Correction of Severe Bimaxillary

Protrusion

Robby Ramadhonie

INTRODUCTION

Bimaxillary dentoalveolar protrusion is a common dentofacial deformity that results in

functional and esthetic problems.
Patients with severe bimaxillary dentoalveolar protrusion are often treated with a
combination of orthodontics and orthognathic surgery to improve the facial profile.
In adult patients with bimaxillary protrusion, correction may involve removal of f our
premolars. The anterior teeth may be retracted with fixed appliances, with or without
orthognathic surgery.
In severe cases of protrusion, the typical orthodontic therapy that includes extraction
of the 4 first premolars and retraction of anterior teeth may not be sufficient to
improve the facial profile.
total arch distalization might be required to supplement the extraction treatment if
patients decline surgical options to improve their profiles.
A modified palatal anchorage plate (MPAP) may overcome this drawback and
effectively distalize the whole dental arch
A corticotomy technique to enable the movement of a bone segment that includes a
tooth by sectioning of the layer of compact bone. It is a surgical technique which
allows the fairly rapid movement of a tooth or group of teeth without requiring the
teeth to move a great distance through bone. A corticotomy poses less risk than a
segmental osteotomy or orthognathic surgery

CASE REPORT I
A young woman, aged 20 years 4 months, came to the orthodontic
department of Seoul St. Mary's Hospital, Catholic University of Korea,
in Seoul with the chief complaint of lip protrusion.
Her lips were incompetent because of the severe proclination of her
maxillary incisors at rest. When smiling, the left side of her upper lip
lifted more than the right.
No significant skeletal asymmetry or temporomandibular joint
disease was found.
She was healthy, with no specific medical problems.
She had an overjet of 6.5 mm, a 10% overbite, and mild crowding in
both arches.
She had Class I molar relationships and dental caries on her
mandibular second molars.
The panoramic radiograph showed a missing mandibular left third
molar, and her other third molars were in the developmental stage

Pretreatment facial and intraoral photographs

The panoramic radiograph showed a missing

mandibular left third molar, and her other third
molars were in the developmental stage.

The lateral cephalometric analysis

indicated a skeletal Class I pattern
(ANB, 3.5; Witsappraisal,1.0 mm) with
a hyperdivergent growth pattern
(FMA, 33.0).
The maxillary and mandibular
incisors were proclined (U1-FH, 135.0;
IMPA, 94.5;U1/L1,97.5).
The upper and lower lips were
protrusive (upper lip to E-line, 2.5
mm; lower lip to E-line, 5.0 mm) with
an acute nasolabial angle (79.0).
She had a short upper lip
(subnasale-stomion, 17.0 mm) with
an increased ratio of lower lip and
chin to upper lip (stomion-soft tissue
menton/subnasale-stomion, 3.0)

TREATMENT OBJECTIVES
The treatment objectives were to improve the patient's facial
profile, obtain optimal inclination of her anterior teeth, obtain
normal overjet and overbite, maintain a Class I molar and canine
relationship, and resolve the crowding in both arches.

TREATMENT ALTERNATIVES
The first treatment option was to perform an anterior segmental
osteotomy combined with first premolar extractions because of her thin
anterior alveolus.
The second treatment option was to fully retract her anterior teeth
after extraction of her first premolars. However, if the improvement in
her profile was not satisfactory after closure of the extraction space, a
further treatment option was to distalize the entire maxillary dentition
using a palatal plate appliance.
The mandibular dentition would be distalized along with the maxillary
dentition using Class III elastics.
The patient refused the surgical treatment option. Therefore, the
second and the additional treatment options were used to improve her
profile.

TREATMENT PROGRESS

Before orthodontic treatment, the patient was referred to a general dentist

for treatment of the dental caries and extraction of all first premolars.
She was also sent to an oral surgeon to evaluate the extraction of her third
molars, but she declined the extractions.
Preadjusted appliances with 0.022-in slots were bonded on both arches for
leveling and alignment.
Her maxillary arch was leveled with archwires. two miniscrews were placed
between the maxillary first and second molars for maximum anchorage.
The maxillary and mandibular anterior teeth were retracte.
Unfortunately, even after retraction of the maxillary anterior segment with
maximum anchorage, the patient still had protrusive lips.
Therefore, to improve her profile, an MPAP was used to distalize the whole
dentition of both arches.
A palatal arch running along the gingival margin was soldered to the
banded maxillary first molars.
At the finishing stage, final detailing of the occlusion was accomplished
with 0.0163 0.022-in stainless steel archwires in conjunction with posterior
vertical and Class III elastics. Bonded lingual premolar to premolar
retainers were placed on both the maxillary and mandibular dentitions, and
additional Essix retainers were delivered.
Total treatment time was 24 months.

CASE REPORT II
This female patient, aged 50 years, 10 months, presented with
pronounced dental and labial protrusion, and advanced
periodontal disease. Pocket depths ranged from 4 - 8 mm. All
molar furcations were affected, and the mandibular incisors
were over-erupted.
She was treated with universal curettage and periodontal
surgery, and followed until basic periodontal health was evident.
The extraoral examination revealed a very convex profile with
significant mentalis muscle strain.
The intraoral examination revealed a Class II canine and Class I
molar relationship.
In the maxilla, the anteriors
were spaced and severely
protruded. The mandibular anteriors were moderately crowded.

Lateral cephalometric view revealed that the patient had a skeletal

Class II relationship (ANB angle = 3.2o, Mx.1 to NA angle = 30.7o,
Mx.1 to NA distance = 11.5 mm), a steep occlusal plane (SN-OP
angle = 20.6o), a high mandibular plane angle (FMA = 32.2o), and
proclined incisors (Interincisal angle = 114.4o, Mandibular incisor to
NB angle = 31.7o, Mandibular incisor to NB distance = 12.3 mm)
(Fig 3A, Table 1).

 The diagnosis was a skeletal Class II

malocclusion with bidentoalveolar
protrusion
and
compromised
periodontal status.
The panoramic radiogram revealed a
missing lower right first molar. The
periodontal bone levels were low.

 TREATMENT OBJECTIVES
The treatment objectives based on the
analysis of the cephalometric tracings,
dental x-rays, photographs, and study
models were to extract all the first
premolars, align and retract the anterior
teeth, improve the interincisal angle
relationship, decrease the lip protrusion,
maintain
the
posterior
occlusal
relationship, and improve the convex
profile - all without a deterioration of the
periodontal condition.

TREATMENT ALTERNATIVES
Fixed appliances with removal of two maxillary premolars and two mandibular incisors, retracting the
maxillary anterior teeth against mini-screw anchors.
Remove the upper and lower first premolars. Then
perform a corticotomy to outline a block of bone
around the maxillary anteriors and retract the
mandibular anteriors with an anterior segmental
osteotomy under local anesthesia. Use the C-lingual
retractor and C-plate in the maxilla as rigid anchorage.
Remove the four first premolars and perform anterior
segmental osteotomies in both arches to affect the
retraction surgically under general anesthesia.

 The patient chose the second option

even though she was made aware
that the lower anterior teeth were
more periodontally at risk than the
lower first premolars. She noted the
advantages of a shortened treatment
time and felt the overall risks were
less.

TREATMENT PROGRESS
After a three month stabilization of the periodontal
status, and home care was improved, the designated
teeth were removed and corticotomy was performed
in the maxilla, and anterior segmental osteotomy
performed in the mandible under local anesthesia.
Two weeks later, to allow reconnection of the palatal
blood supply after the palatal corticotomy, a buccal
corticotomy was executed and a C-plate, a C-lingual
retractor and a C-tube were installed (Figs.5A and 6).
Fixed orthodontic appliances were placed on the
maxillary posterior teeth and lower teeth, followed
by the mandibular anterior segmental osteotomy.

 In the mandible, after a healing

period of about 6 weeks, leveling and
alignment began. In the maxilla,
retraction
of
the
anterior
corticotomized segment required five
months, after which the C-lingual
retractor was removed and anterior
brackets placed for four more months
to level and align the anterior teeth

CONCLUSION
A combination of extraction treatment and total arch
distalization might be a feasible treatment option to avoid
surgery in patients with moderate bimaxillary protrusion and
achieve better facial esthetics. The application of the palatal
anchorage plate shows the correction of a severely
protrusive soft tissue profile without orthognathic surgery by
4 first premolar extractions along with total distalization
As shown in this reported case of an adult with severe
periodontal disease and bimaxillary protrusion careful
treatment of periodontal disease and appropriate periodontal
maintenance during treatment allowed a
protocol of
treatment using perisegmental corticotomy and skeletal
anchorage under local anesthesia to provide a correction that
could be used as an alternative to orthognathic surgery

Daftar Pustaka
Seong-Hun Kim, dkk. Severe bimaxillary
protrusion with adult periodontitis treated by
corticotomy and compression osteogenesis.
Vol. 39, No. 1, 2009. Korean J Orthod.
Yoon-Ah Kook, dkk. Correction of severe
bimaxillary protrusion with first premolar
extractions and total arch distalization with
palatal anchorage plates. American Journal
of Orthodontics and Dentofacial Ortho,
Vol.148. 2015.

TERIMA KASIH
MOHON ASUPAN