In low-level maxillectomy (Brown class II), the need for bony reconstruction is questionable depending on the horizontal component. With the preservation of the orbital floor, zygomatic prominence and some bony support for the nose, facial appearance, in the experience of the authors and, as demonstrated by this case, is not significantly worsened despite low-level removal of the maxilla. The key issues in these low level defects are adequate clearance of tumour, dealing with the oro-nasal communication and reconstruction of the dentition. Whilst prosthodontic obturation can deal with these aspects in a simple manner, the stability of the obturator prosthesis and its ability to completely seal the oro-nasal defect has limitations. In addition, these prostheses require a significant amount of adjustments, clinic visits and on-going maintenance. The soft lining materials perish, discolour and harbour surface biofilm often resulting in some mal-odour and the need for regular replacement. For many patients, there is a psychological impact of retaining the maxillectomy defect and high anxiety related to the insertion and removal of the prosthesis as well as concerns relating to the handicap they would experience to speech, and eating should their prosthesis fracture or fail in some way. The use of implants to retain maxillary obturators certainly improves their stability and retention, but efficacy of the oro-nasal seal still requires regular maintenance and patients still often dislike the hygiene aspects of looking after the defect and their implant supra-structure within the defect.

The use of soft tissue flaps to close a typical hemi-maxillectomy defect is an effective way of dealing with the oro-nasal communication, but in isolation, this technique works against dental rehabilitation as the bulk of the flap provides a very poor moveable foundation for a subsequent removable prosthesis. The move towards the use of composite reconstruction (especially the fibula flap) has been facilitated by the use of digital planning in which dental implants can be inserted into the fibula flap at the time of harvest and inset facilitated by the use of stereolithographic guides. However, this procedure is not widely applicable for all patients due to financial, technological and medical restrictions and is not currently able to provide patients with an early loaded fixed dental prosthesis especially when post-operative radiotherapy is being utilised. Many older patients presenting with maxillary malignant tumours also have significant peripheral vascular disease and other significant medical co-morbidities which may prevent the harvest of a vascularised composite flap.