Multi-Bracket Appliance in Management of Mandibular ...

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
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