## 4 Discussion
Maintaining adequate mouth cleanliness after surgery is sometimes made even more complex by the type of prosthetic rehabilitation (as we will see later); post-operative outcomes, such as trismus and altered oral cavity anatomy; or radiotherapy outcomes, such as mucositis and xerostomia. Radiotherapy, in contrast, could be considered a predisposing factor for implant failure, in particular due to the reduced bone healing capacity and increased susceptibility to infections, which eventually lead to bone resorption and compromised implant stability [49; 50; 51]. Despite the data in the literature, the statistical analysis performed in this study did not show a correlation between the implant failure rate and radiotherapy treatment (\(p>0.01\)). In any case, the bias of a statistically small sample should be taken into account due to the limited data currently available in the literature. As pointed out by [PERSON] et al., there might be a difference in terms of bone resorption between the main flaps used for maxillary reconstruction. The scapular flap, in fact, seems to be the most prone to resorption, with 69% residual volume after 48 months. In their population, this percentage rose to 88% and 95% for the DCIA and fibula flaps, respectively. Although these data are extracted from a relatively small sample (a total of 38 patients), they can certainly provide interesting insights regarding implant placement. However, it must be said that not only the quantity, but also the quality of the bone used has its importance. Furthermore, this work shows a progressive reduction in volume over time (which does not stop after the first 6 months), despite having a limited follow-up (2 years) [6]. Therefore, more data are certainly needed to understand the extent of long-term bone resorption in different types of flaps. Another interesting finding from the work of [PERSON] et al. is that there are no differences in terms of bone resorption between irradiated and non-irradiated patients. This latter finding further confirms what was reported in our analysis. The importance of this observation lies in the fact that radiotherapy undoubtedly induces a profound alteration of the soft tissues, leading to problems such as mucositis, tissue retraction, and xerostomia, which can compromise implant stability [51]. In contrast to [PERSON]'s work, more recently, [PERSON] et al. retrospectively analyzed their case series (18 patients) of mandibular reconstructions with scapula flaps. A median volume loss of 0.5% and a mean volume loss of 5.1% were observed in all the flap segments. The limitation of this study is certainly related to the selective evaluation of mandibular reconstructions, whereas those of the upper jaw were not analyzed. Also in this work, however, radiotherapy did not influence bone resorption [52]. Also, in the work of [PERSON] et al., no difference in implant success/survival was observed between the patients who received radiotherapy and those who did not receive radiotherapy. As expected, however, smoking negatively influenced implant survival. Interestingly, they also showed a significantly better outcome in mandibular implants than in maxillary implants [23]. Looking further into the relationship between prosthetic rehabilitation and oral health, it can be stated that the specific type of prosthetic rehabilitation (mainly fixed or removable prosthesis) is particularly impactful due to the different results in terms of achievable oral hygiene. For example, [PERSON] et al. showed a statistically significant difference in the oral hygiene of these two groups, with the group with removable prostheses achieving much better oral hygiene than the group with fixed prostheses [22]. Unfortunately, this aspect was scarcely analyzed in the selected articles, just as the timing of the final restoration was scarcely considered. Although not crucial from a clinical point of view, it is dramatically important for the patient from a psychological point of view.