Importance Dental implantation has been used for oral rehabilitation to improve cosmesis and function. OBJECTIVE We aim to evaluate the clinical outcomes and success rates of primary and secondary dental implant placement in vascularized fibula bone grafts used for segmental mandibulectomy defects. DESIGN, SETTING, AND PARTICIPANTS A retrospective reviewwas performed between November 2005 and July 2014 on all patients undergoing both fibula free tissue reconstruction of mandibular defects and endosseous dental implantation at an academic tertiary care referral hospital. INTERVENTIONS Either primary (n = 20) or secondary (n = 26) dental implantation of the fibula was performed. MAIN OUTCOMES AND MEASURES Timing of implantation, location of implants, history of tobacco, alcohol, and radiation, reason for mandibulectomy, and outcomes related to these parameters. RESULTS Forty-six patients (31 males, 15 females; mean age, 58.0 years) underwent dental implantation to the fibula graft. A total of 227 implants were placed, with a mean of 5 implants per patient (range, 2-7). Of these, 44 were placed into native mandible and 183 into fibula flap. Twenty patients underwent primary implantation and received 96 implants, while 26 patients underwent secondary implantation and received 131 implants. There were no flap failures and 22 implant-related complications in 16 patients (implant failure, n = 10; granulation or soft-tissue overgrowth, n = 6; exposed bone around implant, n = 6). An implant failure occurred in 10 patients (22%) resulting in removal of 15 implants. Nine of these patients underwent successful dental rehabilitation, 5 without further implantation, and 4 with replaced implants. One patient was not rehabilitated secondary to failed implantation. Therefore, there was a 93%overall implant survival rate (n = 212) and 98%overall implant-supported prosthesis success rate (n = 45) at a mean follow-up of 22 months. There was no difference in implant survival between primary (94%) (n = 90) and secondary (93%) (n = 122) implantation. Neither a history of preimplant or postimplant radiation exposure nor the diagnosis of osteoradionecrosis affected implant survival. CONCLUSIONS AND RELEVANCE Osseointegrated dental implantation is a relatively safe procedure with few complications. Vascularized fibula grafts are a suitable method of mandibular reconstruction and are amenable to successful primary and secondary endosseous implantation.