29.1 Introduction

Not in all cases of dentofacial malformations does the combination treatment of orthodontic and maxillofacial surgical measures lead to the desired treatment goal. The individual assessment of whether a malocclusion is more of dental origin and is treated orthodontically/dentally or has a predominantly facial (skeletal) cause that requires adjustment osteotomies often determines the therapeutic procedure.

Table 29-1 Cephalometric analysis at the start of treatment

The following reasons may lead to preferential treatment of the dental cause of a malocclusion, in order to avoid extensive surgical measures:

• general medical conditions that increase the risk of extensive conversion osteotomies, eg recurrent pulmonary embolism, coagulation problems.

• psychologic reasons such as phobias or lack of compliance

• dysostoses, eg fibrous dysplasia, cherubism

• osteopathies, eg fibrous dysplasias, osteogenesis imperfecta

• bite correction after joint splint therapy (may make it possible to dispense with new dentures)

• borderline cases with minor maxillary hypoplasia (compression and dental open bite)

• pretreatment of maxillomandibular treatment cases

• narrow spaces that are to be resolved in a short treatment time

• molar intrusion/extrusion.

Other simple arguments can also come into play, such as increased surgical risks in advanced age, so that dentoalveolar surgical measures in combination with orthodontics, periodontics, implantology, and prosthetics can also produce an excellent treatment result. This chapter describes the periodontally accelerated osteogenic orthodontics (PAOO) method in the context of an individual case description.

29.2 Anamnesis / screening

29.2.1 The patient’s perspective

The patient wanted a functional and esthetic improvement of her tooth position. She only felt contact on her posterior left molar. The bite was increasingly unpleasant. She was bothered by the fact that she could no longer bite and chew properly. Several dental practitioners and orthodontists she had previously consulted refused orthodontic treatment because of her advanced age.

29.2.2 Medical history

The patient’s medical history was as follows:

• First presentation age 70 years

• Nonsmoker.

• Medication for hypertension and reflux.

• Partially prolonged bleeding after dental procedures.

• 6 months previously, she had undergone septorhinoplasty with bone implantation, concheotomy of the inferior and middle conchae, microsurgical excision of the maxillary sinuses, frontal sinuses, and ethmoid bones, as well as the sphenoid bones on both sides, and laser treatment of the inner nose due to deviation of the bony-cartilaginous nose, nasal obstruction, chronic sinusitis, and nasal polyps.

• The maxillary and mandibular right first molars (teeth 16 and 46) had been removed on the advice of a general dental practitioner because of tooth loosening. A restoration was not planned. Tooth and jaw malocclusions as well as periodontitis were not known in her family. The patient was unable to provide any information about the missing tooth 35 and gap closure. So far, no systematic periodontal therapy had been carried out.

29.3 Clinical evaluation

The initial clinical evaluation revealed the following:

• tendency to frontal open bite

• tongue dysfunction

• limited chewing ability

• tooth and jaw malocclusion

• periodontally severely damaged dentition

• due to the position of the jaws in relation to each other, no indication for an orthognathic adjustment

• presence of lip closure insufficiency, with mouth breathing, caries incidence, for functional reasons vertical chin reduction plasty would be considered to achieve involuntary permanent lip closure.

29.4 Recommendation

The following recommendations were made:

• control of the coagulation values

• oral hygiene instruction

• systematic pretreatment with extended diagnostics

• consultative examination and consultation with the orthodontist.

29.5 Initial situation (70 years, 3 months)

29.5.1 Findings

The initial findings (Fig 29-1) were as follows:

• missing teeth 18, 16, 15, 28, 38, 35, 46, and 48

• bleeding on probing (BOP) 59%

• suppuration 11%

• plaque control record (PCR) 32%

• tooth 26: all surfaces Class III furcation

• tooth 27: distal and vestibular Class II furcation

• tooth 17: mesial Class I furcation

• teeth 36 and 37: vestibular and oral Class I furcation

• probing depths of up to 11 mm

• tooth 21: composite filling with marginal gap caries lesion

• teeth 47, 45, 36, 37, and 27: protruding crown margins

• teeth 17, 26, 27, 36, 37, and 47 showed grinding marks in the ceramic with exposed metal parts

• left-sided occlusion single contacts on teeth 26 and 27

• compensation of the nonocclusion on the right and anteriorly by tongue insertion

• masticatory musculature bilaterally painful on palpation

• caudal traction of both temporomandibular joints severely limited

• prosthetically incomplete and partially insufficiently rehabilitated dentition

• sufficiently supplied with preservative except for one filling.

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