ABO CASE REPORT

Treatment of a Class I malocclusion with

severe bimaxillary protrusion
Blaine J. Langberg, DMD, MMSc,a and Anne Todd, DMD, MMScb
Ridgefield, Conn, and Hudson, NH

This report describes the treatment of a 20-year-old woman from Nigeria who had severe bimaxillary
dentolveolar protrusion. The main issue in determining the appropriate treatment plan was the severity of the
dentoalveolar protrusion. Four first premolars were extracted to reduce lip procumbancy. The change in the
patient’s facial esthetics was dramatic. Significant retraction of the upper and lower lips was achieved, and
lip eversion and dentoalveolar protrusion were significantly improved. As the lips were retracted, mentalis
strain was reduced; this improved chin projection. This case report was presented at an AAO meeting as part
of the ABO student case display. It was chosen by committee to be published in the AJO-DO. (Am J Orthod
Dentofacial Orthop 2004;126:739-46)

A
common treatment approach for patients with Diagnosis
severe bimaxillary dentoalveolar protrusion, Facially, the patient had a convex profile, a long
facial convexity, lip incompetence, and crowd- lower face height, and excessive vermilion show of
ing is to extract 4 first premolars and then retract the the upper and lower lips. She had procumbent and
anterior teeth.1,2 However, the treatment plan becomes everted upper and lower lips, a deep mentolabial
more complex and controversial when the patient is sulcus, and excessive lip strain on closure (Fig 1).
black and has slight to moderate bimaxillary protrusion Her dentition was characterized by a Class I maloc-
with minimal crowding of teeth. The options are to clusion with severe dentoalveolar protrusion (Figs 2
extract 4 teeth and reduce the convexity of the face or and 3). She showed mild mandibular crowding, 4
to align the teeth without extractions and possibly mm of overjet, 2 mm of overbite, and coincident
increase the convexity of the face. This case report midlines. Soft tissue analysis indicated that she had
describes the treatment approach and rationale for protrusive lips (Table).
extraction in a black patient with bimaxillary dentoal- The panoramic radiograph showed no evidence of
veolar protrusion. bony pathology. All 32 teeth were present. After
obtaining orthodontic records, all 4 third molars were
extracted, as recommended by her oral surgeon. The
CASE PRESENTATION
lateral cephalometric radiograph showed a Class I
The patient was a healthy 20-year-old woman from bimaxillary dentoalveolar protrusive skeletal pattern
Nigeria. Her chief complaint was, “I want to get braces (Fig 4). As evidenced by the SN-mandibular plane
because my two front teeth are protruding.” She re- angle of 42°, the skeletal pattern was hyperdivergent.
ported previous orthodontic treatment in Africa with a This rotated the patient’s mandible clockwise, masking
removable appliance. There was no history of dental a Class III skeletal tendency supported by a Wits
trauma or oral habits. The patient had good oral appraisal of – 4 mm and a Harvold relationship of 34
hygiene, but occlusal caries were detected on the mm. The patient had protruded and proclined maxillary
maxillary first molars. Her medical history showed no incisors.
contraindication to orthodontic treatment.
Treatment objectives

From Harvard School of Dental Medicine. The primary skeletal objective was to maintain the
a
Former orthodontic resident; private practice, Ridgefield, Conn. skeletal divergency. Extrusion of the patient’s maxil-
b
Clinical instructor, Department of Growth and Development; private practice, lary molars would rotate her mandible down and back,
Hudson, NH
Reprint requests to: Dr Blaine J. Langberg, 631 Danbury Rd, Unit 29, increasing her divergency and worsening her profile.
Ridgefield, CT 06877; e-mail, [email protected]. In the maxillary dentition, the treatment objectives
Submitted, September 2003; revised and accepted, October 2003. were to reduce the severe dentoalveolar protrusion and
0889-5406/$30.00
Copyright © 2004 by the American Association of Orthodontists. achieve a more normal axial inclination of the incisors.
doi:10.1016/j.ajodo.2003.10.039 Because the maxillary incisors were excessively pro-
739
740 Langberg and Todd American Journal of Orthodontics and Dentofacial Orthopedics
December 2004

Fig 1. Pretreatment facial photographs.

Fig 2. Pretreatment intraoral photographs.

clined and the patient exhibited lip strain on closure, maintain the overbite, and achieve canine guidance
more anchorage was needed to retract the incisors and with anterior disclusion.
prevent mesial movement of the maxillary molars. To
enhance anchorage, a transpalatal arch was placed from
first molar to first molar, and the second molars were Treatment alternatives
banded. Treatment objectives in the mandibular arch The main issue in determining the appropriate
included resolving the mild mandibular crowding, up- treatment plan was the severity of the dentoalveolar
righting the incisors, and reducing the dentoalveolar protrusion. It was recommended that the 4 first premo-
protrusion. lars be extracted to reduce the patient’s lip procum-
Treatment objectives for the occlusion were to bancy. A complete orthodontic fixed appliance and
maintain the molar neutrocclusion, decrease the overjet, good cooperation with elastic wear would be needed to
American Journal of Orthodontics and Dentofacial Orthopedics Langberg and Todd 741
Volume 126, Number 6

Fig 3. Pretreatment study models.

maintain the molar and canine relationships and reduce

the dentoalveolar protrusion.
Another treatment alternative was a nonextraction
plan with interproximal tooth reduction of the premo-
lars. This plan would not address the patient’s chief
complaint but would alleviate her mild crowding. With
reproximation, the incisal angulations would not be
affected, and the patient’s bidentoalveolar protrusion
would remain the same.

Treatment progress
An .018-in Roth edgewise appliance (GAC Inter-
national, Bohemia, NY) was used. Initially, the maxil-
lary arch was banded and bonded, and a transpalatal
arch was placed on the maxillary first molars to
increase anchorage. Shortly afterward, the 4 first pre-
molars were extracted. The mandibular arch was
banded and bonded 3 months later. After initial leveling
and aligning, all 4 second molars were banded to
increase anchorage.
Initial leveling was accomplished with .016-in nick-
el-titanium archwires. The archwires were cinched to
avoid proclining the maxillary and mandibular incisors
Fig 4. Pretreatment panoramic and lateral cephalomet- during leveling. Maxillary canine retraction was ac-
ric radiographs. complished by tying power thread from the maxillary
742 Langberg and Todd American Journal of Orthodontics and Dentofacial Orthopedics
December 2004

Table. Cephalometric measurements

Area of study Measurement Normal Pretreatment Posttreatment

Maxilla to cranial base SNA (°) 85 84 86

Mandible to cranial base SNB (°) 81 81 83
SNPg (°) 82 80 83
Basal arch relationship ANB (°) 4 3 3
Wits (mm) ⫺1 ⫺4 ⫺5
Maxillary length (mm) 93 90 92
Mandibular length (mm) 119 124 127
Difference (mm) 26 34 35
Skeletal divergency PP-MP (°) 30 37 33
SN-MP (°) 39 42 39
Maxillary incisor angulation Mx1-NA (mm) 23°, 7 44°, 15 27°, 10
Mx1-SN (°) 104 125 113
Mx1-PP (°) 110 132 121
Mandibular incisor angulation Md1-NB 34°, 10 mm 40°, 15 mm 34°, 9 mm
Md1-APg (mm) 4 14 9
IMPA (°) 95 97 93
Soft tissue Upper lip/Lower lip to Rickett’s E line ⫺4/⫺2 ⫹2.5/⫹8 ⫹2/⫹5
(mm)
Lower sulcus to Holdaway line (mm) 5 1 6
Chin soft tissue thickness (Holdaway) 10-12 5 8
(mm)

S, Sella; N, nasion; A, A point; B, B point; Pg, pogonion; PP, palatal plane; MP, mandibular plane; Mx1, maxillary central incisor; Md1,
mandibular central incisor; IMPA, incisor-mandibular plane angle.

second molars to the canines on a .016-in stainless steel her elastics consistently and was always punctual for
stopped archwire. The mandibular incisors and canines appointments. Her cooperation is largely responsible
were retracted en masse by placing a .016-in stainless for the successful result. During treatment, she reported
steel wire with helices distal to the lateral incisors and sensitivity to sweet foods and to cold in her lower right
tying power thread from the mandibular molars to the quadrant. Upon removal of the band, a bitewing radio-
helices. These mechanics lasted 8 months. During this graph showed active caries on that tooth. A mesial-
time, the patient started wearing Class II elastics from occlusal amalgam was placed on the lower right second
maxillary canines to mandibular first molars to main- molar, and the tooth was rebanded. At the deband visit,
tain molar neutroclusion. the patient was given a maxillary removable circum-
As the mandibular incisors uprighted, the patient’s ferential retainer from second molar to second molar
bite started to deepen. This impeded retraction of the and a mandibular modified spring aligner with rests on
maxillary anterior teeth. Therefore, bite-opening was the first molars. The patient was instructed to wear the
added to each archwire with reverse and exaggerated retainers full time for 9 months, half time for 15
curve of Spee. When the maxillary canines were months, then once per week at night indefinitely.
maximally retracted, an .0175 ⫻ .025-in stainless steel
T-loop archwire, with bite-opening, was placed in the Treatment results
maxillary arch to close spaces distal to the lateral The change in the patient’s facial esthetics was
incisors. After the mandibular incisors were retracted to the most dramatic part of her treatment. With extrac-
the proper angulation, as determined by a lateral cepha- tion of the first premolars, significant retraction of
logram, the anterior teeth were coligated from canine to her upper and lower lips was achieved. Her lip
canine, and a wonder wire (.017 ⫻ .025-in anterior, eversion and dentoalveolar protrusion were im-
.018-in posterior) was placed in the mandibular arch to proved. In addition, as the upper and lower lip were
protract the molars. Final positioning was accom- retracted, mentalis strain was reduced, which im-
plished with a maxillary .0175 ⫻ .025-in TMA arch- proved her chin projection (Fig 5).
wire (Ormco, Glendora, Calif). The final result was Posttreatment intraoral photographs, study models,
obtained with occlusal equilibration and Class II elas- and lateral cephalogram (Figs 6-8) show that the
tics. mandibular incisors are inclined appropriately, and the
The patient responded well to treatment. She wore maxillary incisors are slightly proclined because of the
American Journal of Orthodontics and Dentofacial Orthopedics Langberg and Todd 743
Volume 126, Number 6

Fig 5. Posttreatment facial photographs.

Fig 6. Posttreatment intraoral photographs.

underlying Class III skeletal pattern. However, their was taken. These bends, it seems, were not adequate.
position significantly improved when compared with Periapical radiographs are indicated before debonding
the start of treatment. The soft tissue chin thickness has to achieve more ideal root positioning.
improved as the lip strain was reduced.
The panoramic radiograph (Fig 8) showed adequate DISCUSSION
root parallelism in the maxillary arch, except for the Treatment objectives should be directed toward an
distal root angulation of tooth 22. The mandibular ideal. However, facial forms and incisor prominence
anterior roots are irregular and not parallel. In addition, differ among various ethnic groups and races. For
the roots of the mandibular canines are distally tipped. example, whites of Northern European background
This root irregularity could be explained by bends that generally have relatively thin lips, with minimal lip and
were made in the wire after a panoramic radiograph incisor prominence.3 Blacks commonly display bimax-
744 Langberg and Todd American Journal of Orthodontics and Dentofacial Orthopedics
December 2004

Fig 7. Posttreatment study models.

illary dentoalveolar protrusion, which is characterized

by dentoalveolar flaring of both maxillary and mandib-
ular anterior teeth, with resultant protrusion of the lips
and convexity of the face.4-7 Some investigators have
reported that black women preferred a profile that is
“straighter” than the norms for blacks but “fuller” than
the norms for whites.1,8,9 However, the concept of
beauty is subjective, and no single racial study can
apply to all persons of a race.1
The treatment-planning process is even more im-
portant when treatment is likely to alter the soft tissue
profile. Although there have been published at-
tempts10,11 to define a beautiful face, the definition
changes as society and its esthetic values change.12
Orthodontists must consider the patient’s opinion be-
cause society is becoming more esthetically sensitive.
The orthodontist must not simply aim for normal
values, without considering each race separately and
without considering the patient’s opinion. Therefore,
although bimaxillary protrusion is an acceptable char-
acteristic of the black profile, we were able to present
an extraction plan to the patient that she accepted. She
was amenable to the treatment plan because it ad-
Fig 8. Posttreatment panoramic and lateral cephalo- dressed her chief complaint by reducing her dentoalve-
metric radiographs. olar protrusion. A patient’s expectation of treatment
American Journal of Orthodontics and Dentofacial Orthopedics Langberg and Todd 745
Volume 126, Number 6

Fig 9. Superimposed cephalometric tracings. A, Overall superimposition, and B, composite.

must be considered first and foremost, because ideals of Class II elastics. Mandibular anchorage was achieved
esthetic profiles vary.13 by bonding the second molars.
Kocadereli14 found that, when a decrease of lip Various investigators have reported a range of
procumbency is desirable, extracting premolars and mesial molar movement of 0 to 2.4 mm when canine
retracting incisors is a viable option to achieve these retraction is combined with the use of adjunctive
objectives. On the basis of the patient’s chief complaint appliances to control anchorage.15,16-21 When adjunc-
and the diagnosis of the malocclusion, extracting the tive appliances are not used while retracting canines
maxillary and mandibular first premolars was indicated. with traditional mechanics, 1.6 to 4 mm of mesial molar
When extracting premolars is desired to correct the movement has been reported.20,21 Our patient’s maxil-
malocclusion, the treatment plan must address space lary incisors were retracted 5 mm, and the maxillary
closure of the extraction sites. Closure of the extraction molars moved mesially 2 mm on cephalometric super-
sites can occur by retraction of the anterior segments, imposition (Fig 9). Her mandibular incisors were also
protraction of the posterior segments, or a combination retracted approximately 5 mm, and the mandibular
of the two.15 When it is indicated to prevent mesial molars were moved mesially 2 mm.
movement of the posterior segments in the anteropos-
terior dimension, this is termed maximum anchorage. CONCLUSIONS
Maximum anchorage in this case was necessary and
predicated on the need to restrict mesial movement of In an African patient with procumbent upper and
the maxillary and mandibular first molars until the lower lips, a deep mentolabial sulcus, excessive lip
crowding and bimaxillary protrusion were resolved. strain, and proclined and protruded maxillary and
To augment anchorage, adjunctive appliances, mandibular incisors, an acceptable treatment result
such as a transpalatal bar, a Nance holding arch, was obtained with a 4-first-premolar extraction plan.
A positive soft tissue response to treatment was also
palatal implants, or extraoral traction, are usually
achieved. The patient’s profile was improved, with
necessary. Intraoral sources of anchorage include
reduction in lip procumbancy, decrease in lip ever-
alveolar bone, teeth, dental arches, palatal and man-
sion and protrusion, and decreased mentalis strain.
dibular basal bone, differential moment mechanics,
Dentally, the interincisal angulation improved signif-
and lip musculature.15 Renfroe16 stated that, to be
icantly because both the maxillary and mandibular
stable, the anchorage unit must be overwhelmingly
incisors were uprighted after space closure.
more resistant than the teeth being moved. In this
case, anchorage in the maxilla was achieved with a We thank Dr Alexander Waldman for offering
transpalatal bar, bonding of the second molar, and valuable comments and insight.
746 Langberg and Todd American Journal of Orthodontics and Dentofacial Orthopedics
December 2004

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