This document describes a case study of an 11-year-old female patient with bimaxillary protrusion treated without tooth extractions. The patient presented with incompetent lips, a closed nasolabial angle, and a Class II malocclusion. Treatment involved removing only the lower third molars and using headgear, archwires, and elastics to retract the maxilla and tip back the mandibular arch. After 26 months, a Class I occlusion was achieved with improved lip prominence and profile. Nonextraction treatment was able to effectively correct the malocclusion while maintaining facial esthetics.

1. P.33-38 Celli:CR_Celli 1/10/07 2:48 PM Page 33
©2007 JCO, Inc. May not be distributed without permission. www.jco-online.com
CASE
C S REPORT
O
Bimaxillary Protrusion Treated
Without Extractions
DANIEL CELLI, MD, DDS, MSC, PHD
DANIELE GARCOVICH, DDS, MSC
ENRICO GASPERONI, DDS
ROBERTO DELI, MD, DDS
B imaxillary protrusion in ado-
lescent patients has tradition-
ally been treated by extracting
with mild or moderate bimaxillary
protrusion, as the following case
demonstrates.
proclination, the parents refused
premolar extraction treatment.
Therefore, a protocol involving
the four first premolars and the removal of only the lower third
retracting the anterior teeth.1,2 molars was chosen.
Diagnosis and
Although this approach is less
Treatment Plan
complex than nonextraction treat-
Treatment Progress
ment and can produce a good An 11-year-old female pre-
occlusal result, it also tends to sented with a Class II maloc- After the third molar extrac-
retrude the lips and reduce the clusion (Fig. 1). The patient’s tions, the upper arch was bonded,
convexity of the face.3-6 lips were incompetent and and leveling and alignment were
In cases with severe incisor procumbent, and the nasolabial carried out with an .016" heat-
protrusion, facial convexity, lip angle was closed. Cephalomet- activated nickel titanium wire.
incompetence, or crowding, pre- ric analysis (Table 1) showed a Bendbacks and lacebacks were
molar extractions may be marked bimaxillary protrusion added to preserve arch length and
unavoidable. In our opinion, how- (L1-GoGn = 106 ° ; U1-ANS/ avoid worsening the incisor pro-
ever, a nonextraction approach PNS = 126°). clination. A combi headgear was
can be more esthetic in patients Despite the extreme incisor worn to the upper first molars 16
Dr. Celli is a Visiting Professor, Dr.
Gasperoni is a postgraduate stu-
dent, and Dr. Deli is Professor and
Director, Postgraduate Program
(School of Specialization) in
Orthodontics, Università Cattolica
del Sacro Cuore, Largo F. Vito 4,
00100 Rome, Italy. Drs. Celli,
Garcovich, Gasperoni, and Deli
are also in the private practice of
orthodontics in Pescara, Cervteri,
Rimini, and Rome, Italy, respec-
tively. E-mail Dr. Celli at info@
celliortho.it.
Dr. C
Celli Dr. G
Garcovich Dr. G
Gasperoni Dr. Deli
VOLUME XLI NUMBER 1 © 2007 JCO, Inc. 33

2. P.33-38 Celli:CR_Celli 1/10/07 2:49 PM Page 34
Bimaxillary Protrusion Treated Without Extractions
Fig. 1 11-year-old female patient with dental and skeletal Class II mal-
occlusion and bimaxillary protrusion before treatment.
34 JCO/JANUARY 2007

3. P.33-38 Celli:CR_Celli 1/10/07 2:49 PM Page 35
Celli, Garcovich, Gasperoni, and Deli
A
A
Fig. 2 A. Patient after 26 months of treatment. B. Superimposition of cephalometric tracings before and after
treatment.
VOLUME XLI NUMBER 1 35

4. P.33-38 Celli:CR_Celli 1/10/07 2:49 PM Page 36
Bimaxillary Protrusion Treated Without Extractions
hours per day. Treatment Results the chin.9-11 This will maintain a
Seven months later, the more esthetic profile over the long
After 26 months of treat-
lower arch was banded and bond- term, especially in ethnic groups
ment, the patient showed a Class
ed, except for the four incisors. An where moderate lip protrusion is
I occlusal relationship with nor-
.016" heat-activated nickel titani- a desirable feature.
mal overbite and overjet control
um wire with bendbacks and lace- Most cephalometric and pro-
(Fig. 2). The axial inclination of
backs was used in conjunction file standards are derived from
the upper incisors was controlled,
with a lightly activated open-coil North American and northern
as shown by a 6° reduction in
spring from canine to canine. European samples of Caucasian
U1-ANS/PNS (Table 1). The
Light Class III elastics were worn patients.12-17 In recent years, how-
Class II correction was achieved
only when the headgear was in ever, researchers have begun to
mainly by maxillary retraction,
place. After 11 months of treat- develop norms for ethnic sub-
while the mandibular plane
ment, both archwires were groups that may have different
remained essentially stable,
changed to .019" ✕ .025" heat- esthetic concerns.18-23 Specifically,
despite the limited use of Class III
activated nickel titanium, still with Bowman and Johnston proposed
elastics. The lower incisor incli-
bendbacks and lacebacks. that the lips should be 2-3mm in
nation was clearly reduced; the
Further alignment was car- front of the E-plane in African
mandibular superimposition
ried out using .019" ✕ .025" stain- Americans, as opposed to 2-3mm
demonstrated that the entire arch
less steel archwires with tiebacks behind the E-plane in Cau-
was tipped back. The profile was
for torque control, followed by casians.24 In our experience, the
improved, lip prominence was
.014" Australian* wires for fin- Italian norm for lip protrusion is
reduced, the nasolabial angle
ishing. Class II elastics were used somewhere in between.
remained stable, and the facial
to optimize intercuspation. Several studies have found
convexity was reduced (Fig. 3).
that the general public associates
a fuller, more protrusive dentofa-
Discussion cial pattern with a youthful
TABLE 1 appearance. 25-27 Some authors
CEPHALOMETRIC DATA Several factors must be have stated that premolar extrac-
taken into account when planning tions cause a narrowing of the
Pre- Post- the treatment of a patient with arches, producing dark buccal cor-
treatment Treatment moderate bimaxillary protrusion. ridors in smiling28,29—although
The clinician has to consider not this view has been contradicted by
SNA 88.0° 84.5° only the outcome of treatment at recent reports.30,31 To improve the
SNB 81.0° 80.0° debonding, but also how the post-extraction smile, Zachrisson
ANB 7.0° 4.5° results will change throughout the has recommended adding buccal
SN-ANS/PNS 11.0° 11.0° growth and aging process. crown torque to lingually inclined
SN-GoGn 34.0° 35.0° While the subject is contro- canines and premolars.32
ANS/PNS- versial, excessive incisor procli- In severe skeletal Class II
GoGn 23.0° 24.0° nation has been correlated with cases, facial esthetics generally
U1-ANS/PNS 126.0° 120.0° periodontal recession and bony tend to worsen when extractions
defects.7,8 Moderate incisor pro- are performed, even if a good
L1-GoGn 106.0° 98.0°
clination, on the other hand, can occlusion is achieved.33-35 Accor-
L1-APo 5.0mm 4.5mm
improve lip support. In addition, ding to Proffit and Field, Class II
Nasolabial a slight protrusion will help bal-
angle 121.0° 121.0° ance the tendency of the profile to
Lower lip flatten due to continuing growth of *G&H Wire Company, P.O. Box 248, Green-
to E-line 5.0mm –2.0mm the nose and forward rotation of wood, IN 46142; www.ghwire.com.
g
36 JCO/JANUARY 2007

5. P.33-38 Celli:CR_Celli 1/10/07 2:49 PM Page 37
Celli, Garcovich, Gasperoni, and Deli
Fig. 3 Patient one year after treatment.
extraction treatment can result in method for controlling anchorage was designed for borderline cas-
a more prominent nose and a defi- in extraction treatment. 48 Our es of bimaxillary protrusion, in
ciency in the middle and lower results show that these mechan- which nonextraction treatment
thirds of the face.33 This was a ics can also correct a skeletal may produce more esthetic results
concern in the present case, espe- Class II relationship by means of than can be achieved with pre-
cially if mandibular growth turned maxillary growth inhibition or molar extractions.
out to be insufficient. retraction. Mandibular growth
Various nonextraction op- will assist in the Class II cor- REFERENCES
tions were considered for this rection, while Class III elastics
1. Lew, K.: Profile changes following
patient, including anterior inter- can control or retrocline the orthodontic treatment of bimaxillary
proximal enamel reduction.36,37 lower incisors. Alveolar bone protrusion in adults with the Begg appli-
Although the stripping proce- remodeling of the mandibular ance, Eur. J. Orthod. 11:375-381, 1989.
2. Farrow, A.L.; Zarrinnia, K.; and Azizi,
dure is considered safe and reli- arch, supported by planned K.: Bimaxillary protrusion in black
able,38-43 we preferred to maintain extractions of the lower third Americans: An esthetic evaluation and
the patient’s Bolton Index44 and molars, will further improve the treatment considerations, Am. J. Orthod.
104:240-250, 1993.
dental integrity.42,45-47 incisor inclination.49 3. Koch, R.; Gonzales, A.; and Witt, E.:
The combination of head- Profile and soft tissue changes during
gear with light Class III elastics and after orthodontic treatment, Eur. J.
Conclusion Orthod. 1:193-199, 1979.
has been previously described 4. La Mastra, S.J.: Relationships between
by McLaughlin and Bennett as a The protocol described here changes in skeletal and integumental
VOLUME XLI NUMBER 1 37

6. P.33-38 Celli:CR_Celli 1/10/07 2:49 PM Page 38
Bimaxillary Protrusion Treated Without Extractions
points A and B following orthodontic treat- nada based on McNamara’s analysis, J. Cummings, D.R.; Beress, A.; Worley,
ment, Am. J. Orthod. 79:416-423, 1981. Ind. Soc. Pedod. Prev. Dent. 19:41- C.M. Jr.; Chung, B.; and Bergman, R.:
5. Bowbeer, G.R.N.: Saving the face and 51, 2001. Soft tissue cephalometric analysis:
the TMJ, Part 2, Funct. Orthod. 3:9- 20. Evanko, A.M.; Freeman, K.; and Diagnosis and treatment planning of f
17, 1986. Cisneros, G.J.: Mesh diagram analysis: dentofacial deformity, Am. J. Orthod.
6. Bowbeer, G.R.N.: The seventh key to Developing a norm for Puerto Rican 116:239-253, 1999.
facial beauty and TMJ health, Part 2: Americans, Angle Orthod. 67:381- 35. Arnett, G.W. and Bergman, R.T.: Facial
Proper condylar position, Funct. Orthod. 388, 1997. keys to orthodontic diagnosis and treat-
7:4-21, 1990. 21. Faustini, M.M.; Hale, C.; and Cisneros, ment planning, Am. J. Orthod. 103:299-
7. Artun, J. and Krogstad, O.: Periodontal G.J.: Mesh diagram analysis: Devel- 312, 395-411, 1993.
status of mandibular incisors following oping a norm for African Americans, 36. Sheridan, J.J.: Air-rotor stripping, J.
excessive proclination: A study in adults Angle Orthod. 67:121-128,1997. Clin. Orthod. 19:43-59, 1985.
with surgically treated mandibular pro- 22. Lew, K.K.; Ho, K.K.; Keng, S.B.; and 37. Sheridan, J.J.: Air-rotor stripping update,
gnathism, Am. J. Orthod. 91:225- Ho, K.H.: Soft-tissue cephalometric J. Clin. Orthod. 21:781-788, 1987.
232, 1987. norms in Chinese adults with esthetic 38. Sheridan, J.J.: The physiologic rationale
8. Djeu, G.; Hayes, C.; and Zawaideh, S.: facial profiles, J. Oral Maxillofac. Surg. for air-rotor stripping, J. Clin. Orthod.
Correlation between mandibular central 50:1184-1189, 1992. 31:609-612, 1997.
incisor proclination and gingival reces- 23. Sahin Saglam, A.M.: Holdaway mea- 39. Hanachi, F.: The demineralization and
sion during fixed appliance therapy, surement norms in Turkish adults, remineralization potentials of stripped
Angle Orthod. 72:238-245, 2002. Quintess. Int. 33:757-762, 2002. enamel surfaces, thesis, Louisiana State
9. Forsberg, C.M. and Odenrick, L.: 24. Bowman, S.J. and Johnston, L.E. Jr.: University, New Orleans, 1992.
Changes in the relationship between the The esthetic impact of extraction 40. El-Mangoury, N.H.; Moussa, M.M.;
lips and the aesthetic line from eight and nonextraction treatments on Cau- Mostafa, Y.A.; and Girgis, A.S.: In-vivo
years of age to adulthood, Eur. J. Orthod. casian patients, Angle Orthod. 70:3- remineralization after air-rotor stripping,
1:265-270, 1979. 10, 2000. J. Clin. Orthod. 25:75-78, 1991.
10. Luppanapornlap, S. and Johnston, L.E. 25. Peck, S. and Peck, L.: Selected aspects 41. Radlanski, R.; Jager, A.; and Zimmer,
Jr.: The effects of premolar extraction: A of the art and science of facial esthetics, B.: Morphology of interdentally stripped
long-term comparison of outcomes in Semin. Orthod. 1:105-126, 1995. enamel one year after treatment, J. Clin.
“clear-cut” extraction and nonextraction 26. Peck, S. and Peck, H.: The aesthetical- Orthod. 23:748-750, 1989.
Class II patients, Angle Orthod. 63:257- ly pleasing face: An orthodontic myth, 42. Boese, L.R.: Fiberotomy and reproxima-
272, 1993. Trans. Eur. Orthod. Soc., 1971, pp. tion without lower retention, 9 years in
11. Bishara, S.E.; Jakobsen, J.R.; Hession, 175-184. retrospect, Angle Orthod. 50:88-97, 169-
T.J.; and Treder, J.E.: Soft tissue profile 27. Nguyen, D.D. and Turley, P.K.: Changes 178, 1980.
changes from 5 to 45 years of age, Am. in the Caucasian male facial profile as 43. Betteridge, M.A.: The effects of inter-
J. Orthod. 114:698-706, 1998. depicted in fashion magazines during the dental stripping on labial segments eval-
12. Downs, W.B.: Analysis of the dentofa- twentieth century, Am. J. Orthod. uated one year out of retention, Br. J.
cial profile, Am. J. Orthod. 26:191- 114:208-217, 1998. Orthod. 8:193-197, 1981.
212, 1956. 28. Spahl, T.J. and Witzig, J.W.: The 44. Bolton, W.A.: Disharmony in tooth size
13. Harvold, E.P.: The Activator in Orthodon- Clinical Management of Basic Maxillo- and its relation to the analysis and treat-
tics, Mosby, St. Louis, 1974, pp. 37-56. facial Orthopedic Appliances, vol. 1: ment of malocclusion, Angle Orthod.
14. Hasund, A.: Clinical cephalometry of the Mechanics, PSG Publishing Co., 28:113-130, 1958.
Bergen Technique, University of Bergen, Littleton, MA, 1987. 45. Arends, J. and Christoffersen, J.: The
Norway, 1977. 29. Dierkes, J.M.: The beauty of the face: An nature of early caries lesions in enamel,
15. Jarabak, J.R. and Fizzell, J.A.: Tech- orthodontic perspective, J. Am. Dent. J. Dent. Res. 65:2-11, 1986.
nique and Treatment with Light-wire Assoc. (special issue):89E-95E, 1987. 46. Bertzbach, F.: Raster-Elektronen-mikro-
Edgewise Appliances, Mosby, St. 30. Johnson, D.K. and Smith, R.J.: Smile skopische Darstellung von Kavitaten- und
Louis, 1972. esthetics after orthodontic treatment Fullungsrandern: Ein Modell fur die klin-
16. McNamara, J.A. Jr.: A method of with and without extraction of four first isch-periodische Nachuntersuchung der r
cephalometric evaluation, Am. J. premolars, Am. J. Orthod. 108:162- approximalen Situation mit Hilfe einer r
Orthod. 86: 449-469, 1984. 167, 1995. modifizierten Replika-Methode, thesis,
17. Ricketts, R.M.; Bench, R.W.; Gugino,
k 31. Gianelly, A.A.: Arch width after extrac- University of Gottingen, Germany, 1987.
C.F.; Hilgers, J.J.; and Schulhof, R.: tion and nonextraction treatment, Am. J. 47. Heath, J.R. and Wilson, H.J.: Surface
Bioprogressive Therapy, Rocky Mountain Orthod. 123:25-28, 2003. roughness of restorations, Br. Dent. J.
Orthodontics, Denver, 1979, pp. 55-70. 32. Zachrisson, B.U.: Making the premolar 140:131-137, 1976.
18. Alcalde, R.E.; Jinno, T.; Orsini, M.G.; extraction smile full and radiant, World 48. McLaughlin, R.P. and Bennett, J.C.: The
Sasaki, A.; Sugiyama, R.M.; and Matsu- J. Orthod. 3:260-265, 2002. transition from standard edgewise to
mura, T.: Soft tissue cephalometric 33. Proffit, W.R. and Field, H.W.: Ortho- preadjusted appliance systems, J. Clin.
norms in Japanese adults, Am. J. Orthod. dontic treatment planning: Limitations, Orthod. 23:142-153, 1989.
118:84-89, 2000. controversies and special problems, in 49. Proffit, W.R. and Field, H.W.: The bio-
19. Bhat, M.; Sudha, P.; and Tandon, S.: Contemporary Orthodontics, 3rd ed., logical basis of orthodontic therapy, in
Cephalometric norms for Bunt and Mosby, St. Louis, 2000. Contemporary Orthodontics, Mosby, St.
Brahmin children of Dakshina Kan- 34. Arnett, G.W.; Jelic, J.S.; Kim, J.; Louis, 1993, pp. 266-288.
38 JCO/JANUARY 2007