Camouflage Management of Adult Bimaxillary Protrusion With Pre-Existing Mandibular First Molar Loss: A Three-Premolar Extraction Case Report

Background : Bimaxillary dentoalveolar protrusion (BM) is a common esthetic complaint in young adults and is often treated with premolar extractions to retract the incisors and improve the lip profile. When a permanent first molar is already missing in one quadrant, an asymmetric three‑premolar extraction protocol can harmonize arch symmetry, correct the dental midline, and minimize unnecessary extractions. Case presentation : A 21‑year‑old adult presented with BM, lip incompetence, and proclined incisors. Clinical records showed a pre‑existing absence of one mandibular first molar, mild crowding, and protrusive lips. The treatment objectives were to retract anterior segments, correct midlines, optimize canine guidance, and finish with a balanced soft‑tissue profile. The chosen plan extracted the bilateral maxillary first premolars and the mandibular first premolar contralateral to the missing molar (three‑premolar extraction), followed by anchorage‑controlled space closure and incisor retraction with 0.022‑inch fixed appliances. Space management in the mandibular arch included coordinated posterior protraction and anterior retraction to achieve occlusal harmony. Treatment achieved normalized overjet/overbite, bilateral canine Class I relationships, acceptable molar intercuspation, and improved facial esthetics on post‑treatment photographs and radiographs. Conclusions : In adult BM with a pre‑existing first molar loss, a three‑premolar extraction protocol is a viable camouflage option that can efficiently align treatment mechanics with asymmetry correction while delivering predictable soft‑tissue benefits and stable occlusion. This approach aligns with current evidence on extraction indications, anchorage control, and expected soft‑tissue response.