Bimaxillary Protrusion

Management of
B i m a x i l l a r y P ro t r u s i o n
Rama Krsna Rajandram, MBBS, DDS, MFDS, MDS-OMFS (HKU), Associate Professora,*,
Lavanyah Ponnuthurai, DDS, MClinDent in Prosthodontics (London)b,
Komalam Mugunam, BDS, MJDFa, Yunn Shy Chan, BDS, MJDFa
KEYWORDS
Bimaxillary protrusion Extraction orthodontics Non-extraction orthodontics
Obstructive sleep apnea Orthognathic surgery Skeletal surgery
KEY POINTS
All cases of bimaxillary protrusion should be analyzed in holistic manner which includes a subjective
and objective assessment.
Bimaxillary protrusion patients with an underlying Class II skeletal pattern and a hypoplastic chin
should receive a full airway assessment to ensure that there is no increased risk to develop obstruc-
tive sleep apnea with the orthodontic only approach.
Treatment planning must be individualized based on each patient’s facial type to ensure favorable
posttreatment changes in the vertical direction.
Clinicians should be able to predict the long-term esthetic and functional outcomes and provide a
good informed consent especially in patients who receive orthodontics with extractions before
skeletal maturity.
All moderate to severe bimaxillary protrusion cases would benefit from a combined discussion be-
tween the oral and maxillofacial surgeon and orthodontist before coming up with a final treatment
plan.
INTRODUCTION effects translating from poor self-

esteem.1,3,7,10,12–15 The key factor in ensuring
Bimaxillary protrusion is a dentofacial deformity good treatment outcome is often focused on
trait that can present in all different skeletal pat- ensuring esthetic satisfaction. It is therefore impor-
terns. Clinically, the trait is associated with the tant that the selected treatment modality is able to
presence of a protrusive anterior dentoalveolar address the patient’s esthetic concern in short
segment of the maxilla and mandible. This pro- term as well as long term.1,3
duces an appearance of unsightly protruding ante- However, very often clinicians find themselves in
rior teeth, increased procumbence of the lips and a a dilemma in selecting the right treatment modal-
convex lateral facial profile. These clinical features ity. This is due to the heterogeneity of clinical pre-
are often perceived negatively with regard to facial sentation in every patient with bimaxillary
attractiveness.1–6 It can occurs in almost every protrusion. Bimaxillary protrusion can be treated
ethnic group but relatively more common in the orthodontically or by a combination of orthodon-
Asian and African populations2,3,7–11 tics with segmental orthognathic surgery. The
Patients with this trait often seek esthetic im- traditional orthodontic approach to this skeletal
oralmaxsurgery.theclinics.com
provements. This is because the clinical features trait is often via extractions of all four first premo-
have been shown to lead to negative psychosocial lars to reduce the anterior proclination.
a
Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, National University of Malaysia, Jalan Raja
Muda Abdul Aziz, Kuala Lumpur 50300, Malaysia; b Department of Restorative, Faculty of Dentistry, National
University of Malaysia, Kuala Lumpur 50300, Malaysia
* Corresponding author.
E-mail addresses: [email protected] (R.K.R.); [email protected] (L.P.)
Oral Maxillofacial Surg Clin N Am 35 (2023) 23–35

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24 Rajandram et al
Advancements related to the usage of skeletal patients that should postpone definitive treatment
anchorage devices (SADs) in orthodontics have until skeletal maturity is fundamental especially
introduced approaches that distalize the anterior when segmental orthognathic surgery is indicated.
segment using a non-extraction protocol. Last, Fig. 1 shows a patient whom received orthodontic
management can include a combined orthodontic treatment at the age of 15 with all four first premo-
and surgical approach which would involve lar extractions. She is now 30 years old and dissat-
segmental orthognathic surgery. isfied with the current aesthetic outcome.
Treatment planning that focuses on only the Corrective surgery at this point is more compli-
biomechanics to correct the anterior proclination cated because of the previous treatment that
without proper clinical analysis can lead to a satis- included extractions. This highlights the impor-
factory occlusion from a clinical point of view but tance of age at the point of consultation. The clini-
an unhappy patient from an esthetic point of cian must be able to ensure a treatment modality
view. Fig. 1 is an example of an end point of a that has a good functional and esthetic outcome
case with bimaxillary protrusion. She was treated on skeletal maturity. This is especially important
orthodontically by retraction of the anterior if the treatment involves irreversible interventions
segment with extraction of all four first premolars. such as extractions. The decision of not consid-
The patient however was dissatisfied at the end of ering a combined surgical orthodontic approach
the treatment with the esthetic outcome. It is in an indicated case may lead to compromised
therefore fundamental to have a good approach outcomes and possible medicolegal implications.
in reaching a diagnosis that then guides an individ- Clinicians need to balance patient expectations
ualized patient-specific treatment modality. together with objective clinical findings when com-
ing up with their final treatment plan.
APPROACH TO DIAGNOSIS
Objective Clinical Assessment
Clinical diagnosis before deciding on the treat-
ment modality of choice depends on the following: Facial esthetics assessment
Pretreatment facial esthetic assessment guides the
A. Subjective assessment initial consultation. It improves patient understand-
B. Objective clinical assessment (Fig. 2) ing with regards to the expected posttreatment
C. Radiographic Assessment changes based on the treatment offered. This is
especially important in the skeletal immature pa-
tients. This assessment can prevent unnecessary
Subjective Assessment
extractions that may compromise long-term man-
Patient factor agement of the esthetic component as seen in the
Every patient comes with a certain perception of case shown in Fig. 1.
their problem and an expectation on the treatment Facial esthetic assessment involves a frontal
outcome. They also have an expected timeline for and lateral facial analysis. The frontal facial anal-
treatment completion. This must be clearly identi- ysis classifies the facial types into mesofacial, bra-
fied at the pretreatment consultation stage. Clini- chyfacial, or dolichofacial. This is to ensure
cians must ensure that each patient is aware of posttreatment facial harmony. The pretreatment
the limitations and risks for each treatment amount of incisor show at rest is the next impor-
approach. An important factor is the age of the pa- tant assessment. Retractions of the anterior
tient at the consultation. Identifying growing segment to correct the protrusion can lead to
Fig. 1. A patient that came dissatisfied with her posttreatment facial profile and aesthethics. Patient was treated
by orthodontics with extractionn before skeletal maturity.
Management of Bimaxillary Protrusion 25
Fig. 2. Objective Clinical Assessment Checkpoints.
26 Rajandram et al
changes to the incisal show and upper lip length. manage expectations with regards to treatment
These changes should meet the patient’s expecta- time and esthetic outcomes.
tions as it has implications to the patient’s smile.
Underlying concomitant skeletal asymmetries Lateral cephalometry analysis can be systemati-
need to be diagnosed to ensure that the patient cally divided to :
understands the limitations of each treatment mo-
dality in addressing the skeletal asymmetry. Skeletal Analysis
The lateral facial analysis helps to group patients Dental Angular Measurements
with bimaxillary protrusion to the skeletal Classes Esthetic Predictions
I–III. It also identifies a hypoplastic chin. Several
Skeletal Analysis
soft tissue angles and characteristics play an
important role in facial esthetics. These include Skeletal angular measurements help to predict the
the nasolabial angle, labiomental fold, and the feasibility of an orthodontic only approach. It gives
presence of an incompetent lip. Clinicians must a prediction on the amount of dental movement
be familiar with the expected changes that will that will be needed to correct the bimaxillary pro-
happen to these parameters with each suggested trusion and diagnose any underlying skeletal de-
treatment modality. formities. It also allows analysis of the posterior
pharyngeal space to identify patients at risk of
FUNCTIONAL ASSESSMENT developing OSA posttreatment. The important
baselines angles include:
The presence of functional issues also plays a part
in deciding the treatment of choice. Functional Sella to Nasion and A-point (SNA): Assess-
assessment includes an airway and dental exami- ment of the anterior posterior position of the
nation. Airway assessment is important as ortho- maxilla to indicate if the maxilla is normal,
dontic correction of the anterior dentoalveolar prognathic, or retrognathic.
proclination by extractions of all four first premo- Sella to Nasion and B-point (SNB): Assessment
lars in the presence of an underlying skeletal Class of the anterior posterior position of the mandible
II, and hypoplastic chin will increase the risk of to determine if the mandible is normal, progna-
developing obstructive sleep apnea (OSA) in a thic, or retrognathic.
susceptible patient. The airway assessment A-point to Nasion and B-point (ANB): This
should include tonsil grading, the body mass in- angle will determine if the patient is a skeletal
dex, and the presence of transverse discrepancies Class I, II, or III.
of the maxilla or a V-shaped maxilla. These are all Frankfurt-mandibular plane angle (FMPA):
independent risk factors for OSA. If these factors This angle will determine the facial proportion
are present in a patient whom receives extractions and vertical growth pattern of the patient. This
for distalization of the anterior segment, the risk for helps support the earlier clinical assessment
OSA will be potentiated. This group of patients of facial type. This component has an impor-
stands to benefit skeletal segmental orthognathic tant correlation to the types of biomechanics
surgery to correct the bimaxillary protrusion as that need to be considered when correcting
well as to improve their airway parameters. the anterior proclination which has an impact
Next is the dental assessment. This includes to the vertical height of the face. This change
identifying space restrictions/crowding, presence must be in favorable to the baseline facial
of a favorable overjet and overbite, and the angle’s type of the patient.
classification. These findings lead to the possible
need for extractions as well as if SADs or Dental angular measurements
segmental orthognathic should be considered. This measurement indicates the amount of retrac-
tion needed at the level of the anterior incisors to
correct the convex lateral facial appearance. This
RADIOGRAPHIC ASSESSMENT
amount indirectly translates to the distal space
Lateral Cephalometry
needed to retract the anterior segment and if this
Lateral cephalometry acts as an adjunct to clinical can be achieved by premolar extractions or by
assessment (Fig. 3). It provides angular measure- the use of skeletal anchorage devices (SADs). In
ments to supplement the diagnosis with regards to the presence of severe skeletal deformities and
skeletal analysis, baseline dental deviations, and discrepancy, the retraction of the anterior segment
esthetic prediction. This enhances the ability of cli- will require segmental orthognathic surgery.
nicians to give valid information to their patients The important parameters that will need mea-
based on the suggested treatment modality and surement include:
Fig. 3. Radiographic Assessment Parameters.
Upper incisor to palatal plane (U1-PP): This acceptable limits according to age. At the same
documents the degree of proclination of the time, it also indicates the reference position of mo-
anterior upper incisors. lars and their respective vertical dimension. This
Lower incisor mandibular plane angle (IMPA): assessment is important as it takes into consider-
This documents the degree of proclination of ation the posttreatment outcome in patients with
the lower incisors. different skeletal patterns. Bimaxillary protrusion
Interincisal angle (IIA): This angle determines patients stand to benefit significantly from this
the severity of bimaxillary protrusion leading assessment as it incorporates esthetic outcomes
to the procumbence of the incisors. instead of focusing purely on the biomechanics
required to correct the angular measurements.
Esthetic predictions
Functional esthetic occlusal plane The functional Esthetic plane The esthetic plane (E-plane) is a
esthetic occlusal plane (FAOP) provides important simple linear line drawn from the tip of the nose
information concerning the (i) vertical relationship to the tip of the chin. It allows for an assessment
of the incisors with the lips at rest and (ii) the posi- of the position of the upper lip and lower lip in rela-
tion of molars in contact. This facilitates under- tion to this line. It has been documented that a
standing with regards to the limitation of a pleasant smile is produced if the lower lip is
selected treatment modality to the esthetic and 2 mm behind this line and the upper lip is 4 mm
functional demands (occlusion) of the patient. It behind this line. This assessment helps the clini-
also provides valuable esthetic information as it an- cian to decide if an extraction protocol or a non-
alyzes the relationship of the incisor with the lips. extraction protocol would produce a good smile
This will then indicate if the exposure is within the at the end of the treatment. This line can also
28 Rajandram et al
determine the degree of concavity or convexity must be taken to ensure that the patient agrees
from an underlying skeletal problem that may indi- to accept a compromised outcome.
rectly indicate the need for segmental orthog-
nathic surgery.
DISCUSSION
THERAPEUTIC OPTIONS Patients with bimaxillary protrusion often seek for
esthetic improvement due to the clinical presenta-
This review article attempts to group bimaxillary
tion of this trait.16–19 It is a unique dentofacial defor-
protrusion patients into mild, moderate, and se-
mity trait as very often there is a need to look
vere. This will improve the ability to screen patients
beyond biomechanics in deciding the treatment
holistically. The grouping suggested is based on
approach. The principle behind a nonsurgical or-
the specific clinical and radiographic criteria as
thodontic approach versus a combined orthodon-
shown in Tables 1 , 2 and 3. The management
tics with segmental orthognathic surgery defers
suggested for each group is based on the treat-
from each other. Orthodontics uprights and retracts
ment approaches reported in the literature. It can
the anterior dentition, whereas surgery repositions
either be via orthodontics only or orthodontics
the anterior segments of the bony jaw. A combined
with segmental orthognathic surgery.
skeletal segmental orthognathic surgery approach
The orthodontics only management includes
two major approaches. It can either involve
orthodontics with all four first premolar/bicuspid
Table 1
extractions or non-extraction orthodontics with
Mild bimaxillary protrusion
intra-alveolar skeletal anchorages devices
(SADs). In the latter, the device is used to torque Treatment Approach: Orthodontics
and distalize the anterior segment.
Segmental orthognathic surgery incorporates Non-Extraction Extraction
Orthodontics Orthodontics
anterior maxillary segmentalization (Le Fort I seg-
mentalization or Wassmund osteotomy) surgery Frontal facial Frontal facial
together with anterior mandibular subapical assessment: assessment:
osteotomies (Hofer/Kole osteotomy) to correct Competent lips Competent lips
the bimaxillary protrusion. The maxillary anterior 1–2 mm incisal 1–2 mm incisal
show show
segmental osteotomy is done together with the
No skeletal No skeletal
maxillary Le Fort I and bilateral sagittal split osteot- asymmetry asymmetry
omies with the movements dependent on the Facial proportion Facial proportion
overall clinical diagnosis of the skeletal deformity. in harmony in harmony
This surgery is technically difficult as the surgical Lateral facial Lateral facial
movement requires manipulation at the region of assessment: assessment:
the posterior maxilla to allow the set back of the Acute nasolabial Acute nasolabial
maxilla. This anatomic area is known to have sig- angle angle
nificant surgical morbidity due to vascular and Normal to slight Shallow labiomen-
neurologic risk. The need for segmentalization in- changes of labio- tal fold
mental fold Intraoral assessment:
creases the risk of avascular osteonecrosis and
Intraoral assessment: No open bite
can compromise periodontal health. No open bite Significant over jet
Based on the suggested grouping, the authors Mild overjet and and overbite
recommend that mild cases be treated orthodon- overbite Class I/II molar
tically. Severe cases should be managed by com- Class 1 molar occlusion
bined orthodontics and segmental orthognathic occlusion Presence of
surgery. The moderate group, however, is a No crossbites crowding
unique group with regards to management. These Lateral Cephalometry
cases can be approached orthodontically or by a FAOP increase FAOP increase
combination of orthodontics with segmental U1-PP increase U1-PP increase
orthognathic surgery. The decision depends on IMPA increase IMPA increase
the patient expectations and the clinicians experi- IIA decreased IIA decreased
ence in ensuring that the selected treatment mo- (closer to 115.3 ) (closer to 115.3 )
dality can address the patient’s expectation. If Horizontal line of Horizontal line of
the patient chooses against segmental orthog- lips to E-line lips to E-line
increase increase
nathic surgery due to the fear of surgical risk,
proper documentation and informed consent
Table 2
Moderate bimaxillary protrusion
Treatment Approach : Orthodontics OR Combined Orthodontics with Segmental Orthognathic Surgery

Combined Skeletal Surgery
Non-Extraction Orthodontics Extraction Orthodontics and Orthodontics
Frontal facial assessment: Frontal facial assessment: Frontal facial assessment:
Incompetent lips Incompetent lips Incompetent lips
No asymmetry No asymmetry Gummy smile with
1–4 mm incisal show at rest 1–4 mm incisal show at rest >4 mm incisal show at rest
Lateral facial assessment: Lateral facial assessment: Presence of any asymmetry/
Acute nasolabial angle Acute nasolabial fold canting
Obtuse labiomental fold Obtuse labiomental fold Lateral facial assessment:
Intraoral assessment: Intraoral assessment: Acute nasolabial angle
No open bite No open bite Obtuse labiomental fold
Mild overjet and overbite Significant over jet and Intraoral assessment:
values overbite Open bite—limit < 3
Class 1 M occlusion Classes I–III molar occlusion Significant over jet and
No crossbites Presence of significant overbite
Mild crowding crowding Classes I–III molar occlusion
Airway assessment
Risk of sleep disordered
breathing or OLA
Lateral Cephalometry
Skeletal Class 1 Skeletal Class I and mild Significant underlying ante-
FAOP increased skeletal Class II rior posterior skeletal
U1-PP increased FAOP increase discrepancy
IMPA increase U1-PP increase Vertical maxillary excess
IIA decreased (significantly IMPA increase Hyperdivergent face
reduced from 125 ) IIA decreased (significantly FAOP increase
Lips less than 2–3 mm pro- reduced from 125◦) U1-PP increase
trusive from E-line Lips more than 2–3 mm IMPA increase
protrusive from E-line IIA decreased (significantly
further from 125◦)
Lips more than 2-3 mm pro-
trusive from E-line
can offer a correction that improves the facial profile by closing the extraction space. Cases ideal for
and balance concurrently with the bimaxillary pro- non-extraction orthodontics include the absence
trusion. This is especially relevant in the moderate of crossbites, crowding, and a Class I molar rela-
and severe cases.11 The amount of treatment tionship.20 These cases can incorporate the use
time as well as the role of orthodontics also differs of SADs.21 Types of skeletal anchorage devices
between these two approaches. The combined or- reported in the literature with regards to a non-
thodontics and segmental orthognathic surgery extraction approach to bimaxillary protrusion
approach also has more systemic risk which may include intra-alveolar and extra-alveolar screws.22
be a deterring factor to many patients. A prerequisite to this non-extraction protocol with
the SADs is there must be adequate space at the
Mild Bimaxillary Protrusion retromolar region.This is to allow distalization of
the whole arch.22 However, there is certain risk
Mild bimaxillary protrusion cases can be managed
associated with this non-extraction approach
by orthodontics only (see Table 1). This group of
with mini anchorage screws. The risk includes
patients often presents with an underlying skeletal
risk of damage to the adjacent roots due to the
Class I relationship with minimal deranged soft tis-
limited space available to guide the biomechanics.
sue esthetic parameters. The clinical dilemma in
This increases treatment time.23 Considerable
this group of patients often surrounds the need
clinical experience is also needed as there is a
for four premolar/bicuspid extractions. Extraction
need to constantly review and change the me-
simplifies and accelerates the ability to correct
chanics of the force to direct the distalization of
the dentoalveolar protrusions which is achieved
30 Rajandram et al
Table 3
Severe bimaxillary protrusion
Combined Segmentalization Orthognathic Surgery and

Orthodontics Lateral Cephalometry
Frontal facial assessment: Severe anterior-posterior
Incompetent lips skeletal discrepancies
Gummy smile Vertical maxillary excess
Greater than 4 mm incisal show FAOP significantly increased
Presence of any asymmetry/canting U1-PP increased
Lateral facial assessment: IMPA increased
Acute nasolabial angle IIA decreased (significant
Obtused labiomental fold further from 125 )
Intraoral assessment: Horizontal line of lips
Anterior open bite >4 mm to E-line increased
Significant overjet and overbite
Class II/III molar occlusion
Airway assessment
Risk of sleep-disordered breathing
or obstructive sleep apnea
the anterior segment. Patients must therefore be presence of crowding and any significant overjet.
compliant to the need for multiple visits and a The non-extraction methods can be considered if
longer treatment duration. the baseline dental malocclusion (overjet, overbite,
Extraction of premolars offers benefits of im- molar relationship) is minimal and patients’ expec-
provements to the soft tissue esthetics which tation with regard to esthetics is low. Facial con-
include the nasolabial and labiomental fold vexity can also be improved with the extractions
together with correction of the overjet, overbite, of the first premolars. It has been shown that the
and crowding. In cases of a Class II molar relation- facial convexity reduces an extra 2 to 3 mm in pro-
ship, a camouflage effect can be obtained with the trusion in comparison to non-extraction
extraction of the premolars, thus reducing the pro- cases.26,27
cumbence of the lips by 3.4 mm and 3.6 mm in up- Combined segmental orthognathic surgery and
per and lower lips.24 Fig. 4 shows an example of a orthodontics should be considered if there is any
mild case classified based on the objective clinical significant asymmetry or vertical skeletal dispro-
assessment mentioned in this article. portions in addition to all the clinical and radio-
graphic criteria for this group. Vertical skeletal
Moderate Bimaxillary Protrusion disproportions can be corrected by impaction us-
ing the Le Fort I osteotomy which is combined with
This group of patients can be managed either by an anterior segmentalization to improve the
nonsurgical orthodontics or by combined ortho- bimaxillary protrusion. Patients with radiographi-
dontics with segmental orthognathic surgery (see cally thin anterior alveolar bone are also suitable
Table 2). Very often patients with a skeletal Class for surgical cases. This is to avoid any bony dehis-
II malocclusion are seen in this group. Important cence or root resorption due to the need for retrac-
consideration for treatment of choice is based on tion forces.20,28
the amount of soft tissue and skeletal improve- Fig. 5 shows the importance of the age of the
ment needed as well as the length of treatment patient in deciding the treatment modality of
time.20 In moderate cases, patients with incompe- choice in patients grouped as moderate bimaxil-
tent lips, with a 1 to 4 mm incisal show at rest and lary protrusion. Extractions in their growth phase
no other significant skeletal and occlusal derange- to correct the bimaxillary protrusion may lead to
ment as mention in Table 2 can undergo ortho- complications related to poor esthetic outcome
dontic treatment alone.25 The decision to as well as increased risk of OSA later if they are
consider premolars extractions in this group of pa- susceptible. Fig. 6 shows another case of moder-
tients are dependent on the relationship of the lips ate bimaxillary protrusion based on our criteria
protrusion to the E-line. Premolar extractions in the which can be treated by orthodontics with
nonsurgical orthodontic patient can also camou- extractions.
flage a mild Class II skeletal discrepancy in the
Fig. 4. Mild bimaxillary protrusion.
Severe Bimaxillary Protrusion greater change in upper lip projection compared

with orthodontic treatment alone.2 Thus, instant
These patients have significant underlying skeletal
and optimal effect of esthetic facial results can
discrepancies (Table 3) Combined skeletal
be obtained from the surgery when compared
segmental orthognathic surgery and orthodontics
with orthodontics alone.4,8,29,33
offers an ideal solution to these patients with re-
gard to functional and esthetics demands as well
as long-term stability.10 Skeletal surgery is able Special Consideration Group
to overcome the periodontal and alveolar housing
Patients with moderate and severe bimaxillary
limitations, extend the achievable range of tooth
protrusion may also present with risk of sleep-
movement, provide faster retraction rate which in
disordered breathing which includes OSA.34 Risk
turn leads to a higher rate of space closure with
factors for OSA in patients with bimaxillary protru-
better anchorage control.2,29–31 This indirectly
sion include a Class II facial pattern, brachyfacial
leads to the reduced treatment time and is suitable
type, presence of a small or retruded mandible
for adults who are desirous for shorter treatment
and chin, elongated face, chronic mouth breathers
time with significant functional and esthetic expec-
secondary to the hypertrophy of the inferior turbi-
tations.4,8,32 Surgery has an advantage over the
nate’s, enlarged adenoids and tonsils, deep and
conventional nonsurgical orthodontic treatment
narrow hard palate, and long soft palate.35–37 It is
because it offers simultaneous three-dimensional
especially important to screen all bimaxillary pro-
skeletal correction which includes (i) severe incisor
trusion patients with these clinical features. This
proclination; (ii) extreme anterior open bite and
is to avoid an only orthodontic approach with
deep bite; and (iii) vertical or antero-posterior
extraction of all four first premolars that is often fol-
discrepancy.8,30 Surgery also allows for larger
lowed by retraction and retroclination of the maxil-
basal bone retraction which in turn provides a
lary and mandibular incisors to close the
32 Rajandram et al
Fig. 5. Growing child with moderate bimaxillary protrusion.A case suitable to avoid extractions before skeletal
maturity in view a clincal risk of susceptibility to obstructive sleep apnea (OSA). The case has indications for
possible conbined orthodontics with skeletal segmentalization surgery.
Fig. 6. Moderate bimaxillary protrusion case that can be treated by premolar extractions.
Fig. 7. Severe bimaxillary case.
extraction spaces.2,3,7,38 This leads to oropharyn- to ensure patients are fully aware and agreeable
geal crowding, which develops secondary to the to proceed with the suggested treatment.
posterior dislocation of the hyoid bone as the ante-
rior segment is distalized. This then decreases the SUMMARY
cross-sectional area behind the soft palate and
uvula.14,38,39 Besides that, the retraction of the in- Approach to the management of bimaxillary pro-
cisors leads to a reduction in tongue’s space. The trusion requires clinicians to look beyond biome-
tongue may then fall backward and eventually in- chanics only. There is a need for a
creases the risk of airway obstruction during comprehensive approach that ensures long-term
sleep.5,14,39 Segmental orthognathic surgery esthetic and functional outcomes. Multidisci-
should be considered in individuals with bimaxil- plinary discussion involving orthodontists and
lary protrusion presenting with risk factors for oral and maxillofacial surgeons at the pretreatment
OSA. Anterior segmental osteotomy of the maxilla stage especially in the moderate and severe cases
offers an added advantage to correction of the with functional requirements should be recom-
anterior proclination. It has been shown to exert mended. Failure to individualized treatment plan-
a minimal effect on the pharyngeal airway in com- ning based on age, esthetics, and functional
parison to orthodontic treatment only.4 In cases requirement can lead to the perceived treatment
with severe deficiency of the chin, skeletal surgery failure by patients in the long term despite a satis-
approach offers the advantage of doing a simulta- factory occlusion.
neous genioplasty to achieve better facial profile
as well as increasing posterior airway space.2 CLINICS CARE POINTS
Fig. 7 shows an example of a case that should
receive a combined surgical and orthodontic man-
agement as it falls under the severe group and also
the special consideration group. She is at risk of All patients with bimaxillary protrusion which
developing OSA if she receives only orthodontic are from the growing age population with an
treatment with extractions of premolars. underlying Class II skeletal profile and
As with all surgeries there are major risks requiring premolar extractions should be
involved in comparison to the nonsurgical ortho- screened for underlying risk of worsening of
dontic approach. This should be well communi- oropharyngeal crowding and chronic mouth
cated to patients before any treatment is started breathing to avoid risk of progression to
34 Rajandram et al
obstructive sleep apnea when they are older. vertical maxillary excess: A multi-faceted case
This group may benefit multimodal and report of difficult treatment management issues. Int
multidisciplinary management. Orthod 2020;18(1):178–90.
Airway screening prior to orthodontic extrac- 8. Ogundipe O, Otuyemi O. Surgical and orthodontic
tions should include: treatment methods in patients with bimaxillary
protrusion-a systematic review. J West Afr Coll Sur-
Identfying underlying presence of nasal geons 2017;7(2):31.
obstruction that leads to chronic mouth
9. Ahmad Nasir S, Ramli R, Abd Jabar N. Predictors of
breathing
enophthalmos among adult patients with pure orbital
Anatomic risk factors for oropharyngeal blowout fractures. PloS one 2018;13(10):e0204946.
crowding: 10. Chen G, Teng F, Xu T-M. Distalization of the maxillary
i. Reduced tongue space that includes and mandibular dentitions with miniscrew
transverse discrepancy of the maxilla anchorage in a patient with moderate Class I bimax-
or V-shaped maxilla. illary dentoalveolar protrusion. Am J Orthod Dento-
ii. Severe tongue scalloping that maybe facial Orthop 2016;149(3):401–10.
due to constricted tongue space sec- 11. Solem RC, Marasco R, Guiterrez-Pulido L, et al.
ondary to the presence of mandibular Three-dimensional soft-tissue and hard-tissue
tori or macroglossia. changes in the treatment of bimaxillary protrusion.
iii. Skeletal Class II discrepancy. Am J Orthod Dentofacial Orthop 2013;144(2):
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Bimaxillary Protrusion

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Management of

INTRODUCTION effects translating from poor self-

Oral Maxillofacial Surg Clin N Am 35 (2023) 23–35

Fig. 2. Objective Clinical Assessment Checkpoints.

Fig. 3. Radiographic Assessment Parameters.

Treatment Approach : Orthodontics OR Combined Orthodontics with Segmental Orthognathic Surgery

Combined Segmentalization Orthognathic Surgery and

Fig. 4. Mild bimaxillary protrusion.

Severe Bimaxillary Protrusion greater change in upper lip projection compared

Fig. 7. Severe bimaxillary case.

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