Multi-Bracket Appliance in Management of Mandibular ...

I Original Articles I 

Multi-Bracket Appliance in Management of Mandibular 

Reconstruction with Vascularized Bone Graft 

Jpn J Clin Oncol1999;29(3)1l9-126 

Akihiko Takushima 1 , Takafumi Susami 2 , Takashi Nakatsuka 1 , Kiyonori Harii 1 and Tuyoshi Takato 2 

Departments of 1Plastic and Reconstructive Surgery and 20 ral Surgery, Graduate School of Medicine, University 

of Tokyo, Tokyo, Japan 

INTRODUCTION 

Background: The most commonly used tool for maxillo-mandibular fixation to the patient who 

underwent reconstruction using a vascularized bone graft after mandibular resection is a dental 

arch-bar. However, the occlusal relationship achieved by this method is not ideal. Different from 

the dental arch-bar, the multi-bracket appliance which is frequently used in orthodontic treatment 

can control the position of each individual tooth three dimensionally. Thus, this appliance was 

applied for maxillo-mandibular fixation to patients who underwent mandibular reconstruction using 

a vascularized bone graft. 

Methods: A multi-bracket appliance was applied to three patients. Prior to the surgery, standard 

edgewise brackets were bonded to the teeth in the maxilla and in the remaining mandible. After 

mandibular resection, wires for maxillo-mandibularfixation were applied. The harvested bone was 

then carefully fixed with miniplates to maintain the occlusion. The multi-bracket appliance was 

worn for 3 months when the wound contraction became mild. 

Results: All three cases demonstrated stable and good occlusion. They also demonstrated 

satisfactory post-surgical facial appearance. 

Conclusions: Compared to conventional dental arch-bars, a multi-bracket appliance offers 

improved management of mandibular reconstruction. Firstly, its properties are helpful in 

maintaining occlusion of the remaining dentition accurately in bone grafting procedure as well as 

protecting against postsurgical wound contraction. Secondly, the multi-bracket appliance keeps 

the oral cavity clean without periodontal injury. As a result, stable occlusion of the residual teeth 

and good facial appearance were obtained. 

Key words: maxillo-mandibularfixation - bracket - vascularized bone. 

Mandibular reconstruction after tumor ablation presents several 

challenges for reconstructive surgeons. Although microsurgical 

tissue transfer leads to relatively high quality morphological 

tissue restoration (1), functional recovery is less than ideal (2). 

Destruction of the remaining occlusion often occurs due to 

post-surgical mandibular deviation, resulting in difficult rehabilitation 

of masticatory and speech function. To minimize these 

post-surgical problems, precise replication of the bone defect and 

preservation of the remaining occlusion are very important. 

Received October 19,1998; accepted December 9,1998 

For reprints and all correspondence: Akihiko Takushima, Department of 

Plastic and Reconstructive Surgery, Graduate School of Medicine, 

University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113, Japan. 

E-mail: takushima-pla@h.u-tokyo.ac.jp 

Furthermore, even if the proper occlusal relationship of the 

remaining dentition is preserved, it is very difficult to maintain 

this dentition against the remodeling strength of surrounding 

tissue produced by wound contraction mechanisms. 

To overcome these post-surgical problems, maxillo-mandibular 

fixation plays an important role. The most commonly used tool 

for maxillo-rnandibular fixation is a dental arch-bar. This tool is 

simple to use and helpful in fixing the mandible to the maxilla 

during the early postsurgical phase to obtain primary union of the 

transferred bone (3). However, the occlusal relationship achieved 

by this method is not always ideal because of its insufficient 

rigidity. This appliance is applied by circumdental wires and is not 

adhered to the teeth directly. Furthermore, the arch-bar is easily 

deformed by external pressure. Thus, the fixational strength is not 

strong enough to overcome the pressure of wound contraction 

which can last for several months after the operation. The 

arch-bar often loosens gradually, resulting in malocclusion 

particularly in cases with wide resection. 

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120 Multi-bracket appliance in management ofmandibular reconstruction 

b 

a 

Figure 1. (a) Bracket with a rectangular groove is shown. Arch-wire is inserted 

through this groove. (b) Rectangular arch-wire has a proper elasticity to 

maintain the occlusal situation. 

Multi-bracket appliances are frequently used in orthodontic 

treatment (Figs Ia and 1b). Brackets are bonded to the teeth 

directly and firmly, and rectangular arch wires control the position 

of each individual tooth three-dimensionally. This appliance has 

the ability to move the teeth in a predetermined manner, and 

therefore has become widely used in the orthodontic field. 

The present paper describes three cases in which the multibracket 

appliance was applied in mandibular reconstruction using 

a vascularized bone graft. 

MATERIALS AND METHODS 

PREPARATION OF MULTI-BRACKET ApPLIANCE 

First, the extent of the mandibular excision was estimated. 

Standard edgewise brackets (0.018 x 0.025 inch slot) were 

bonded to the teeth in the maxilla and in the remaining mandible, 

and dental impressions were taken . Rectangular wires (0.017 x 

0.022 inch) passively fitted with the brackets were made on a 

dental model and hooks for maxillo-mandibular fixation were 

soldered. An acrylic bite plate to determine the maxillo-mandibular 

relationship was also fabricated on the same dental model in 

two of the three cases. Prior to surgery, the fabricated arch-wire 

was ligated to the brackets after some adjustment in the outpatient 

room. Orthodontists performed these procedures. 

INTRAOPERATION 

After mandibular resection, the occlusion of the remaining teeth 

was replicated precisely. Wires for maxillo-mandibular fixation 

were then applied and the bite plate was placed between the 

maxillary and mandibular dentition in two cases. The harvested 

bone was then contoured to replicate the bone defect and then 

carefully fixed with mini plates to maintain the occlusion. 

POSTSURGICAL TREATMENTS 

Wires for maxillo-mandibular fixation were removed 4 weeks 

after surgery when bone union was recognized by roentgenography. 

The multi-bracket appliance was worn for a further 3 

months when the wound contraction became mild. A plate 

type-retainer was used after removing the multi-bracket appliance. 

RESULTS 

CASE I 

A 45-year-old woman presented with recurrent adenoid cystic 

carcinoma of the right sub-mandibular gland (Figs 2a and 2b). 

The planned mandibular resection approach was from above the 

right angle to the right lateral incisor. She had lost her maxillary 

incisors and she used removable partial dentures. Brackets and 

arch-wires were applied to the proposed residual teeth according 

to the protocol and an orthodontic plate with four artificial 

anterior teeth was also fashioned to maintain the occlusion ofthe 

remaining dentition (Fig. 2c). Resection of the mandible from 

above the right angle to the right canine including the sub-mandibular 

soft tissue and skin, and right radical neck dissection were 

carried out. The facial skin and mandibular defects were 

reconstructed using a fibula osteoseptocutaneous flap from the 

left lower leg (Fig. 2d) . The mucosal defect was directly sutured. 

As the remaining mandible was rigidly fixed to the maxilla, the 

fibula was fixed accurately without any shift ofthe mandible. The 

wires for maxillo-mandibular fixation were removed 4 weeks 

after the operation, and the multi-bracket appliance was worn for 

a further 3 months. One year later, she was satisfied with her facial 

appearance and demonstrated stable occlusion of the residual 

teeth (Figs 2e and 2f). Removable partial dentures were worn in 

the reconstructed mandible and maxilla (Fig. 2g). She was able 

to eat all foods without difficulty. 

CASE 2 

A 44-year-old man presented with left mand ibular malignant 

schwannoma (Figs 3a and 3b) . A segmental mandibulectomy 




a 

Jpn J Clin Oneal 1999;29(3) 121 

Figure2. (a) Preoperative frontal view. (b) Preoperative coronal MRI showing 

adenoid cystic carcinoma in the submandibular gland (arrows). (c) Preoperat ive 

occlusal situation. The patient lost her maxillary incisors and used removable 

partial dentures. Brackets and arch-wires were applied to the proposed residual 

teeth and an orthodontic plate with four artificial anterior teeth was also 

fashioned. (d) After the maxillo-mandibul ar fixation, the fibula was fixed to the 

mandible with miniplates. Then, the peroneal vessels were anastomosed. 




122 Multi-bracketappliance in management ofmandibular reconstruction 

from above the left angle to the midline was planned. Brackets 

and arch-wires were applied to the proposed residual teeth. 

Resection of the mandible from above the right angle to the right 

lateral incisor and right radical neck dissection were carried out. 

The defects of the mandible and oral mucosa were reconstructed 

using a fibula osteoseptocutaneous flap from the right lower leg 

(Fig. 3c). One year after the operation, he demonstrated good 

Figure 2. (e) Postoperative frontal viewone year after surgery. (f) The patients 

shows a 30mmopening. (g)Postoperative occlusalsituation.Removablepartial 

dentureswere worn in the maxilla. 

mastication and was able to consume a completely normal diet 

(Figs 3d and 3e). 

CASE 3 

A 13-year-old boy presented with left mandibular myxofibroma 

(Figs 4a and 4b). Similar to the other two cases, brackets and 




Jpn J Clin OncoI1999;29(3) 123 

Figure 3. (a) Preoperativefrontalview. (b) PreoperativeCT showingmalignant 

schwannoma (arrows). (c) The mandible was fixed to the maxilla by wires 

through arch-wires. Then, the fibula was trimmedto matchto the defect of the 

mandibleand transferred. 





Figure 3. (d) Postoperative frontal view one year after surgery. (e) Postoperative 

panoramic radiograph one year after surgery. 

arch-wires were applied to the proposed residual teeth (Fig. 4c). 

Segmental mandibulectomy from above the left angle to the left 

canine was performed. Bone defect was reconstructed with a 

fibula flap from the left lowerleg. There wereno skin defectsand 

a small mucosal defect was directly sutured. One year after the 

operation, he was very satisfied with his facial appearance. He 

alsodemonstratedstableand goodocclusion. (Figs4d,4e and4f). 

DISCUSSION 

Despite the smallsamplesize,the presentresults from mandibular 

reconstruction using a multi-bracket appliance are very 

encouraging. This technique offers two major advantages over 

the conventional dental arch-bar. 

First, themulti-bracket appliance keepstheoriginaldentalarch 

form firmly. Brackets are bonded to the individual teeth directly 

without any loosening. Rectangular arch-wires control the 

individualtoothpositionthree-dimensionally and have considerable 

stiffness to counter the external pressure. These properties 

are helpful in maintaining occlusion of the remainig dentition 

accuratelyin bonegraftingprocedureas wellas protectingagainst 

postsurgical wound contraction. On the other hand, the dental 

arch-bar is attached to teeth by ligature wires and often loosens 

in maxillo-mandibular fixation . Furthermore, this appliancedoes 

not demonstrate sufficient mechanical strength. In contrast, the 

dental arch-bar, when used for mandibular fracture, enables 

accuratefixation of the mandible. This is due to the lack of bony 

andsoft tissuedefects. Thus,thearchedshape ofthe mandiblecan 

be perfectlyrestoredwhichpreservesthe rigid maxilla-mandibular 

fixation. Baurmash reports that there is little differencein the 

strengthof attachment if one is dealingwitha fulldentalarch, but 

the differencein strength is evidentwhen only a small numberof 

anchoringsare available (4). 

In the case of mandibular resection following tumor ablation, 

the tissue defect is generally large and the number of remaining 

teeth is small. Initially horseshoe-shaped mandibles are divided 

into two relatively straightsticks. A small numberof circumdental 

wires is considered to be insufficient to hold the arch-bars 

rigidly whichresults inconsiderable movementof the mandibles, 

even under maxillo-mandibular fixation. Therefore, holding the 

mandiblesin positionpreciselyduringbonegraftingprocedureis 

difficult. Furthermore, as the teethelongateduring maxilla-mandibular 

fixation, circumdental wires tend to loosen a few weeks 

after surgery and the supporting teeth move toward the reconstructed 

direction. Re-tightening of the wires is often required 

which sometimes leads to periodontal injury (5). We have 

occasionally experienced deterioration of occlusion after the 

removal of the arch-bars due to woundcontractionand resultant 

boneremodelingwhichcontinuefor several monthsaftersurgery. 

The multi-bracketapplianceappearsto solvethese problems, but 

the contributionof the acrylicplate should also be considered. 

The multi-bracket appliance also keeps the oral cavity clean. 

This appliance is designed for long-term use in orthodontic 

treatmentwhileavoidingperiodontal injury. Thus, long-term use 

of this appliance maintains the occlusal relationship against 

wound contraction. In contrast, arch-bars occasionally cause 

gingival infection around the circumdental wires and early 

removal of theseappliances is unavoidable. The wound contracture 

progresses after removal and deviation of the remaining 

mandible occurs, resulting in destruction of occlusion. In the 

present series, multi-brackets were appliedfor 3 months without 

any complications. 

The goals of mandibularreconstruction are the restoration of 

aestheticcontourandoral function includingmastication, speech, 




Jpn J Clin OncoI1999;29(3) 125 

Figure 4. (a) Preoperative frontal view. (b) Preoperative CT showing 

mandibular myxofibroma (arrows). (c) Preoperative occlusal situation. 

(d) ostoperative frontal view one year after surgery. 





Figure 4. (e) Postoperative panoramic radiograph one year after surgery. 

(f) Postoperative occlusal situation. 

and swallowing. Although multi-brackets require the cooperation 

of orthodontists, and it is time-consuming to articulate the dental 

models and apply the multi-brack et appliance, this appliance 

provide s improved functional dental rehabilitation. 

References 

I. Nakatsuka T, Harii K, Yamada A, Veda K, Ebihara S. Dual free flap transfer 

using forearm flap for mandibular reconstruction. Head Neck Surg 

1992;14:452-8. 

2. Wei FC,SeahC5.Tsai YC, Liu51,Tsai MS. Fibula osteoseptocutaneous flap 

for reconstruction of composite mandibular defects. Plast Reconstr Surg 

1994;93:294-304. 

3. Hidalgo DA.Fibula freeflap:a newmethodof mandiblereconstruction.Plast 

Reconstr Surg 1989;84:71-9. 

4. Baurrnash H. Bondedarchbars in oral andmaxillofacial surgery. An update. 

Oral Surg, OralMed, Oral PathoI1993;76:553- 6. 

5. Baurrnash H, Farr D, Baurmash M. Direct bonding of arch bars in the 

management of maxillomandibular injuries. J Oral Maxillofac Surg 

1988;46:813-5.

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