Original Article

Bimaxillary Dentoalveolar Protrusion: Traits and
Orthodontic Correction
Daniel A. Billsa; Chester S. Handelmanb; Ellen A. BeGolec

Abstract: A group of 48 ethnically diverse patients with bimaxillary protrusion was used to study the
pretreatment cephalometric traits of this malocclusion and the effect of orthodontic correction. All patients
were treated with four premolar extractions and retraction of the anterior teeth. Pre- and posttreatment
lateral cephalograms were evaluated using a series of 18 linear and angular measurements, and the effect
of orthodontic correction was determined using paired t-tests. Cephalometric standards were developed for
bimaxillary protrusions, which clarify the overall presentation of this malocclusion for clinicians. Patients
with bimaxillary protrusion demonstrated increased incisor proclination and protrusion, a vertical facial
pattern, increased procumbency of the lips, a decreased nasolabial angle, and thin and elongated upper
and lower anterior alveoli. This study also showed that the extraction of four premolars can be extremely
successful in reducing the dental and soft tissue procumbency seen in patients with bimaxillary protrusion,
thus providing a stronger evidence-based rationale for this treatment modality. (Angle Orthod 2005;75:
333–339.)
Key Words: Bimaxillary protrusion; Dentoalveolar protrusion; Cephalometric standards

INTRODUCTION mation in the literature in terms of the overall characteris-
tics of this malocclusion. However, in one of the few stud-
Bimaxillary protrusion is a condition characterized by
ies of its kind, Keating8 used cephalometrics to determine
protrusive and proclined upper and lower incisors and an
the morphological features of bimaxillary protrusion in a
increased procumbency of the lips. It is seen commonly in
strictly Caucasian population. He reported that bimaxillary
African-American1–4 and Asian5–7 populations, but it can be
seen in almost every ethnic group. Because of the negative protrusion was associated with a shorter posterior cranial
perception of protrusive dentition and lips in most cultures, base, a longer and more prognathic maxilla, and a mild
many patients with bimaxillary protrusion seek orthodontic Class II skeletal pattern. He also showed that Caucasians
care to decrease this procumbency. with this condition displayed a smaller upper and posterior
The etiology of bimaxillary protrusion is multifactorial face height, diverging facial planes, and a procumbent soft
and consists of a genetic component as well as environ- tissue profile with a low lip line.
mental factors, such as mouth breathing, tongue and lip The goals of orthodontic treatment of bimaxillary pro-
habits, and tongue volume.7 There is a paucity of infor- trusion include the retraction and retroclination of maxillary
and mandibular incisors with a resultant decrease in soft
tissue procumbency and convexity. This is most commonly
a
Former resident, Department of Orthodontics, College of Den-
tistry, University of Illinois at Chicago, Chicago, Ill; Private Practice, achieved by the extraction of four first premolars followed
Washington Township and Vineland, NJ. by the retraction of anterior teeth using maximum anchor-
b
Assistant Clinical Professor of Orthodontics, Department of Or- age mechanics.
thodontics, College of Dentistry, University of Illinois at Chicago, The successful orthodontic correction of bimaxillary pro-
Chicago, Ill.
c
Professor of Biostatistics in Orthodontics, Department of Ortho-
trusion has been reported. Tan6 studied orthodontic correc-
dontics, College of Dentistry, University of Illinois at Chicago, Chi- tion of bimaxillary protrusion in 50 Chinese adult patients
cago, Ill. and found favorable soft tissue and dental changes after the
Corresponding author: Chester S. Handelman, DMD, 25 East extraction of four premolars. Lew5 looked at profile changes
Washington Street, Chicago, IL 60602 after the extraction of four first premolars and orthodontic
(e-mail: chandel@uic.edu).
treatment of bimaxillary protrusion in 32 Asian adults. He
Accepted: November 2004. Submitted: May 2004. reported significant improvement in upper and lower incisor
q 2005 by The EH Angle Education and Research Foundation, Inc.
This article is based on research submitted by Dr Bills in partial
protrusion, nasolabial angle, upper and lower lip length, and
fulfillment of the requirements for the degree of Master of Science in upper and lower lip protrusion. Finally, in a case report on
Oral Sciences, University of Illinois at Chicago, Chicago, Ill. the use of four premolar extraction and lingual appliances

333 Angle Orthodontist, Vol 75, No 3, 2005

For. 6. Ten patients were two patients in the sample were African-American. However. and standard deviation (SD) were de- 2. differences in measurements between the two different trac- Angle Orthodontist. by the extraction of first premolars in a large sample of Pretreatment and posttreatment cephalometric radiographs patients with bimaxillary protrusion. Calif). dental. and extraction pattern. a minimum age of 15 for women and 18 for men at start System. For the purpose of error testing.8 This study was Because these patients were treated in a university setting designed to demonstrate the cephalometric characteristics by several different practitioners. APo). viding concrete evidence on the efficacy of this treatment The following information was recorded from each pa- approach. chorage mechanics were used with the variable use of ex- It is rather well accepted by clinicians that the extraction traoral headgear.7 mm. pretreatment lower incisor protrusion (L1-APog) more plane angle. BEGOLE for the corrections of bimaxillary protrusion. resulting in a greatly improved facial profile.and posttreatment cephalograms were traced at the same time. of four first premolars can be effective in the treatment of Table 1 summarizes the sample on the basis of age and sex. change in lower lip to E-plane. ethnic- provide evidence of the changes that occur orthodontically ity. and all radio- The sample consisted of 38 women and 10 men. and pre. this study was designed to tient’s clinical record: age at start of treatment. (L1-MP). Mixed racial From this parent sample.50 this treatment is also variable in terms of the extent of re- traction. The remaining four individ.98 19. anteroposterior position of lower incisors (L1-APo). it is Review Board of the university where the research was surprising that there is relatively little in the literature pro. treatment time. graphs were traced by the same operator. Table previously treated patients at a university orthodontic clinic. pre.13 The most comprehensive study of the traits associated with this malocclusion was done on a sample consisting uals were treated with the extraction of three first premolars solely of Caucasian patients—a subset of the population and one second premolar.67 5. The mean. pretreatment Class I molar relationship. The tracings were analyzed. treatment modalities were of this malocclusion in a sample of ethnically diverse men quite variable.83 38. The premolars (at least three of which were first premolars) treatment results were analyzed in the following parameters with subsequent retraction of anterior teeth. of treatment. completeness of space closure. Age (mo) of Patients in Sample at Start of Treatment that the upper and lower incisors became more retroclined Male Female Combined and retrusive. and soft tissue was used. traced and then retraced by the same operator a minimum ty-four of the patients in the sample were treated with ex. palatal buttons. with bimaxillary protrusion was chosen from the files of The norms for alveolar width and height (Figure 1. and four were Asian. na- than 7. lower anterior face height. anteroposterior position of upper incisors (U1- 5. and mandibular 7.334 BILLS. No 3. range. of upper incisors (U1-SN).51 ment in patients treated with four premolar extraction have SD 5. Mean 23. and analyzed using Dolphin Imag- ing’s ‘‘Cephalometric Tracing and Analysis’’ software (Dol- MATERIALS AND METHODS phin Imaging System. conducted.95 4. traced. HANDELMAN.0 mm. pretreatment upper incisor protrusion (U1-APog) more upper lip to E-plane. 15 were selected. inclination equate diagnostic quality.25 15. were digitized.08 Maximum 38. 48 patients who met the following norms for measurements 1 through 12 (Table 4) were de- selection criteria were included in this study: veloped specifically for this research by Dolphin Imaging 1. duration of treatment in months. and iatrogenic consequences.22 shown results that have varied greatly. sex. Analysis of both the pretreatment and posttreatment ra- A sample of 84 patients who were clinically diagnosed diographs included 18 linear and angular measurements. (n 5 10) (n 5 38) (n 5 48) Several other studies on the amount of profile improve. given the fact that the The rights and privacy of all patients in the sample were practice of dentistry and orthodontics is now increasingly protected.10–12 The efficacy of Minimum 18. than 3. Kurz9 found TABLE 1. posttreatment cephalograms: interincisal angle. pretreatment interincisal angle less than 1248. 2005 .08 15.and posttreatment radiographs were Hispanic. and transpalatal arches. in all cases.60 20. Twenty. and approval was obtained from the Institutional defined by an evidence-based approach to treatment. solabial angle. and the traction of four first premolars. and the clinician reported that maximum an- features of this relatively common orthodontic problem.50 30. 3) were described by Handelman14 (Table 4). by measuring the changes between the pretreatment and 3. With that in mind. Vol 75. Canoga Park. pre. seven were Caucasian. an edgewise appliance and women to clarify the skeletal. However. bimaxillary protrusion. of two weeks later. inclination of lower incisors 4.and posttreatment cephalometric radiographs of ad. with a low prevalence of this condition. orthodontic treatment consisting of the extraction of four termined for each of the pretreatment measurements.

Upper lip position (UL-E) Distance (mm) from most anterior point on upper lip to E planeg 11. rior direction. 2005 . Lower anterior face height Distance (mm) between ANS and Menton 7. and maximum for each measurement are listed. Lower lip position (LL-E) Distance (mm) from most anterior point on lower lip to E plane 12.7 ment cephalograms were evaluated by paired t-test. The mean.28 for the upper in- ings of the same radiograph were calculated. Paired t-tests cisor and 110. (110. This study used the before and after measurements as the paired data with the resulting difference being the variable of interest. d Mandibular plane: plane through points Gonion and Gnathion. Lower incisor position (L1-APog) Angle between L1 axis and A-Pog line 6. Cephalometric Measurements Measurement Description 1. Interincisal angle Angle between U1 axisa and L1 axisb 2. b L1 axis: line through tip and root of L1. e A-Pog line: line between points A and Pogonion.88) and much more obtuse measures of incisor inclination. minimum. Upper lip thickness Perpendicular distance (mm) from most anterior point on upper lip to a line drawn through soft tissue A point perpendicular to Frankfurt horizontal 9. Vol 75. f Frankfurt horizontal: plane through points Porion and Orbitale. g E plane: plane extending from tip of nose to soft tissue Pogonion.3 mm for the upper incisor and 15.78 for the lower incisor) when compared were performed to determine the significant differences be.and posttreat.14 creased interincisal angle (217.14 Patients with bimaxillary protrusion exhibited a de- FIGURE 1. SD. Upper incisor inclination (U1-SN) Angle between U1 axis and SN planec 3. (17. at a minimum of two weeks apart for the purpose of error testing. ments by using related data from nonindependent samples. of lower anterior face height was found to be 5. mixed racial norms are listed in Table 4 as well as the norms for the alveolar measure- ments.BIMAXILLARY DENTOALVEOLAR PROTRUSION 335 TABLE 2. Mandibular plane angle Angle between mandibular plane and Frankfurt horizontalf 8. incisors that were extremely protrusive in an anteroposte- The cephalometric values from the pre. The subjects also had upper and lower tween the two tracings. The for the lower incisor). RESULTS Error testing No significant difference was found between any of the measurements on the 10 cephalograms traced at two dif- ferent time points. This difference represented the effect of treat- ment. with their norm. Nasolabial angle Angle between a line tangent to base of nose and a line tangent to the upper lip a U1 axis: line through tip and root of U1. No 3. Lower lip thickness Perpendicular distance (mm) from most anterior point on lower lip to a line drawn through soft tissue B point perpendicular to Frankfurt horizontal 10. c SN plane: plane through points Sella and Nasion. Cephalometric measurements of alveolar width. The pretreatment mean measurement paired t-test is used for assessing the effectiveness of treat. Lower incisor inclination (L1-MP) Angle between L1 axis and mandibular planed 4.6 mm lon- Angle Orthodontist. Pretreatment characteristics Descriptive data regarding the characteristics measured from the pretreatment cephalometric radiographs of each subject were determined and are given in Table 4. Upper incisor position (U1-APog) Angle between U1 axis and A-Poge line 5. For comparison.

4 4. along a plane parallel to the occulsal plane.5 2. respectively.0 2. and the lower lip was retracted an average of To determine the overall effect of the orthodontic cor. drawn through the apex. A re- had increased measures of mean upper and lower lip thick.1 22.0 and patients as a result of treatment. the upper lip was retracted an average Effect of treatment of 2. LA Bone anterior (labial) to mandibular incisor apex.4 4.8 14.3 97.3 3.1 11.2 64.0 Lower lip thickness 3. 3. respec- tively. respectively).78. Angle Orthodontist.7 Lower anterior face height 75.7 40.0 8. HANDELMAN.7 1.8 118.7 3.8 19.9 4.0 Width of upper anterior alveolus 4.8 3.0 Upper lip position (UL-E) 1. Apex of the maxillary central incisors to the limit of the labial cortex.2 mm.4 2.8 8.9 1.9 11.3 7.48 larger as compared with the norm.0.1 1.7 1.2 90.0 1.0 5.6 6. LH Bone inferior to mandibular incisor apex. along a plane parallel to the palatal plane. TABLE 4.2 Width of lower posterior alveolus 4. The shortest distance from the apex of the mandibular incisor to the lowest point on the mandibular symphysis that is transected by a line parallel to the occlusal plane. significant (P .5 0. as de.4 12. Both the upper and value. drawn through the apex.0 1. The shortest distance from the maxillary incisor apex to the palatal plane.18 in these norm where the lips are behind the E-plane (27.0 6. The mean nasolabial angle of patients retroclined a mean of 12.3 8. Pretreatment Cephalometric Characteristics of Individuals With Bimaxillary Protrusion (N 5 48) Measurement Mean SD Minimum Maximum Norm Mean a. Apex of the mandibular central incisors to the limit of the labial cortex.1 23.3 mm.5 129.6 24.001). The mean Normal values for upper and lower lip thickness.4 2.1 2.14 ger than normal.4 mm.0 3.8 2.3 a Norms are mixed-racial norms developed by Dolphin Imaging System.7 mm.3 1.6 13. In addition.4 87.0 Nasolabial angle 93.3 4.3 Upper alveolar height 10.2 Lower incisor position (L1-APo) 8. No 3.0 mm.9 130. along a plane parallel to the palatal plane.0 mm. UH Bone superior to upper incisor apex.3 27. whereas the lower incisors in this study was found to be decreased at 93. duction in the measurements is represented by a negative nesses at 5.8 102.0 6. BEGOLE TABLE 3.5 Upper lip thickness 5.3 2.9 103.0 Upper incisor inclination (U1-SN) 113.3 8.6 13.1 2.0 19.7 1.6 Lower alveolar height 27. were determined and are given in Table 5.16 Individuals in this study associated P values as determined by paired t-tests. Apex of the mandibular central incisor to the limit of the lingual cor- tex.9 70.0 2.9 12.5 1.4 16. .3 3.336 BILLS.6 10. drawn through the apex. the mean mandibular plane treatment and posttreatment cephalometric radiographs angle was 5.2 49.4 1.8 6. LP Bone posterior (lingual) to mandibular incisor apex. respectively).5 Mandibular plane angle 28. the changes between pre.2 6. The upper and lower in- 1028).2 2.1 8.4 Width of lower anterior alveolus 2. All these changes were found to be statistically rection of bimaxillary protrusion.8 122.9 1. are both 1.5 Lower incisor inclination (L1-MP) 100.2 and 3.68. Vol 75.2 6.3 4.7 2. Cephalometric Measurements of Alveolar Width. and 4.8 2. along a plane parallel to the occlusal plane.5 57.6 2. b Norms for alveolar width and height developed by Handelman.6 and 3.5 7.9 26.3 26.7 6. 2005 .0 ue.7 94.9 22. and this is in contrast to the The mean interincisal angle was increased 18.9 17.4 127. drawn through the apex. The upper incisors were 22.0 Upper incisor position (U1-Apo) 13. change and SD for each measurement are listed along with fined in Table 2.1 Width of upper posterior alveolus 6.b SD Interincisal angle 112. Apex of the maxillary central incisors to the limit of the palatal cortex. From Handelman14 Measurement Description UP Bone posterior (lingual) to upper incisor apex.6 123.0 2. In addition.0 Lower lip position (LL-E) 4.9 2.3 3. cisors were retracted a mean of 5.98 (norm 5 were retroclined a mean of 5.0 5. UA Bone anterior (labial) to upper incisor apex. whereas an increase is represented by a positive val- the lower lips were found to be ahead of the E-plane (1.

however. The nasolabial angle in our subjects was 948. upper and lower incisor proclination and protrusion. norms. this result was less than the 3.71 7.39 2.53 7.09 .0 mm ahead of the E-plane in between the norms generally used for Caucasians and for Caucasian patients with bimaxillary protrusion. respectively.4 mm found by Keating.11 9. The fact African-Americans. Patients with this condition demonstrated increased can patients in this sample. and lower alveolar widths and heights on lateral cephalo- The increased lower anterior face height. Although the correlation between interincisal angle are present in the literature.00 2.000 Lower lip position (LL-E) 23.34 .80 . significant at the . The cephalometric characteristics other than these dental This result is another indication of the soft tissue procum- changes.8 who found hyperdivergent relationship and an average mandibular plane angle as be- facial patterns in a Caucasian sample with bimaxillary pro. they tend to fall somewhere in who found the lower lip 6.8 ported for various races.0 and 2. and upper and lower alveolar heights found in 107 adult Caucasian individuals before orthodontic treat- this study indicate that individuals with bimaxillary protru. were compared with population (mixed racial) norms de.04 . Although he analyzed patients with various maloc- sion tend to have vertical growth patterns.22 1. This finding is clusions. In this study both the up- purposes because they best represent the ethnic variability per and the lower lips in contrast were found to be ahead of this sample. Because no other normal values trusion. 1 SD more erally 2 to 3 SD from the mixed racial norms. Although the actual numerical value of that the upper lip was 1. he classified the 18 patients with a Class I molar consistent with that of Keating. it is difficult to these measurements in this study are compared with these Angle Orthodontist.000 Lower incisor position (L1-APo) 23. Jacobson16 reported that a normal distance for the inci- veloped by Dolphin Imaging System from a collection of sors from both the upper and lower lip is 7.64 5.80 . It should be noted that because these normal of the E-plane.13 10. All mea.000 Upper incisor inclination (U1-SN) 212. in these patients is consistent with the work of Keating.021 Lower anterior face height 20.41 1. tients with bimaxillary protrusion to be decreased at 86. An even more acute mea- was not surprising because of the fact that the measures of surement of the nasolabial angle was found by Tan. mandibular grams and determined these measurements for a sample of plane angle. The procumbent position of the lower lip values represent a combination of cephalometric norms re.BIMAXILLARY DENTOALVEOLAR PROTRUSION 337 TABLE 5. which was their pretreatment cephalometric characteristics.51 .0 mm ahead of the E-plane suggests any reported difference is in comparison to these mixed that the subjects in this sample had protrusive upper lips.000 Nasolabial angle 3.250 DISCUSSION establish causation—does the mandibular divergence cause an increase in interincisal angle or visa-versa? However. Because pre- Table 4 shows the pretreatment cephalometric traits of vious studies have clearly shown that African-American in- the patients in this study and presents a good composite of dividuals tend to have increased lip thickness. the pretreatment values for and mandibular divergence was significant. most likely due to the large percentage of African-Ameri- trusion.000 Upper lip position (UL-E) 22. paint a much larger picture of the patient bency seen in patients with this condition. but.68.000 Upper incisor position (U1-Apo) 25.001 level (this data has not been reported surements (except for those of alveolar width and height) in this paper).67 . These values were used for comparison behind the E-plane. this result is the characteristics present in patients with bimaxillary pro. with bimaxillary protrusion and can give the practitioner a Handelman14 described a technique for measuring upper broader idea of what to expect from these patients.15 surements of upper and lower lip thickness. Pretreatment characteristics stepwise regression analysis of factors influencing an in- This study was the first to look at an ethnically diverse crease in interincisal angle showed a coefficient of deter- sample of patients with bimaxillary protrusion to determine mination of 31.30 .000 Lower incisor inclination (L1-MP) 25.38 . Cephalometric Changes After Orthodontic Correction of Bimaxillary Protrusion (N 5 48) Measurement Mean Change (Post 2 Pre) SD P value Interincisal angle 18. No 3.640 Mandibular plane angle 20. This result acute than the mixed racial norm.6 who these variables were in the selection criteria for inclusion determined the pretreatment nasolabial angle of Chinese pa- in this study and are by definition part of this malocclusion.6% for mandibular divergence.8 creased also differ with respect to the African-American Subjects in this study were found to have increased mea- norms reported by Richardson.0 mm original research. all measurements reported as being increased or de.20 2. ment. ing his normal controls.99 . Vol 75. 2005 . gen.

1999. 10. In addition. Eur J similar to those of Chiasson12 and Hershey. Arvystas BA. Orthod.11. retraction to upper lip retraction—in an attempt to establish 4. Patients at the min. 12:193–201. These findings suggest that this treatment mo. tissue response. These results. A cephalometric evaluation of American movements—most commonly the amount of upper incisor Negro women. pany the mean changes in lip position.104:240–250. . 2005 . Nelson SS. and this is con. This result is maxillary protrusion in adults with the Begg appliance.14 were less than bimaxillary protrusive sample. • The results of this study also showed that the extraction Effect of treatment of four premolars can be extremely successful in re- Patients in this study were treated with the extraction ducing the dental and soft tissue procumbency seen in of four premolars and the retraction of anterior teeth in an patients with bimaxillary protrusion. Bimaxillary protrusion in black Most authors conducting this type of research have es. CONCLUSIONS the small sample size in Handelman’s14 study made it dif- ficult to run any credible comparison. 1989. Farrow AK.3 mm. decreasing the soft tissue procumbency in patients with bi. bodily retraction. Tan TJ. These results suggest that the sistent with the increase in anterior facial height seen in mechanics used in the treatment of individuals with bimax- this sample. a decreased nasolabial angle. The perceived impact of extraction and . Am J for the upper lip was 2. sion. 1993. Lamberton CM.6 and 1. and some of these patients may require surgi. Int.116:352– proclination that is characteristic of bimaxillary protru. HANDELMAN. 1978.2 mm of upper incisor re. The results stronger evidence-based rationale for this treatment of this study demonstrated a significant increase in inter. Fonseca RJ.and the mean values of both upper and lower alveolar heights posttreatment measurements of lower anterior face height were found to be greater in this sample. patients with protrusion. on average. Profile changes following orthodontic correction of bi- 3:1 ratio reported by Diels et al.14 and thin and elongated upper and lower anterior alve- oli. Rosa RA.338 BILLS. the formation on the possible consequences of incisor retrac- mean values of all four measurements of alveolar width tion.4 mm of upper lip retraction). 7. However. as well as the vary. Kurz C. REFERENCES teroposterior position of the upper and lower incisors (P 1. Johnston LE. Triratananimit P. Klein WD. etc. 5. metric study of the morphological features. 1978. Keating PJ. 1980. Am J Orthod Dentofacial Orthop. Factors such as interlabial gap. Reichart PA. DeLoach N. 2.1. but it is less than the 6. Powers M. 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