approach for microvascular reconstruction of the mandible is the IO approach, which avoids all cutaneous incisions and was demonstrated to provide good functional and aesthetic results. The possibility of IO anastomosis of bone flaps was first introduced in the literature in 2009 for alveolar ridge anastomosis.²³ This technique was then adopted for segmental mandibular reconstruction. All cases which specified recipient vessels utilized the facial vessels during reconstruction.^8–10 However, theoretically, the labial vessels could also be accessed through the vertical buccal mucosa incision. As different vessels are available at different anatomical locations (buccal mucosa versus retroauricular incisions), it is understandable that there is a significant difference in recipient vessels among the three approaches (P < 0.0001).

Due to limited exposure, the IO technique heavily relies on virtual planning, which was reported in 100% of cases. It has been shown to be effective for large bilateral defects (8.0%), but theoretically, longer operative times would be required due to the additional time required for IO microvascular anastomosis. One author reported that it took 30 to 60 minutes simply for IO vessel preparation.¹⁰ The authors did not discuss whether a transbuccal trocar was used for plate fixation at the posterior aspect of the mandibular reconstruction, which would require a small cheek incision. Additional opportunities for inquiry would be to understand how the mental nerve is handled using an IO approach and whether additional stretch on the nerve impacts sensory outcomes.

This meta-analysis is limited in comparison of aesthetic and functional outcomes among the three approaches. Due to the subjective nature and different methods of reporting functional and aesthetic outcomes, we simplified outcome to be “good” or “poor” based on descriptors used in original articles. As a result of our binary grading scheme, we were unable to identify an approach with superior aesthetic or functional results. As the IO approach has no incisions, it is possible that this procedure has a better aesthetic outcome than the other two approaches. We can state, however, that there is no difference in complication rates among the three approaches (P = 0.2880). Our study is further limited by not having more granular data on patient-reported outcomes. An opportunity for future investigation would be to study the experiences of patients undergoing MIMMR and to investigate the procedure’s impact on their quality of life compared with patients undergoing reconstruction via conventional methods.

Another metric that was unable to be assessed in this study was difference in operative time among the three methods, as it was not reported for all approaches. Two-team approaches were utilized in all three techniques, with 42% of reviewed papers opting for this collaborative method that can potentially reduce operative time.^3,6,11–13 Additional studies investigating differences in operative time would further assist providers in choosing the best MIMMR approach for their patient.

CONCLUSIONS

Minimally invasive approaches are safe and effective treatment options for patients requiring mandibular reconstruction secondary to benign etiologies. While the MFL/RA approach may benefit select cancer patients, technical difficulties and long operative times suggest physicians lean toward the other two approaches when considering MIMMR for their patients. Both the SM and IO approaches permit resection and reconstruction of large, bilateral lesions, and provide good functional and aesthetic outcomes.

Table 2.

Case Information for All Patients Undergoing MIMMR via MFL/RA Approach

Patient	Age/Gender	Diagnosis (pTNM)	Neck Dissection/Approach	Defect Location	Donor Site	Recipient Vessels	Complications	Virtual Planning	Functional Recovery	Aesthetic Outcome	Source
1	34 M	Ameloblastoma	No	L	Iliac crest	External carotid artery/occipital vein	No	No	Good	Good	Garcia-Diez et al14 2013
2	28 F	Ameloblastoma	No	LC	Fibula	External carotid artery/internal jugular vein	Transient marginal weakness	No	Good	Good	Garcia-Diez et al14 2013
3	32 F	Ameloblastoma	No	L	Iliac crest	External carotid artery/external jugular vein	No	No	Good	Good	Garcia-Diez et al14 2013
4	47 F	Ameloblastoma	No	L	Iliac crest	External carotid artery/external jugular vein	No	No	Good	Good	Garcia-Diez et al14 2013
5	50 M	Myxoma	No	L	Iliac crest	External carotid artery/external jugular vein	No	No	Good	Good	Garcia-Diez et al14 2013
6	38 F	Ameloblastoma	No	L	Iliac crest	Superficial temporal artery/superficial temporal vein	Flap loss	No	Good	Good	Garcia-Diez et al14 2013
7	34 M	Ameloblastoma	No	L	Iliac crest	Superficial temporal artery/external jugular vein	Infection of donor site	No	Good	Good	Garcia-Diez et al14 2013
8	29 F	Mesenchymal chondrosarcoma (T2N0M0)	Yes, robot assisted via MFL incision	L	Fibula	Superior thyroid artery, branch of internal jugular vein	Transient marginal weakness	No	Good	Good	Kim et al 20153
9	59 F	SCC (T4aN1M0)	Yes, robot assisted via RA incision	L	Fibula	Facial artery, branch of internal jugular vein	No	No	Good	Good	Kim et al 20153
10	49 M	SCC (T2N0M0)	Yes, endoscopic via MFL incision	L	Fibula	Superior thyroid artery, branch of internal jugular vein	No	No	Good	Good	Kim et al 20153
11	56 F	SCC (T2N0M0)	Yes, endoscopic via MFL incision	L	Fibula	Superior thyroid artery, branch of internal jugular vein	No	No	Good	Good	Kim et al 20153
12	52 M	SCC (T3N1M0)	Yes, endoscopic via MFL incision	L	Fibula	Superior thyroid artery, branch of internal jugular vein	No	No	Good	Good	Kim et al 20153

pTNM, pathological tumor-node-metastasis staging.

Table 3.

Case Information for All Patients Undergoing MIMMR via Complete Intraoral Approach

Patient	Age/Gender	Diagnosis	Defect Location	Donor Site (Free Flap)	Recipient Vessels	Complications	Virtual Planning	Functional Recovery	Aesthetic Outcome	Source
1	49 F	Stage 2-3 Osteonecrosis	LCL	Fibula	Facial artery/facial vein	Anesthesia of lower lip	Yes	Good	Good	Lim et al6 2020
2	41 F	Ameloblastoma	H	Fibula	Not specified	No	Yes	Good	Good	Mingming et al7 2020
3	52 M	Ossifying fibroma	H	Fibula	Not specified	No	Yes	Good	Good	Mingming et al7 2020
4	26 M	Ameloblastoma	LC	Fibula	Not specified	No	Yes	Good	Good	Mingming et al7 2020
5	39 F	Ameloblastoma	L	Fibula	Not specified	No	Yes	Good	Good	Mingming et al7 2020
6	38 F	Ameloblastoma	L	Fibula	Not specified	No	Yes	Good	Good	Mingming et al7 2020
7	28 F	Ameloblastoma	L	Fibula	Not specified	No	Yes	Good	Good	Mingming et al7 2020
8	24 F	Ameloblastoma	L	Iliac crest	Not specified	No	Yes	Good	Good	Mingming et al7 2020
9	47 M	Ameloblastoma	H	Fibula	Not specified	No	Yes	Good	Good	Mingming et al7 2020
10	30 F	Osteoblastoma	L	Fibula	Not specified	No	Yes	Good	Good	Mingming et al7 2020
11	41 F	Ameloblastoma	LC	Fibula	Not specified	No	Yes	Good	Good	Mingming et al7 2020
12	6 M	Ameloblastoma	L	Fibula	Facial artery/facial vein	Anesthesia of lower lip	Yes	Good	Good	Nkenke et al8 2013
13	23 M	Ameloblastoma	C	Fibula	Facial artery/facial vein	Anesthesia of lower lip	Yes	Good	Good	Nkenke et al9 2013*
14	26 M	Ossifying fibroma	L	Iliac crest	Facial artery/facial vein	No	Yes	Good	Good	Zheng et al10 2019
15	32 F	Osteosarcoma	L	Iliac crest	Facial artery/facial vein	No	Yes	Good	Good	Zheng et al10 2019
16	28 F	Ameloblastoma	L	Iliac crest	Facial artery/facial vein	No	Yes	Good	Good	Zheng et al10 2019
17	12 F	Ossifying fibroma	L	Iliac crest	Facial artery/facial vein	No	Yes	Good	Good	Zheng et al10 2019
18	41 F	Ameloblastoma	L	Fibula	Facial artery/facial vein	No	Yes	Good	Good	Sun et al15 2022
19	52 M	Ossifying fibroma	H	Fibula	Facial artery/facial vein	No	Yes	Good	Good	Sun et al15 2022
20	39 F	Ameloblastoma	L	Fibula	Facial artery/facial vein	No	Yes	Good	Good	Sun et al15 2022
21	30 F	Osteoblastoma	LCL	Fibula	Facial artery/facial vein	No	Yes	Good	Good	Sun et al15 2022
22	47 M	Ameloblastoma	H	Fibula	Facial artery/facial vein	No	Yes	Good	Good	Sun et al15 2022
23	38 F	Ameloblastoma	L	Fibula	Facial artery/facial vein	No	Yes	Good	Good	Sun et al15 2022
24	24 F	Ameloblastoma	L	Iliac crest	Facial artery/facial vein	No	Yes	Good	Good	Sun et al15 2022
25	28 F	Ameloblastoma	L	Fibula	Facial artery/facial vein	No	Yes	Good	Good	Sun et al15 2022