89 Oral functioning in maxillectomy patients 4 Patients at the University of Alberta have been included as part of the HREBA.CC17-0167 study [12], and at Maastricht UMC+ as part of the METC.15-4-123 study [21]. For both studies medical-ethical approval was given. Written informed consent was obtained from each participant before entering the study. Clinical patient charts were examined for age, sex, duration since dental oral rehabilitation, origin of defect, type of tumour, type of treatment (surgery alone or surgery with adjuvant radiotherapy), radiation dose as well as number of dental implants. The initial defect was recorded by the classification of the extents of maxillary defects according to Brown [23]. The horizontal, or dentoalveolar component of this classification describes the functional side of the defect. Dental status was examined and scored according to present natural dentition, dental implants, and prostheses in both jaws. Furthermore, the occluding pairs were scored as premolar equivalents [24]. Occluding fixed dental prostheses were included in the number of occluding pairs. In contrast third molars and tissue- or implant-supported prostheses were not included. Masticatory performance The mixing ability test (MAT) was used to measure masticatory performance [25, 26]. This test measures how well a participant mixes a two-coloured wax tablet by chewing on it. The tablet has a diameter of 20 mm and consists of two 3 mm layers of red and blue wax. The test-wax is a soft material (Plasticine modelling wax, non-toxic DIN EN-71) that forms a compact bolus during chewing and was presented to the participant at room temperature (20˚C). After chewing, the wax was flattened between foils to a thickness of 2 mm to avoid shadows. Then the test wax was illuminated by a scanner lamp and photographed on both sides using a high-quality scanner (Epson V750). The images of the wax were analysed and processed using a commercially available program for image analysis (Adobe Photoshop CS3). Intermediate colour intensities appear and the spreads of the intensities for red and blue decrease. A lower mixing ability index score (MAI) implies a better colour-mixed tablet, hence better masticatory performance. Patient reported eating ability Oral health related quality of life (OHRQoL) was measured with the OHIP-14 at iRSM and the OHIP-EDENT at MUMC+. Both questionnaires are based on the original OHIP consisting of 49 items and have a symptom scale, with higher scores representing stronger symptoms. The overlapping seven questions of OHIP-14 [27] and OHIP-EDENT [28] were used in this study (see Appendix A).
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