BIMAXILLARY PROTRUSION - A CASE REPORT

CASE REPORT Hemant Kumar Halwai, Sumit Kumar Yadav, Kishor Dutta, Sandeep Kumar Gupta, Raju Shrestha, Anish Kumar Shah

BIMAXILLARY PROTRUSION - A CASE REPORT

Hemant Kumar Halwai,1 Sumit Kumar Yadav,1 Kishor Dutta,1 Sandeep Kumar Gupta,1 Raju Shrestha,1 Anish Kumar Shah1

ABSTRACT

Correction of a severe bimaxillary protrusion with maximum anchorage can be challenging. This case report describes the
treatment of a girl with a bimaxillary protrusion. Orthodontic treatment included extraction of her 4 first premolars. The
total treatment time was 18 months. Her dental proclination and facial appearance was significantly improved.

KEYWORDS Bimaxillary protrusion, extraction, premolars, profile

1. Department of Orthodontics and Dentofacial Orthopedics, UCMS College of Dental Surgery, Bhairahawa, Nepal

DOI: https://doi.org/10.3126/jucms.v7i1.24697

For Correspondence
Dr. Hemant Kumar Halwai
Department of Orthodontics and Dentofacial Orthopedics
UCMS College of Dental Surgery, Bhairahawa, Nepal
E-mail: drhemanthalway@gmail.com

Journal of Universal College of Medical Sciences (2019) Vol.07 No.01 Issue 19 70

 BIMAXILLARY PROTRUSION - A CASE REPORT
CASE REPORT Hemant Kumar Halwai, Sumit Kumar Yadav, Kishor Dutta, Sandeep Kumar Gupta, Raju Shrestha, Anish Kumar Shah

INTRODUCTION Table 1. Cephalometric Appraisal

Bimaxillary protrusion is a condition characterized by Parameter Normal Pretreatment Post treatment

protrusive and proclined upper and lower incisors and an SNA 82° 82° 81.5°
increased procumbency of the lips.1 It is seen commonly in SNB 80° 80° 79.5°
African-American2 and Asian3 populations, but it can be seen ANB 2° 2° 2°
in almost every ethnic group. Because of the negative FMA 25° 28° 28°
perception of protrusive dentition and lips in most cultures, U 1 to NAmm / deg 4mm/22° 10mm/42° 5mm/24°
many patients with bimaxillary protrusion seek orthodontic L 1 to NBmm / deg 4mm/25° 9mm/32° 4mm/25°
care to decrease this procumbency. IMPA 90° 100° 92°
Nasolabial angle 102° 92° 100°
The etiology of bimaxillary protrusion is multifactorial and Upper lip to S line 0 mm 3 mm 0.5 mm
consists of a genetic component as well as environmental
Lower lip to S line 0 mm 5 mm 0 mm
factors, such as mouth breathing, tongue thrusting, lip biting
habits, and tongue volume.3
Treatment Objectives
The goals of orthodontic treatment of bimaxillary protrusion
include the retraction and retroclination of maxillary and The primary objective was to correct bimaxillary dental
mandibular incisors with a resultant decrease in soft tissue proclination and lip procumbency. Treatment objectives for
procumbency and convexity. The successful orthodontic the occlusion were to maintain the molar neutrocclusion, to
correction of bimaxillary protrusion has been reported.4-5 Tan achieve ideal overjet, overbite and achieve canine guidance.
studied orthodontic correction of bimaxillary protrusion in 50
Chinese adult patients and found favorable soft tissue and
dental changes after the extraction of four premolars.6 In a case
report on the use of four premolar extraction and lingual
appliances for the corrections of bimaxillary protrusion, Kurz7
found that the upper and lower incisors became more
retroclined andretrusive, resulting in a greatly improved facial
pro? le.
CASE PRESENTATION
A 22-year-old girl reported to department of Orthodontics,
UCMS College of Dental Surgery with a chief complaint of Figure1. Pre-treatment extra-oraland intra-oral
forwardly placed upper and lower front teeth. There was no photographs
history of dental trauma or oral habits. The patient had good
oral hygiene. Her medical history showed no contraindication The main issue in determining the appropriate treatment plan
to orthodontic treatment. was the severity of dentoalveloar protrusion. It was
recommended that the 4 first premolars be extracted to reduce
DIAGNOSIS the patient's lip procumbency. Another treatment alternative
was a non-extraction plan with interproximal tooth reduction
Patient had a convex pro? le with orthognathic maxilla and of the premolars. This plan would not address the patient's
orthognathic mandible. She had procumbent upper and lower chief complain. With reproximation, the incisal angulations
lips (Figure 1). Her dentition was characterized by a Class I would not be affected, and the patient's bimaxillary protrusion
malocclusion with bimaxillary dental proclination (Figure 1 would remain the same.
and 2). Panoramic radiograph showed presence of 30 teeth
with missing maxillary 3rd molar and with no evidence of any
bony loss (Figure 3). The lateral cephalometric radiograph
showed ANB angle of 2°, indicative of Class I skeletal jaw
bases (Figure 3). As evidenced by Frankfort-mandibular plane
angle of 28°, skeletal pattern was average growth pattern.
The patient had proclined maxillary and mandibular incisors
with UI-NA 10 mm/42° and L1-NB 9 mm/32° (Table 1). Figure 2. Pretreatment study models

Journal of Universal College of Medical Sciences (2019) Vol.07 No.01 Issue 19 71

 BIMAXILLARY PROTRUSION - A CASE REPORT
CASE REPORT Hemant Kumar Halwai, Sumit Kumar Yadav, Kishor Dutta, Sandeep Kumar Gupta, Raju Shrestha, Anish Kumar Shah

Treatment Result
The change in the patient's facial esthetics was the most
impressive part of her treatment. With extraction of the 1st
premolars, 5 mm retraction of upper and lower anterior teeth
was achieved. Her lip incompetency was reduced; nasolabial
angle and mentolabial sulcus improved (Figure 4).The molar
relation and vertical dimension were maintained during
orthodontic treatment (Figures 4 and 5). Post treatment
intraoral photographs and lateral cephalogram showed that the
maxillary and mandibular incisors were inclined
Figure 3 . Pretreatment radiographs appropriately (Figures 4 and 6). The panoramic radiograph
showed adequate root parallelism in both upper and lower
Treatment Progress arches (Figure 6).
MBT appliance 0.022 × 0.028˝ slots was used. A transpalatal
arch in maxilla and lingual arch in mandible was placed on
banded 1st molars to enhance the anchorage. Alignment and
leveling was accomplished with following sequence of arch
wires: (a) 0.016˝nickel-titanium arch wires (b) 0.018˝stainless
steel arch wires and (c) 0.017×0.025˝ stainless steel wires. The
arch wires were cinched distal to molar to avoid maxillary and
mandibular incisor proclination. After aligning and levelling,
the maxillary and mandibular dentition was consolidated on
Figure 5. Post-treatment study models
0.017×0.025˝ stainless steel wire.The en masse retraction was
accomplished by sliding mechanics using 9 mm NiTi coil
spring on 0.019×0.025˝ stainless steel wire. The NiTi coil
spring delivered 150 grams of continuous force without any
permanent deformation.Finishing and detailing was carried
out by 0.021×0.025˝stainless steel wire. Upper and lower
retainers were placed and case debonded. The treatment was
finished in eighteen months. The patient was given a maxillary
and mandibular anterior bondable lingual retainer. The patient
was recalled for follow up every six months, but patient did
not come for follow up. Figure 6. Post-treatment radiographs
DISCUSSION
Bimaxillary protrusion is common among various ethnic
groups, the most affected population being Asians and
American of African descent.3 It is characterized by severe
proclination of anterior teeth of both the arches, with a
resultant increase in lip procumbency. The treatment protocol
includes extraction of ? rst premolars to correct dental
proclination and to reduce lip incompetency. Drobocky and
Smith revealed that almost all patients treated with extraction
of ? rst premolars have an average reduction of 3.4 mm and 3.6
mm in upper and lower lip procumbency in relation to
Rickett's E-line.8 When premolars are extracted to correct the
malocclusion, the treatment plan must account for closure of
extraction space.
Figure 4. Post-treatment extra-oral and intra-oral
photographs The main challenges confronted by the orthodontist are
anchorage maintenance, since mesialization of the posterior

Journal of Universal College of Medical Sciences (2019) Vol.07 No.01 Issue 19 72

 BIMAXILLARY PROTRUSION - A CASE REPORT
CASE REPORT Hemant Kumar Halwai, Sumit Kumar Yadav, Kishor Dutta, Sandeep Kumar Gupta, Raju Shrestha, Anish Kumar Shah

segment may compromise retraction of anterior teeth. 7 Kurz C. American Journal of orthodontics and
dentofacial orthopedics The use of lingual appliances for
Andreasen Gf 9 have reported a range of mesial molar
correction of bimaxillary protrusion ( four premolars extraction ).
movement of 0 to 2.4 mm when retraction is combined with Am J Orthod Dentofacial Orthop. 1997;112(4):357-363.
the use of adjunctive appliances to control anchorage.
Maximum anchorage has been considered vital in such cases. 8 Drobocky OB, Smith RJ. changes in facial profile during
In our case, we used transpalatal arch given by Goshgerian; it orthodonitcs treatment with extraction of four first premolars.
Am j orthod dentofacial orthop. 1989;95(3):220-30.
is economical, easy to fabricate, and the most reliable method
to augment anchorage10. 9 Andreasen GF, Zwanziger D. A clinical evaluation of
diferential force concept as applied to the edgewise bracket. Am J
MBT appliance was used in this case because this prescription Orthod. 1980;78:25-40.
can achieve excellent force levels and resulting in tooth
movement with excellent control of the biomechanics during 10 Stivaros N, Lowe C, Dandy N, Doherty B, Mandall NA. A
the space closure of theextraction sites.11 randomized clinical trial to compare the Goshgarian and Nance
palatal arch. The European Journal of Orthodontics. 2010;
32(2):171-176.
CONCLUSION
11 Mclaughlin, Bennett, Trevisi. systemized orthodontic treatment
In this patient with procumbent upper and lower lips, mechanics. Mosby publisher limited, 2001.
excessive lip strain, proclined maxillary and mandibular
incisors, an acceptable treatment result was obtained with 4-
first-premolars extraction plan.
.
The patient's profile was improved, with reduction in lip
procumbency and decrease in lip protrusion. The interincisal
angulation improved significantly because both the maxillary
and the mandibular incisors were uprighted after space
closure.

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