221 General discussion 7 Several authors advocate for the benefits of surgical reconstruction over obturation of maxillary defects, especially for larger defects. Amongst them are authors mainly describing a personal preference solely based on experience [74, 75], or combining the best available literature with clinical experience [39, 66, 76]. Unfortunately, the best available literature is limited, and study populations are usually small. Our study in Chapter 4a and an South-African study in 2007 confirm the benefits of implant-support to obturators [54, 68] and other studies even suggests equivalent functional results as compared to surgical reconstruction [77, 78]. When choosing between obturation or surgical reconstruction, it is important to inform the patient as well as possible. There are benefits for microsurgical reconstruction of extended maxillary and midface defects. Surgical reconstruction has the advantage of avoiding the discomfort of placing and cleaning obturators. There is also less nasalance for hard palate defects reconstructed with a surgical design and simulation fibula free flap [79]. Patients requiring adjuvant RT will take advantage of reconstructive surgery, as the risk of post-radiogenic changes in the irradiated tissues will be less pronounced. Tissue atrophy, fibrosis, and the most feared risk of osteoradionecrosis can be prevented by vascularized tissue transfer into the defect site. Moreover, surgical defect repair can lead to aesthetic benefits, and implant-retained fixed dentures can be applied. However, all this comes with a higher price. Patients should take into account longer operating times and longer hospital stays. In addition to the higher costs, operations with a longer duration have a higher chance of increased pain, increased functional limitations, poor global recovery and decreased HRQoL 6 months after surgery [80]. Finally, despite all advances in radiology, it remains difficult to distinguish between benign post-treatment changes and recurrent malignancy [81]. In addition to the fact that the oncologist with the surgical reconstruction loses direct visual inspection, the assessment of post-surgical radiological images also becomes more difficult. Related to mastication, the Rohner-procedure gives immediate chewing ability like obturators do, but for patients with a malignant tumor, the obturator offers a faster recovery of chewing capacity than the ART-procedure. Since dental oral rehabilitation under the ART procedure is initiated after completion of all cancer treatments and tissue healing, it can easily take up to 6 months to start.
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