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Social Determinants of Health and Dental Rehabilitation After Mandibular Reconstruction: A Scoping Review of an Evidence Gap

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09 September 2026

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11 September 2026

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Abstract
Background: Vascularized free-flap reconstruction reliably restores mandibular continuity, but dental rehabilitation is delivered inconsistently. As dental rehabilitated has been examined almost entirely through a clinical lens, we investigated how social determinants of health (SDOH) affect dental rehabilitation receipt after mandibular reconstruction. Methods: Scoping review of literature was performed combining terms for mandibular reconstruction, dental rehabilitation, and social determinants. Studies were charted by SDOH exposure and rehabilitation outcome. Results: Reported rehabilitation ranged from roughly 20% to 78%. Nearly every study examined clinical determinants alone. One study measured a social exposure against rehabilitation receipt, finding race associated with implant placement and cost the most cited barrier; a second measured SDOH in the relevant surgical population but reported only surgical outcomes. Conclusions: Whether social circumstance determines dental rehabilitation after mandibular reconstruction is essentially unstudied. The financing divide is a plausible, measurable mechanism, and cohort studies designed around SDOH exposures are needed.
Keywords: 
social determinants of health
;  
dental restoration
;  
mandible reconstruction
;  
fibula free flap
;  
scoping review
Subject: 
Medicine and Pharmacology  -   Surgery
Introduction
Segmental resection of the mandible for oral cavity malignancy, osteoradionecrosis, osteomyelitis, aggressive benign tumors, or trauma produces a discontinuity defect that impairs mastication, speech, swallowing, and facial form. Vascularized osteocutaneous free-flap reconstruction, most often with the fibula, is the standard for restoring continuity and achieves excellent flap survival1. However, bony continuity is a means, not the end. The end is a functional, occluding dentition, and reaching it requires a second phase of care comprising osseointegrated implants, implant-supported or conventional prostheses, or, where reconstruction is not feasible, obturators.
This second phase is where reconstruction most often stalls. A patient can leave the operating room with a well-contoured neomandible and often never receive the implants and prosthesis that would let them eat a normal diet or speak intelligibly2-4. We found that the clinical literature has extensively characterized how to rehabilitate the reconstructed mandible and how well implants survive once placed but has paid far less attention to who receives rehabilitation, and why some patients do not5-8. There are minimal data that describes whether social circumstances, rather than biology or surgical technique, determine the answer9. This scoping review maps that gap and argues that it is both consequential and tractable.
For clarity, we use “dental rehabilitation” to mean the completed restoration of function (osseointegrated implants, an implant-supported or conventional prosthesis, or an obturator) rather than an intermediate step such as implant placement alone, and we use “social determinants of health” in its established sense: the non-medical conditions in which people are born, live, work, and access care, including insurance and dental-benefit design, income, race and ethnicity, language, education, transportation, and area-level deprivation, rather than narrowly as insurance or cost.
Methods
We searched PubMed/MEDLINE from January 2000 through July 2026, combining terms for mandibular reconstruction (mandibular reconstruction, fibula free flap, osteocutaneous flap, segmental mandibulectomy), for dental rehabilitation (dental implant, osseointegrated implant, prosthetic rehabilitation, oral rehabilitation, obturator), and for social determinants (social determinants of health, socioeconomic status, insurance, Medicaid, race, ethnicity, disparity, area deprivation). Eligible records were peer-reviewed, English-language reports of original research meeting the population and outcome criteria below; review articles, conference abstracts, and other unpublished or grey literature were excluded. Reference lists of included articles and of relevant reviews were hand-searched. We included studies of adults undergoing segmental mandibular reconstruction that reported the receipt, timing, or determinants of dental rehabilitation, and we retained studies of social determinants in this surgical population even where the outcomes reported were surgical rather than dental. Case reports were retained only where they addressed the affordability or accessibility of prosthetic care, since no comparative evidence on that question exists. Because the aim was to map the boundaries of an evidence base rather than to pool effect estimates, studies were charted descriptively by population, rehabilitation outcome definition, determinants examined, and whether any social exposure was measured (TABLE 1). One reviewer (T.J.S.) screened titles/abstracts and full texts against these criteria and abstracted data on population, exposures, and rehabilitation outcomes into a structured chart. Consistent with scoping review methodology, no formal risk-of-bias assessment or meta-analysis was undertaken.
Table 1. Studies reporting on the receipt or timing of dental rehabilitation after mandibular reconstruction, and the determinants each examined.
Table 1. Studies reporting on the receipt or timing of dental rehabilitation after mandibular reconstruction, and the determinants each examined.
Study (year) Design, n, population Rehabilitation outcome reported Rehabilitation received Determinants examined Social exposure measured?
Peacock & Ji (2017) Retrospective cohort; n = 52; resection for benign mandibular neoplasm Implant placement; prosthesis delivery Implants 38.6%; prosthesis in 10 of 20 implanted Age, sex, race; patient-reported reasons for non-receipt Yes: race; cost and insurance coverage
Bhethanabotla et al. (2025) Retrospective cohort; n = 131; osteocutaneous free flap for mandibular malignancy None (surgical outcomes only) Not reported Race, language, insurance, county Social Vulnerability Index, travel distance Yes, but no dental outcome
Nham et al. (2024) Systematic review; 36 observational studies; fibula free flap jaw reconstruction Dental prosthetic rehabilitation rate 51.6% pooled (38–55% by indication) Radiotherapy timing, prosthesis type, virtual surgical planning No
Ritschl et al. (2024) Cross-sectional; n = 59; mandibular reconstruction with fibula free flap Implant placement; prosthetic restoration; quality of life Implants 37.3%; complete oral rehabilitation 23.7% Implant survival, satisfaction, patient motivation No
Oldén et al. (2023) Retrospective cohort; n = 41 (42 flaps); mandibular reconstruction with fibula free flap Implant placement; completed rehabilitation Implants 27%; completed rehabilitation 20% Radiotherapy; death and recurrence cited as reasons for non-receipt No
Lodders et al. (2021) Retrospective cohort; 161 fibula free flap reconstructions; head and neck cancer Implant-based rehabilitation started and completed Started in 27.9%; 37 completed, 29 functional Radiotherapy, tobacco use, body mass index No
Tumuluri et al. (2023) Retrospective cohort; n = 52; vascularized bone flap mandibular reconstruction Rehabilitation achieved; time to prosthesis 62% immediate vs 78% delayed; median 150 vs 843 days Timing of implant placement (immediate vs delayed) No
Tabet et al. (2024) Cohort; n = 21 (9 prefabricated, 12 delayed); benign or previously treated malignant jaw tumor Time to occlusal rehabilitation Mean 12.1 vs 60.4 months Reconstructive technique No
Jelmini et al. (2024) Retrospective cohort; n = 13; immediate fibula free flap with implants for malignancy Immediate prosthesis delivery; implant success Prosthesis delivered in all (highly selected) Implant success, delay to radiotherapy No
Of the studies identified, only one measured a social exposure against dental rehabilitation receipt (Peacock & Ji), and one measured social exposure in the relevant surgical population but did not follow patients to rehabilitation (Bhethanabotla et al.). Rehabilitation is defined differently across studies, so rates are not directly comparable.
Results
The PubMed/MEDLINE search combining mandibular-reconstruction and social-determinants terms returned 122 records; the narrower search additionally requiring dental-rehabilitation terms returned 12 records, 10 of which remained after excluding review articles and non-English-language reports. All 122 records were screened by title and abstract against the eligibility criteria above, and three records addressed the intersection of mandibular reconstruction, dental rehabilitation, and social determinants closely enough to warrant full-text review and charting.
Two met full inclusion criteria. A 52-patient retrospective cohort measured race against dental-implant receipt after resection for benign mandibular neoplasms, finding implant receipt lowest among Black patients and cost the most-cited barrier to proceeding9. A case report of prosthetic rehabilitation framed explicitly around affordability in a low-resource setting was retained under our affordability-focused case-report criterion23. A third record, a 131-patient cohort that measured county-level social vulnerability, travel distance, race, language, and payer in patients undergoing osteocutaneous free-flap reconstruction for mandibular malignancy, met the population and exposure criteria but reported only surgical outcomes rather than dental rehabilitation; it is charted separately as adjacent context rather than as a directly included study22.
No identified study modeled a social determinant against dental-rehabilitation receipt using a validated area-level deprivation measure, such as the Area Deprivation Index or Social Vulnerability Index, or a multivariable framework accounting for clinical confounders. The broader clinical literature identified through hand-searching and citation chaining, charted for context in TABLE 1, reported rehabilitation rates ranging from roughly 20% to 78%, but examined clinical or technical determinants almost exclusively; only the two directly included records measured a social exposure against that outcome.
Discussion
Dental Rehabilitation as the Functional Endpoint of Reconstruction
Restoration of occlusion and oral function is widely framed as the ultimate objective of jaw reconstruction, not an optional add-on10. Implant-supported prostheses overcome the limitations of tissue-borne dentures on reconstructed, often insensate and irradiated soft tissue, and are associated with improved oral function and quality of life11. When rehabilitation is completed, patients regain mastication, intelligible speech, and aesthetic support; when it is not, the reconstruction delivers a fraction of its potential benefit. The equity stakes of dental rehabilitation are therefore not only cosmetic; they are the difference between an anatomically successful operation and a functionally successful one12,13.
The Reconstruction – Rehabilitation Gap
Multiple analyses show that a substantial share of reconstructed patients never complete rehabilitation, and that even successful pathways are slow. A 2023 systematic review of 36 studies estimated the pooled dental prosthetic rehabilitation rate after fibula free-flap jaw reconstruction at roughly 52% (ranging from about 38% to 55% by benign versus malignant indication)14. Consistent with this, fewer than 40% of patients in a benign-neoplasm cohort went on to receive implants, and only half of those proceeded to a prosthesis9.
The pathway is also protracted. In a cohort of 52 patients reconstructed with vascularized bone flaps, rehabilitation was reached in 62% of an immediate-implant group versus 78% of a delayed group, with a striking difference in timeline. There was a median 150 days to prosthesis in the immediate pathway versus 843 days in the delayed pathway15. A comparison of prefabricated versus conventional bone-driven, delayed strategies reported mean time to occlusal rehabilitation of roughly 12 versus 60 months10. Immediate rehabilitation at the time of reconstruction, though feasible even in malignancy, remains uncommon in practice16-19.
Two themes emerge. Non-receipt is common, affecting roughly half of patients. Further, the conventional delayed pathway that spans for months to years creates a long corridor during which patients can be lost to rehabilitation, including recurrence, death, attrition, or the accumulating friction of cost and access. Any factor that raises that friction differentially across social groups will produce inequity in the functional outcome of reconstruction.
The Traditional Lens
The dominant framing of “who gets rehabilitated” is clinical. Radiotherapy is the most consistently cited biological barrier: pooled data show implant survival falling from about 90–93% in non-irradiated bone to roughly 76% in irradiated bone, with survival as low as 38% when implants are placed within 12 months of radiotherapy, recovering toward 77% by 24 months14,20. Adequate flap bone height, favorable defect geometry, disease control, and comorbidity burden all bear on candidacy.
In parallel, technique has advanced specifically to close the rehabilitation gap: the double-barrel fibula to gain vertical height, with systematic-review evidence of high flap survival (~98%) and low implant failure (~1.7%)21; virtual surgical planning; and immediate and prefabricated approaches that compress the timeline10,16. This literature is mature and valuable, but it implicitly treats non-receipt as a matter of biology and technique. It optimizes candidacy and success conditional on the patient reaching the dental chair; it does not ask which patients reach the chair at all.
This binary is not exhaustive, however. Non-receipt need not be either a biological or technical failure on one hand or a marker of social disadvantage on the other: health-system characteristics, such as whether a prosthodontist is embedded in the cancer center or how surgical and dental teams coordinate care, and psychosocial factors not reducible to social position, such as treatment exhaustion, symptom burden, depression, or a patient’s own weighing of whether a prosthesis is worth pursuing, plausibly shape rehabilitation receipt as well. We focus below on social determinants because that is the axis this review set out to map and because, as detailed below, it remains almost entirely unstudied in this population; the near-absence of evidence on system-level and psychosocial explanations is a parallel gap that merits its own inquiry.
The Missing Lens
The step from “reconstructed” to “rehabilitated” is an access-and-utilization transition, which is exactly where SDOH exert their influence, yet it has almost never been studied through that lens. The single most direct evidence comes from Peacock & Ji: in their benign-neoplasm cohort, race was associated with the likelihood of receiving implants (Black patients were the least likely), and cost was the most cited reason for not proceeding9. This is a small, single-center, benign-disease study, but it is essentially the only one that measures a social exposure against dental-rehabilitation receipt after mandibular resection.
Some caution is warranted in weighing this single study, however. The report does not fully specify how long after resection patients’ reasons for not proceeding were ascertained, and cost was not the only reason cited: patient disinterest was nearly as common a reason for declining implants as cost was. Reasons recorded years removed from surgery are vulnerable to recall and rationalization, and a “disinterest” response may itself be downstream of the very barriers reviewed here rather than independent of them.
The closest adjacent work examined SDOH in patients undergoing osteocutaneous free-flap reconstruction for mandibular malignancy, which are the right population and right exposures, but its outcomes were surgical, not dental rehabilitation, and within a well-resourced tertiary center it found largely equitable surgical outcomes22. It therefore establishes the population and the plausibility of studying SDOH here while leaving the rehabilitation question open. Beyond these, the direct evidence thins to case reports of prosthetic rehabilitation framed around affordability in low-resource settings23.
Two features of this literature deepen the concern. First, the Bhethanabotla et al. study measured county-level social vulnerability, travel distance, race, language, and payer in 131 patients and found surgical outcomes to be equitable; its only significant social finding, which was that non-minoritized patients travelled farther to reach care, likely reflects referral catchment rather than an access barrier. Equity at the operative step, however, says nothing about equity at the prosthetic one, and these patients were not followed to rehabilitation22. Second, the cohorts that report non-receipt attribute it almost entirely to causes that appear straightforward in the medical record: death and recurrence in a ten-year series in which 27% received implants and 20% completed rehabilitation, and patient motivation in a cross-sectional cohort in which complete oral rehabilitation reached 23.7%2,4. It is important to note that motivation is not a fixed patient trait. It is shaped by out-of-pocket cost, travel burden, time away from work, and whether a prosthodontist is embedded in the cancer center. Reasons recorded in clinical language may therefore conceal social ones, which is precisely the misattribution a study designed around SDOH would detect (TABLE 1).
The broader head-and-neck oncology literature makes it highly plausible that social gradients operate at the rehabilitation step24. Disparities by race, socioeconomic status, and insurance are best documented in head and neck cancer among all otolaryngologic conditions, with differences in survival, recurrence, and mortality25; and socioeconomic deprivation is associated with materially worse spatial access to treatment, i.e. the most deprived patients travel nearly twice as far to care26. However, plausibility is not evidence, and the specific question remains unanswered: after the mandible is rebuilt, do social circumstances determine whether it is made functional?
A Proposed Mechanism
There is a structural reason to expect inequity at precisely this step, and one that clinical studies are not designed to detect. Reconstruction is financed as medical care; dental rehabilitation frequently falls into the “dental” category that traditional Medicare has excluded and that many commercial and Medicaid plans cover sparingly or carve out entirely27. The consequence is a discontinuity in coverage that maps onto the discontinuity in care: the same patient whose resection and free flap are fully covered may face large out-of-pocket costs for the implants and prosthesis that make the reconstruction usable. Commentators have increasingly named this shortfall of restorative dental care for head-and-neck cancer patients as a systemic failure requiring policy attention27,28.
If cost and coverage are the dominant barriers as Peacock & Ji’s data suggest, then the disparity is not primarily biological and will not be closed by better flaps9. It will track insurance type, dental-benefit design, income, and the geographic distribution of prosthodontic care. This is the mechanistic, measurable heart of the gap.
Why the Gap Has Persisted
Part of the reason this question remains open is that dental rehabilitation is nearly invisible in the data sources reconstructive research relies on. Cancer registries and national surgical databases capture resection, flap type, and adjuvant therapy but not implant placement or prosthesis delivery. In administrative claims, dental procedures are coded in a separate nomenclature and adjudicated by separate carriers, so a patient’s implants may leave no trace in the medical claims that record their free flap. Institutions reproduce the same divide: the operative record sits in the medical chart while the prosthodontic record often sits in a dental practice-management system, sometimes at another site and frequently unlinked. The consequence is that a well-designed study can fail to observe its own outcome. Any serious attempt at this question must therefore begin with outcome ascertainment, through deliberate linkage of surgical and dental records or prospective capture, rather than assuming rehabilitation status can be extracted retrospectively from existing fields. This is tractable, but it is not trivial, and it is a large part of why plausibility has outrun evidence.
Why This Matters and a Research Agenda
Dental rehabilitation converts an anatomically successful reconstruction into a functionally successful one. If its receipt is patterned by social circumstance, then technically-equitable reconstructive surgery may deliver unequal functional outcomes. Testing this requires studies designed around social determinants and dental rehabilitation rather than surgical outcomes. A single-institution retrospective cohort at a high-volume center is a natural first step and, on its own, would roughly double the directly relevant literature.
These questions benefit from an explicit theoretical scaffold rather than an atheoretical list of exposures. Andersen’s Behavioral Model of Health Services Use, which organizes predisposing (demographic and social-structural), enabling (income, insurance, access to a prosthodontist), and need (perceived and clinical) factors, maps directly onto the reconstruction-to-rehabilitation transition and would let a study distinguish whether non-receipt reflects a structural barrier, a resource barrier, or a needs-assessment gap29. The NIMHD Research Framework, which crosses levels of influence (individual, interpersonal, community, societal) with domains (biological, behavioral, physical/built environment, sociocultural environment, healthcare system), offers a complementary way to organize which exposures are captured and at what level30. A single-institution retrospective cohort, our own proposed first step, is also necessarily bounded by what the chart contains: payer, race/ethnicity, language, and area-level indices are extractable, but constructs central to the frameworks above, including health literacy, transportation, housing stability, instrumental and emotional social support, perceived financial or nutritional insufficiency, and work accommodations, are not. Closing that gap ultimately requires prospective data collection, whether through patient-reported measures embedded in a cohort or a mixed-methods design pairing chart-derived exposures with qualitative interviews on the reasons for non-receipt.
Priorities should be:
  • Measure SDOH as exposures against rehabilitation receipt at the individual-level (payer, and specifically dental coverage; race/ethnicity; language; social support) and area-level (Area Deprivation Index, Social Vulnerability Index, rurality, travel distance).
  • Model time to rehabilitation with competing-risks methods (death, recurrence), not naive time-to-event given the multi-year pathway.
  • Use complementary designs including institutional cohorts (rich clinical and pathway detail) and large administrative or registry datasets (statistical power and area-level linkage) to provide answers to full scope of questions.
  • Standardize the outcome. Reported rehabilitation ranges from roughly 20% to 78% across the cohorts in TABLE 1, and much of that spread is definitional rather than real: some studies count implant placement, other studies count prosthesis delivery, and some count function at last follow-up. Equity research needs a stable denominator and one explicit endpoint. We would favor that being “functional prosthesis” with “placement of implants” retained as an intermediate step.
Conclusions
The field of has largely solved how to rehabilitate the reconstructed mandible and how to keep implants alive once placed. However, it has not established who receives that rehabilitation, and why, and the available evidence is insufficient. Given a plausible and measurable structural mechanism, the equity of the reconstruction-to-rehabilitation transition is an open and pressing question that well-designed cohort studies must address.

Funding

No funding was received for conducting this study.

Conflicts of Interest

The authors have no relevant financial or non-financial interests to disclose.

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