To explore the function and therapeutic mechanism of Withaferin A (WFA) in treatment of periodontitis using network pharmacology analysis and experiment validation. The optimal concentration of WFA was determined using CCK-8 assay. IL-6 and IL-1β protein levels were measured by ELISA. Osteogenic differentiation under inflammation was evaluated via ALP staining and activity, Alizarin Red staining, and mineralization quantification. Expression of osteogenic markers (RUNX2, OCN, ALP) was analyzed by Western blot and RT-qPCR. Network pharmacology and molecular docking were used to predict and validate WFA targets, followed by experimental verification with WB and RT-qPCR. Mitochondrial status was examined using JC-1 staining and TEM, while ROS levels were detected to assess oxidative stress. Expression of SLC7A11, GPX4, and OPA1 was measured by WB and RT-qPCR. WFA’s therapeutic effect was further validated in a ligature-induced periodontitis (LIP) rat model using micro-CT, H E staining, and immunohistochemistry. Our study demonstrated that WFA exerts multi-faceted therapeutic effects on periodontitis. It promoted osteogenesis by upregulating osteogenic markers (RUNX2, OCN, ALP) and counteracted Pg-LPS-induced inflammation, reducing IL-6 and IL-1β levels and attenuating bone resorption in vitro. Bioinformatics analysis identified 119 potential targets of WFA, with 100 overlapping periodontitis-related genes. GO and KEGG enrichment highlighted the AGE-RAGE, IL-17, and Relaxin signaling pathways. Molecular docking confirmed strong binding of WFA to JUN, FN1, and TGFβ, which were functionally validated. Mechanistically, WFA reduced ROS, preserved mitochondrial integrity, and upregulated SLC7A11 and GPX4, indicating anti-ferroptotic effects via the SLC7A11/GPX4 axis. In vivo, WFA alleviated Pg-LPS-induced bone loss. In conclusion, WFA exhibits therapeutic potential in periodontitis through suppressing ferroptosis via SLC7A11/GPX4 axis, which promotes osteogenesis and inhibits Pg-LPS-induced inflammation. WFA demonstrates significant potential as a therapeutic intervention for periodontitis.
Evaluating a cold atmospheric plasma (CAP) device using ambient air for enamel pretreatment before bracket bonding and the impact on surface roughness. 180 human third molars were assigned to 12 groups. After pretreatment with a) phosphoric acid+Transbond XT Primer (TXP), H₃PO₄, b) CAP (30 s)+TXP, CAP-30, c) CAP (60 s)+TXP, CAP-60, d) CAP+Transbond Plus self-etching primer (SEP-CAP) a metal bracket was bonded (Transbond XT adhesive). Shear bond strength (SBS) was tested after 1) 24 hours wet storage, 2) 500 thermal cycles (5°/55°C), 3) 90 days of wet storage with a universal testing machine. The adhesive remnant index (ARI) was determined. Additional specimens were fabricated, pretreated as groups a),b),d) before application of Transbond XT adhesive, removal with a tungsten bur and surface measurements before and after polishing with a profilometer. After 24 hours, SBS in the H₃PO₄ and SEP-CAP group was higher than in both CAP groups (p<0.001). 500 thermal cycles reduced SBS in both CAP groups compared to 24 hours (p<0.001) and 90 days (CAP-30 p=0.001; CAP-60 p=0.008). In both CAP groups, an ARI of 0 was predominant. Surface roughness before polishing was higher in the CAP group. The use of CAP with air as working gas does not ensure sufficient SBS for clinical use, but in combination with SEP. Surface roughness was more impacted by CAP than H₃PO₄. H₃PO₄ etching is still considered the gold standard for bracket bonding. Further research is required to understand the effect of CAP to enamel.
This study evaluated the physicochemical and biological properties of three ready-to-use bioceramic sealers, BioRoot® Flow (BRF), ZenSeal™ (ZS) and EndoCeramic™ (EC), in comparison with an epoxy resin–based sealer, AH Plus Jet® (AHP). Setting time, solubility, pH, radiopacity, and flow were assessed following ISO standards. Biological response was evaluated by cell viability using the XTT assay, and gene expression of osteogenic and inflammatory markers was analyzed by quantitative PCR. Data were analyzed at a 5
The rising demand for zygomatic implants (ZIs) in contemporary dental implantology underscores the need for an anatomy-based categorization system and a surgical decision-making panel that takes into account anatomical, biomechanical, and prosthetic factors to determine the final surgical strategy. This article proposes a new Z-Classification, the anatomical division of the maxillo-zygomatic complex. The classification was developed from the authors’ clinical experience of 882 ZIs placed in 234 patients across two centres over a ten-year period. According to anatomical presentations, 6 classes were described. The classification is intended as a practical framework for preoperative assessment and treatment planning in ZI rehabilitation. It has not yet been validated against clinical outcomes. Additionally, a decision funnel for surgical strategy development and the structured checklists consisting of crucial clinical parameters for long-term success in ZI therapy were proposed. The presented tools will potentially optimize a complex decision-making algorithm in zygomatic implantology. The proposed Z-Classification and the decision funnel carry the potential to reduce the risk of complications associated with zygomatic surgery.
To assess the effects of surgically assisted rapid maxillary expansion (SARME) on the color of maxillary anterior teeth, to evaluate the associations between tooth color changes, pulp sensibility, trabecular bone structure of the midpalatal suture and suture-adjacent alveolar bone and to compare these findings with a non-expanded control group. Fifteen patients undergoing SARME (22.07 ± 3.37 years) and 15 untreated controls (23.87 ± 1.13 years) were included. In the SARME group at baseline (T0), immediately after expansion (T1), at 3 (T2) and 6 months (T3), tooth color of the maxillary anterior teeth was measured with a spectrophotometer to obtain CIE L*, a*, b* (L*: lightness; a*: red–green axis; b*: yellow–blue axis) values and calculate ΔE₀₀ (Color changes), and pulp sensibility was assessed with an electric pulp tester (EPT). In the control group, these assessments were conducted at baseline (T0), 1 month (T1), 3 months (T2), and 6 months (T3). In the SARME group, baseline and 6-month cone-beam computed tomography images (CBCT) were analyzed using fractal analysis (FA) to evaluate the trabecular structure of the midpalatal suture and adjacent alveolar bone. In the SARME group, L* values increased significantly at 3-months and showed no change from 3 to 6 months. ΔE₀₀ values were significantly higher than control group at 6 months. Negative pulp sensibility responses increased immediately after expansion and decreased by 6 months. Fractal dimension values decreased at both sites, but only the suture-adjacent alveolar bone showed moderate correlations with ΔL* and ΔE00 of the maxillary incisors. Within the 6-month follow-up, SARME induced color differences in the maxillary anterior teeth that remained clinically acceptable. Pulp sensibility improved toward baseline levels by 6-months. FD values demonstrated a significant decrease during the observation period. SARME may cause clinically acceptable color changes and temporary alterations in pulp sensibility. These findings should be considered during treatment planning and patient information.
This study evaluated the impact of apical bone height (ABH) on implant survival after lateral sinus floor elevation (LSFE) with simultaneous implantation, controlling for confounding factors. A retrospective cohort of 195 implants was analyzed. ABH was measured immediately postoperatively (T1), at 6 months (T2), and at ≥ 2 years (T3), and stratified as ≤ 2 mm or > 2 mm. Survival was assessed using Kaplan-Meier curves and multivariable Cox regression, adjusting for demographic, surgical, behavior, and anatomic variables. ABH and endo-sinus bone gain significantly declined from T1 to T2 (p < 0.001) and continued to decrease at T3 (p < 0.001). Multivariable analysis identified ABH > 2 mm as a significant independent protective factor for implant survival at all timepoints (T1: HR = 0.100, p = 0.035; T2: HR = 0.039, p < 0.001; T3: HR = 0.040, p = 0.007). Conversely, the magnitude of ABH change did not significantly influence survival. Kaplan-Meier analysis showed markedly lower cumulative survival rates (CSRs) for ABH ≤ 2 mm (log-rank p < 0.001). At 40 months, CSRs were 20.0
Dental caries results from dysbiotic shifts in the microbial community, so modulating biofilm composition represents a valid preventive strategy. The aim of this double-blind randomized crossover in situ study was to investigate how a fluoride rinse can modify the composition of the early oral biofilm formed on enamel and dentine. Twelve volunteers wore mandibular appliances containing 3 enamel and 3 dentine specimens for 1 min, to allow basal pellicle formation, then rinsed (1 min) with a NaF solution (500 ppm F⁻) or deionized water (DW) and kept the appliance overnight (8 h). The composition of the biofilms was analysed using full-length 16 S rRNA gene sequencing. Alpha and beta diversity did not differ between groups. Dominant genera were Streptococcus (61–71
To determine the clinicopathological features of 2,238 endodontic and non-endodontic periapical lesions (PLs) retrieved from a database of an oral and maxillofacial pathology laboratory. This retrospective cross-sectional study analyzed 12,441 histopathological records registered between 1956 and 2019. Of these, 2,238 cases diagnosed as PLs were selected. The lesions were classified as endodontic or non-endodontic, and clinicopathological variables, including microscopic diagnosis, sex, age, anatomical location, and lesion size, were evaluated. During the study period, the laboratory recorded 12,441 lesions, of which 2,238 (18
To evaluate the clinical and radiographic outcomes of the Biomet stock alloplastic temporomandibular joint replacement (ATJR) after seven progressive surgical modifications in Chinese patients at a single center. Patients who underwent ATJR from 2005 to 2025 were retrospectively reviewed. Seven surgical modifications were progressively introduced to optimize outcomes. Maximum interincisal opening (MIO), visual analogue scale (VAS) for pain, dietary function and mandibular mobility, and quality of life (QoL) were compared between baseline and final follow-up of at least 12 months. Postoperative computed tomography (CT) was used to evaluate prosthesis stability, screw position and heterotopic ossification (HO). Complications, revision rates, and Kaplan-Meier prosthesis survival rate were analyzed. 300 patients with 392 prostheses were included in the study. After a mean follow-up of 67.4±43.5 (12-208) months, MIO improved significantly from 23.7±13.5 mm to 34.2±6.9 mm (p < 0.001). QoL improved by 36.6
This systematic review analysed the oral health status, chewing function, and quality of life among individuals aged ≥ 65 years in Switzerland using studies published from 1970 onwards. The electronic databases Embase, MEDLINE via PubMed, Swiss data repositories, and manual searches were screened. Risk of bias was assessed using the Joanna Briggs Institute tools. Meta-analyses were performed using the random-effects models with 95
Bioceramic sealers have been increasingly used in endodontics due to their favorable physicochemical and biological properties. However, evidence regarding the physicochemical properties, push-out bond strength, and adhesive interface characteristics of BioRoot Flow compared with other root canal sealers remains limited. Therefore, this study evaluated the physicochemical properties, push-out bond strength, failure pattern, and adhesive interface quality of BioRoot Flow (BRF), BioRoot RCS (BRR), and the epoxy resin–based sealer AH Plus (AHP). Setting time, dimensional change, solubility, radiopacity, and flow were assessed following ANSI/ADA Specification No. 57. Setting time was recorded using cylindrical molds tested with a Gillmore needle. Dimensional change was measured in five specimens per sealer before and after 30 days in distilled water. Solubility was assessed in ten specimens after seven days of immersion, followed by desiccation. Radiopacity was evaluated using acrylic plates radiographed beside an aluminum step wedge. Flow was assessed according to ANSI/ADA standards. For bond strength and interface analysis, thirty single-rooted teeth were prepared with the Reciproc system and irrigated with sodium hypochlorite and EDTA. Canals were obturated with the single-cone technique using the tested sealers (n = 10). Three slices were obtained from each root third; two were used for push-out testing and failure analysis, and one for confocal laser scanning microscopy. AHP showed the shortest setting time, highest radiopacity, and greatest flow. BRF exhibited the highest solubility, while dimensional change did not differ among materials. Bond strength varied significantly among sealers and root thirds; AHP presented the highest values, followed by BRF and BRR. Adhesive failures predominated for AHP, whereas bioceramic sealers showed mainly mixed failures. AHP demonstrated superior physicochemical properties, higher bond strength, and better adhesive interface adaptation. BRF performed better than BRR regarding bonding and interface quality.
This study assessed the global burden of two major oral conditions: dental caries (including caries of deciduous teeth (CDT) and caries of permanent teeth (CPT)) and periodontal disease (PD) among children and adolescents aged 0–19 years. Data were extracted from the Global Burden of Disease Study (GBD) 2021. We examined the number and age-standardised rates (ASRs) of prevalence, incidence, and disability-adjusted life years (DALYs) for these two major oral conditions: dental caries (including CDT and CPT) and periodontal disease across different age groups, sexes, social development index (SDI) levels, regions, and countries. The age-standardized global rates per 100,000 population reached 19,903.7 (prevalence), 47,546.7 (incidence), and 7.6 (DALYs) for CDT; 15,440.1, 24,083.2, and 15.5 for CPT; and 309.0, 103.3, and 2.1 for PD in 2021, respectively. The overall number of prevalent cases reached 524.6 million for CDT, 407 million for CPT, and 8.1 million for PD. From 1990 to 2021, CDT and CPT showed an overall decline in prevalence and DALYs, whereas PD exhibited an upward trend across all metrics. In addition, The highest CDT burden was observed in Central Asia, while Western Europe had the lowest rates in 21 regions. For CPT, Andean Latin America and Central Europe recorded the highest prevalence and incidence, whereas East Asia had the lowest. South Asia contributed the largest absolute number of CDT and CPT cases globally. Across 204 countries, Georgia and Paraguay had the highest CDT and CPT prevalence rates, respectively, while Denmark and Taiwan (Province of China) had the lowest. The SDI and regions analysis revealed distinct patterns: high-middle SDI regions exhibited the greatest CDT and CPT burden, whereas high SDI regions consistently showed the lowest prevalence and DALY rates aged 0 to 19 years. From 1990 to 2021, the most significant declines in CDT burden occurred in low-middle SDI regions, while CPT increased most prominently in low SDI regions. By contrast, PD showed consistent growth globally, with Central Asia bearing the heaviest burden and Western Europe the lightest. Although the prevalence of dental caries and periodontal disease among children and adolescents has declined over the past three decades, the overall burden remains substantial. These findings underscore the need to sustain and strengthen global and regional oral health initiatives targeting younger populations.
To investigate the effects of onlay materials and resin core thickness on stress distribution in partial coverage restorations under static and thermal loading using finite element analysis (FEA). A 3D mandibular first molar model was created from CBCT data. Four materials (zirconia, lithium disilicate [LD], polymer-infiltrated ceramic network [PICN], gold alloy [GA]) and five resin core thicknesses (1 mm to 4 mm, plus full crown control) were tested. A total of 20 models were loaded with 100 N occlusal force and thermal stresses (5–37 °C and 37–55 °C). The distribution characteristics of the maximum principal stress (MPS) were analyzed for different combinations of variables. Under mechanical loading, thin resin cores (1–2 mm) performed best. Increasing thickness to 3 mm sharply raised enamel stress (zirconia: 77.35–80.72 MPa); at 4 mm, restoration stress peaked (zirconia: 150.12 MPa). Zirconia showed highest restoration stress (54.01-150.12 MPa) but lowest dentin stress (5.02–7.70 MPa); PICN had low and most stable restoration stress (55–91 MPa) but highest dentin stress (8–13 MPa). Under high-temperature thermal stress, enamel stress jumped sharply at ≥ 3 mm resin thickness, markedly higher than under low-temperature stress. GA with an extremely thin resin core (1R4O) caused abnormally high dentin stress (50.83 MPa) at low temperature. A thin resin core (1–2 mm) offered better overall mechanical performance. Material type markedly influenced stress distribution. High-temperature thermal stress posed a greater threat to tooth structure than low-temperature stress. Thermal stress barely affected periapical/periodontal tissues. For extensive MOD restorations, a 2 mm resin core is recommended as the safe threshold. Material selection should balance the protection of the restoration itself and the stress transfer to the tooth structure.
Comparison of external apical root resorption (EARR) between space-closure techniques remains inconsistent due to 2D imaging limitations. This study aimed to quantify and compare EARR in maxillary anterior teeth following en-masse versus two-step retraction using 3D cone-beam computed tomography (CBCT). This prospective randomized controlled trial included 60 male and female patients (mean age 19.87 ± 4.01 years) requiring bilateral maxillary first premolar extractions and maximum anchorage. Participants were randomly allocated to en-masse retraction (210 g/side) or two-step retraction (70 g canine retraction, then 140 g incisor retraction). CBCT scans were obtained before (T1) and after (T2) space closure. Three-dimensional root models were reconstructed using Mimics software. Linear root length and volumetric changes were compared (Mann–Whitney U test; p < 0.05). Both groups exhibited statistically significant reductions (p < 0.001) in root length (two-step: -0.56 ± 0.09 mm; en-masse: -0.57 ± 0.11 mm) and root volume (two-step: -8.88 ± 3.24 mm3; en-masse: -10.12 ± 4.49 mm3). No statistically significant differences were observed between techniques for any tooth or overall mean values (p > 0.05). Lateral incisors showed the greatest linear resorption in the two-step group, while volumetric reductions were substantial across central incisors and canines. En-masse and two-step space closure produce comparable linear and volumetric resorption; neither technique confers a protective or detrimental advantage regarding EARR. Neither retraction technique increases the risk of EARR, allowing clinicians to select either approach without concern for differential root resorption when biomechanical control is appropriately maintained. The trial was registered at ClinicalTrials.gov: NCT05606185 on October 31, 2022 (first posted: November 4, 2022; ( https://clinicaltrials.gov/study/NCT05606185 ).
Various non-invasive diagnostic techniques have been developed and assessed to improve early detection and monitoring of oral squamous cell carcinoma and oral potentially malignant disorders. However, a clear overview of the diagnostic performance and their ability to detect clinically relevant changes, is lacking. This study evaluated clinically tested, non-invasive techniques for early detection and monitoring of oral squamous cell carcinoma and potentially malignant disorders, focusing on diagnostic accuracy. After a structured search strategy and critical selection of all relevant systematic reviews, data was extracted from 57 reviews in total, of which 29 were included for qualitative analysis, 20 for meta-analysis and eight for both qualitative and meta-analysis. Among nine techniques that are available in practice, optical coherence tomography, spectroscopy, and cytology with oral brushes demonstrated the highest effectiveness. Optical coherence tomography demonstrated the highest diagnostic accuracy, with a sensitivity and specificity estimated at 0.91 and a diagnostic odds ratio of 108.5. Furthermore, when combined with artificial intelligence, diagnostic accuracy is even further improved. Most studies evaluating diagnostic accuracy of non-invasive diagnostic tests for potentially malignant disorders and oral squamous cell carcinoma grouped these conditions together without stratifying by lesion type. Therefore, no firm conclusions can be made about the diagnostic accuracy in detecting oral squamous cell carcinoma or different types of potentially malignant disorders. More high quality, primary studies should be conducted to specifically assess the diagnostic accuracy of different diagnostic tests per lesion type. No clinical guidelines are currently available for management of oral potentially malignant disorders, and practical guidelines for clinical decision making in the field of oral squamous cell carcinoma and oral potentially malignant disorders will be helpful. The results of this umbrella review can inform clinical practice, guideline development, and future research priorities.
This study analyzed 3162 CBCT images to explore age and gender features in midpalatal suture (MPS) maturation staging, and identify the statistically significant age threshold for MPS ossification. Axial CBCT sections of 3162 participants (1690 females, 1472 males, aged 3–90 years) were classified into six MPS maturation stages (A, B, C, D1, D2, E) based on Angelieri’s criteria. The Youden index defined the diagnostic age threshold for MPS maturation; chi-squared tests assessed correlations between age, gender and stages. Kolmogorov-Smirnov, t-test and Wilcoxon test analyzed subgroup data distribution similarity, with statistical significance set at p < 0.05. The optimal age threshold for distinguishing MPS stages A, B, C and D was 11.2 years (males:11.2 years, females:10.75 years), with high diagnostic sensitivity and specificity. Age correlated significantly with MPS maturation (p < 2.2e-16). D2 stage, morphologically intermediate between D1 and E yet distinct, had a significantly different age distribution from both (p < 0.05), warranting independent staging. Adolescents (0–20 years) showed significant gender differences (p < 0.05), with females maturing earlier. The critical MPS ossification age threshold is 11.2 years, supporting reduced unnecessary radiological examinations in younger patients. MPS maturation advances with age and is earlier in females, especially in 0–20 years.
To investigate the association between root canal filling quality and the prevalence and volume of apical periodontitis (AP) lesions in a Chilean population using cone-beam computed tomography (CBCT). This retrospective cross-sectional study evaluated CBCT scans acquired between 2021 and 2024 at a private radiology clinic in Santiago, Chile, for reasons unrelated to this investigation. A total of 830 root canal–treated teeth from 520 patients were analyzed. AP prevalence was recorded and lesion volume was quantified with the CBCT Periapical Volume Index. Fillings were classified as adequate or inadequate, and the canal-to-root diameter ratio was measured 1 mm short of the filling terminus. Associations, correlations, and odds ratios (OR) were analyzed at a 5
Accurate radiographic identification of dental implant systems is essential for effective clinical management; however, manual assessment remains time-consuming and susceptible to diagnostic error. Furthermore, conventional computational approaches are constrained by their dependency on manually annotated regions of interest. To overcome these limitations, this study introduces DentalImplantNet, an end-to-end automated deep learning architecture engineered for robust, high-precision implant classification across heterogeneous and radiographically noisy clinical settings. A multi-modal dataset was constructed from 2,714 panoramic and periapical radiographs alongside high-resolution Bruker micro-CT scans of 64 standalone implant fixtures. An automated pipeline utilizing RT-DETR for real-time localization and ROI extraction was implemented to eliminate manual intervention. To enhance robustness, a Causal-Informed Generalization Framework based on Backdoor Adjustment was utilized to dissociate invariant morphological features from non-causal radiographic noise. Model performance was benchmarked against ResNet-50, EfficientNet-B2, and 12 dental professionals who were divided into three levels of expertise. DentalImplantNet achieved an overall accuracy of 95.29
Orthodontic appliances may induce mechanical and biochemical stress on the oral mucosa, potentially leading to early cytological alterations. To evaluate and compare the cytomorphometric parameters and micronuclei (MN) frequency in fixed metal, ceramic, and removable orthodontic appliances in adolescents at 1 and 6 weeks after appliance placement. This prospective exploratory comparative study was conducted on 30 adolescents divided into three groups: metal, ceramic, and removable orthodontic appliance (n = 10 each). Exfoliative cytology using Papanicolaou staining was performed at two experimental sites (S1, S2) and one non-contact intraoral comparison site (S3) at 1 week (T1) and 6 weeks (T2). No true pre-treatment baseline (T0) was available. Intergroup comparisons were made using Kruskal–Wallis, and the Wilcoxon signed-rank test was used for within-group comparisons. Intergroup comparison showed no significant differences for cytoplasmic (C ) area and nuclear (N) area, and N: C ratio across most comparisons (p > 0.05) (p = 0.096–0.995; η² = 0.0003–0.16). A difference was noted only for MN frequency at the S1T1 (p = 0.04; η²=0.22). The principal findings were derived from intragroup T1-to-T2 comparisons. In the fixed metal appliance group, MN (p ≤ 0.028) and N: C ratio (p = 0.002) increased significantly across all sites(S1, S2, S3), with strong effect sizes. The ceramic appliance group showed limited, site-specific changes, with micronucleus frequency significantly increased at S1 (p = 0.014), while the N: C ratio (p = 0.037) and nuclear area (p = 0.002) showed significant changes at S3. The removable appliance group showed a significant increase in MN frequency, N:C ratio, and cytoplasmic area across selected sites, with strong effect sizes. Within the limitations of this small exploratory study, early post-placement cytological alterations were observed in the oral mucosa during orthodontic treatment, particularly in MN frequency and N: C ratio. However, these findings should be interpreted cautiously due to lack of true pre-treatment baseline. Also, most intergroup comparisons were non-significant. MN frequency and N: C ratio may indicate promising research indicators of cytological alterations suggestive of cytogenetic stress, especially in the fixed metal and removable appliance groups. Nevertheless, there is need for larger longitudinal studies with true baseline assessment before stronger conclusions can be drawn.
This study aims to develop a data-driven decision model to optimize reconstructive strategies for oral squamous cell carcinoma. We investigated the threshold between local/regional techniques and microvascular reconstruction by analyzing objective tumor-related and healthcare-economic parameters. A retrospective analysis was conducted on 88 patients with OSCC. The cohort was divided into Group I (local/regional reconstruction, n = 57) and Group II (microvascular reconstruction, n = 31). We evaluated predictors such as tumor location, diameter, and resection type. Statistical analysis included also classification tree analysis and healthcare-economic data (DRG-based reimbursement). Tumor location, diameter, and resection type emerged as the decisive predictors for the reconstructive strategy. The classification tree analysis demonstrated high diagnostic performance, providing a robust cut-off to differentiate between local and microvascular indications. Local reconstructions were significantly superior regarding perioperative morbidity, showing lower rates of tracheotomies, PEG tube requirements, and shorter ICU/hospital stays. Economically, regional techniques proved substantially more cost-efficient, while microvascular procedures required significantly longer operating times. Flap survival was excellent at 96.7
