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

From Harvard School of Dental Medicine.
a
Former orthodontic resident; private practice, Ridgefield, Conn.
b
Clinical instructor, Department of Growth and Development; private practice,
Hudson, NH
Reprint requests to: Dr Blaine J. Langberg, 631 Danbury Rd, Unit 29,
Ridgefield, CT 06877; e-mail, braceyourself9902@yahoo.com.
Submitted, September 2003; revised and accepted, October 2003.
0889-5406/$30.00
Copyright © 2004 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2003.10.039
The primary skeletal objective was to maintain the
skeletal divergency. Extrusion of the patient’s maxil-
lary molars would rotate her mandible down and back,
increasing her divergency and worsening her profile.
In the maxillary dentition, the treatment objectives
were to reduce the severe dentoalveolar protrusion and
achieve a more normal axial inclination of the incisors.
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,
more anchorage was needed to retract the incisors and
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
banded. Treatment objectives in the mandibular arch
included resolving the mild mandibular crowding, up-
righting the incisors, and reducing the dentoalveolar
protrusion.
Treatment objectives for the occlusion were to
maintain the molar neutrocclusion, decrease the overjet,
maintain the overbite, and achieve canine guidance
with anterior disclusion.
Treatment alternatives
The main issue in determining the appropriate
treatment plan was the severity of the dentoalveolar
protrusion. It was recommended that the 4 first premo-
lars be extracted to reduce the patient’s lip procum-
bancy. A complete orthodontic fixed appliance and
good cooperation with elastic wear would be needed to
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 126, Number 6
Fig 3. Pretreatment study models.
Fig 4. Pretreatment panoramic and lateral cephalomet-
ric radiographs.
Langberg and Todd 741
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
during leveling. Maxillary canine retraction was ac-
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
stopped archwire. The mandibular incisors and canines
were retracted en masse by placing a .016-in stainless
steel wire with helices distal to the lateral incisors and
tying power thread from the mandibular molars to the
helices. These mechanics lasted 8 months. During this
time, the patient started wearing Class II elastics from
maxillary canines to mandibular first molars to main-
tain molar neutroclusion.
As the mandibular incisors uprighted, the patient’s
bite started to deepen. This impeded retraction of the
maxillary anterior teeth. Therefore, bite-opening was
added to each archwire with reverse and exaggerated
curve of Spee. When the maxillary canines were
maximally retracted, an .0175 ⫻ .025-in stainless steel
T-loop archwire, with bite-opening, was placed in the
maxillary arch to close spaces distal to the lateral
incisors. After the mandibular incisors were retracted to
the proper angulation, as determined by a lateral cepha-
logram, the anterior teeth were coligated from canine to
canine, and a wonder wire (.017 ⫻ .025-in anterior,
.018-in posterior) was placed in the mandibular arch to
protract the molars. Final positioning was accom-
plished with a maxillary .0175 ⫻ .025-in TMA arch-
wire (Ormco, Glendora, Calif). The final result was
obtained with occlusal equilibration and Class II elas-
tics.
The patient responded well to treatment. She wore
her elastics consistently and was always punctual for
appointments. Her cooperation is largely responsible
for the successful result. During treatment, she reported
sensitivity to sweet foods and to cold in her lower right
quadrant. Upon removal of the band, a bitewing radio-
graph showed active caries on that tooth. A mesial-
occlusal amalgam was placed on the lower right second
molar, and the tooth was rebanded. At the deband visit,
the patient was given a maxillary removable circum-
ferential retainer from second molar to second molar
and a mandibular modified spring aligner with rests on
the first molars. The patient was instructed to wear the
retainers full time for 9 months, half time for 15
months, then once per week at night indefinitely.
Treatment results
The change in the patient’s facial esthetics was
the most dramatic part of her treatment. With extrac-
tion of the first premolars, significant retraction of
her upper and lower lips was achieved. Her lip
eversion and dentoalveolar protrusion were im-
proved. In addition, as the upper and lower lip were
retracted, mentalis strain was reduced, which im-
proved her chin projection (Fig 5).
Posttreatment intraoral photographs, study models,
and lateral cephalogram (Figs 6-8) show that the
mandibular incisors are inclined appropriately, and the
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
position significantly improved when compared with
the start of treatment. The soft tissue chin thickness has
improved as the lip strain was reduced.
The panoramic radiograph (Fig 8) showed adequate
root parallelism in the maxillary arch, except for the
distal root angulation of tooth 22. The mandibular
anterior roots are irregular and not parallel. In addition,
the roots of the mandibular canines are distally tipped.
This root irregularity could be explained by bends that
were made in the wire after a panoramic radiograph
was taken. These bends, it seems, were not adequate.
Periapical radiographs are indicated before debonding
to achieve more ideal root positioning.
DISCUSSION
Treatment objectives should be directed toward an
ideal. However, facial forms and incisor prominence
differ among various ethnic groups and races. For
example, whites of Northern European background
generally have relatively thin lips, with minimal lip and
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

Fig 8. Posttreatment panoramic and lateral cephalo-
metric radiographs.
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-
dressed her chief complaint by reducing her dentoalve-
olar protrusion. A patient’s expectation of treatment
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 126, Number 6
Fig 9. Superimposed cephalometric tracings. A, Overall superimposition, and B, composite.
must be considered first and foremost, because ideals of
esthetic profiles vary.13
Kocadereli14 found that, when a decrease of lip
procumbency is desirable, extracting premolars and
retracting incisors is a viable option to achieve these
objectives. On the basis of the patient’s chief complaint
and the diagnosis of the malocclusion, extracting the
maxillary and mandibular first premolars was indicated.
When extracting premolars is desired to correct the
malocclusion, the treatment plan must address space
closure of the extraction sites. Closure of the extraction
sites can occur by retraction of the anterior segments,
protraction of the posterior segments, or a combination
of the two.15 When it is indicated to prevent mesial
movement of the posterior segments in the anteropos-
terior dimension, this is termed maximum anchorage.
Maximum anchorage in this case was necessary and
predicated on the need to restrict mesial movement of
the maxillary and mandibular first molars until the
crowding and bimaxillary protrusion were resolved.
To augment anchorage, adjunctive appliances,
such as a transpalatal bar, a Nance holding arch,
palatal implants, or extraoral traction, are usually
necessary. Intraoral sources of anchorage include
alveolar bone, teeth, dental arches, palatal and man-
dibular basal bone, differential moment mechanics,
and lip musculature.15 Renfroe16 stated that, to be
stable, the anchorage unit must be overwhelmingly
more resistant than the teeth being moved. In this
case, anchorage in the maxilla was achieved with a
transpalatal bar, bonding of the second molar, and
Langberg and Todd 745
Class II elastics. Mandibular anchorage was achieved
by bonding the second molars.
Various investigators have reported a range of
mesial molar movement of 0 to 2.4 mm when canine
retraction is combined with the use of adjunctive
appliances to control anchorage.15,16-21 When adjunc-
tive appliances are not used while retracting canines
with traditional mechanics, 1.6 to 4 mm of mesial molar
movement has been reported.20,21 Our patient’s maxil-
lary incisors were retracted 5 mm, and the maxillary
molars moved mesially 2 mm on cephalometric super-
imposition (Fig 9). Her mandibular incisors were also
retracted approximately 5 mm, and the mandibular
molars were moved mesially 2 mm.
CONCLUSIONS
In an African patient with procumbent upper and
lower lips, a deep mentolabial sulcus, excessive lip
strain, and proclined and protruded maxillary and
mandibular incisors, an acceptable treatment result
was obtained with a 4-first-premolar extraction plan.
A positive soft tissue response to treatment was also
achieved. The patient’s profile was improved, with
reduction in lip procumbancy, decrease in lip ever-
sion and protrusion, and decreased mentalis strain.
Dentally, the interincisal angulation improved signif-
icantly because both the maxillary and mandibular
incisors were uprighted after space closure.
We thank Dr Alexander Waldman for offering
valuable comments and insight.
746 Langberg and Todd
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