Titanium mesh and tray systems for mandibular continuity reconstruction with bone grafting: a systematic review and proportional meta-analysis of device-related complications.

Background: Titanium mesh/tray systems have been used with bone grafting for mandibular continuity reconstruction, but evidence is scattered across small cohorts and device eras. We systematically reviewed this literature and quantified device-related complications while accounting for cohort overlap and outcome-specific denominators. Methods: PubMed, Embase, Web of Science, Scopus, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov were searched for human clinical studies evaluating titanium mesh/tray systems used as graft-containing reconstruction chambers for segmental or continuity mandibular defects. Representative independent cohorts were selected to avoid double-counting. The primary outcomes were device exposure, infection, mechanical failure, and unplanned reoperation or device removal. Pooled proportions were estimated using logistic-normal generalized linear mixed models. Risk of bias and certainty of evidence were assessed using JBI, ROBINS-I, and GRADE. Results: After screening 736 unique records and assessing 53 full-text reports, 40 reports were retained for quantitative synthesis, qualitative interpretation, evidence mapping, or cohort adjudication. Ten representative independent cohorts were included, of which eight contributed to at least one primary pooled outcome. In the primary analyses, the pooled proportions were 8.8% (95% CI, 3.7%-19.4%) for device exposure, 14.5% (95% CI, 8.4%-23.8%) for infection, 5.3% (95% CI, 2.0%-13.2%) for mechanical failure, and 14.5% (95% CI, 8.0%-24.9%) for unplanned reoperation or device removal. Sensitivity analyses incorporating one cohort without confirmable minimum follow-up, and excluding the single cohort reported using reconstruction-site-level denominators, were directionally consistent. Graft consolidation or mandibular continuity restoration, implant placement, and prosthetic rehabilitation were summarized as exploratory downstream outcomes. Only two cohorts used additively manufactured patient-specific systems, precluding reliable subgroup inference. Certainty of evidence was very low for all primary outcomes. Conclusion: Titanium mesh/tray systems may be considered in selected clinical contexts for mandibular continuity reconstruction, but exposure, infection, and unplanned reoperation or device removal remain important concerns. Current estimates should be interpreted as exploratory clinical benchmarks rather than definitive evidence of safety or effectiveness. Prospective multi-institutional studies with standardized outcome definitions and appropriate comparator groups are needed.