Alveolar Augmentation Research Articles

The Effect of Advanced Platelet-Rich Fibrin Plus (A-PRF+) on Graft Stability in Dental Implants and Alveolar Ridge Augmentation Procedures: A New Low-Speed Standardized Centrifugation Protocol

Background: Platelet-rich fibrin (PRF) is a concentrate derived from autologous blood, containing platelets, fibrin, and growth factors (GF) obtained through centrifugation. PRF can be mixed with bone replacement material to form sticky bone, which is then introduced into the desired area for stabilizing and graft-covering. Depending on the centrifugation protocol, the effectiveness of the end products can vary. This controlled clinical study examines the impact of our established PRF protocol in alveolar augmentation and dental implant placement on vertical bone loss. Materials and Methods: A total of 362 implants were performed in 170 patients at the Department of Oral and Maxillofacial Surgery at the University Hospital Innsbruck between 2018 and 2021. After accounting for lost implants, we retrospectively evaluated a radiological vertical bone loss exceeding 1 mm in the first year as the primary endpoint. Results: The use of PRF was significantly associated with vertical bone loss > 1 mm (OR = 0.32, 95% CI (0.13–0.81), p = 0.016). There were no significant associations between PRF and the number of implants lost, the type of augmentation, or bone loss. Discussion: A-PRF+ sticky bone grafts, when combined with bone graft materials, show reduced resorption rates, indicating their potential to enhance graft stability in oral implantology. Our data indicate that the Medifuge MF 100 (Silfradent srl, Forlì, Italy) is effective in producing A-PRF+.

Proximal tibia for alveolar augmentation and augmentative rhinoplasty—a suitable option? A retrospective clinical study on donor and recipient site morbidity

BackgroundAutologous bone grafts are essential in reconstructive oral and maxillofacial surgery, and depending on the donor site, they can be associated with specific harvesting morbidities. One of the most commonly applied bone grafts is the iliac crest bone graft, irrespective of other grafts, which might be associated with an easier surgical procedure or the possibility of harvesting them under local anaesthesia. Objective of the study is the clinical evaluation of proximal tibia bone grafts regarding their eligibility for maxillofacial bone grafting.MethodsIn this retrospective study, proximal tibia bone grafts were examined with regard to associated donor and recipient site morbidity and their suitability for alveolar ridge augmentation and rhinoplasty.ResultsIn total, 21 tibia grafts were included. Fifty-seven percent of the bone grafts were used for alveolar ridge reconstruction, and 43% were used for augmentative rhinoplasty. No significant complications occurred during or after harvesting, but in 14.3% of the patients, minor wound healing disorders were recorded at the donor site, and in 19% of the patients, they were recorded at the recipient site. Statistically, patient sex, age, nicotine and alcohol abuse and metabolic diseases had no significant influence on the complication rate. Graft harvesting under local anaesthesia and at summer temperatures was associated with significantly more complications at the harvesting site (p < 0.05). In cases of dental implant insertion into augmented sites, the implants (n = 31) were followed up for a median period of 40.5 months, during this time 86.7% of the implants survived.ConclusionThe proximal tibia is a suitable donor site for harvesting autologous bone grafts for alveolar ridge augmentation or rhinoplasty because the donor site morbidity is low, and in contrast to iliac crest bone grafts, they can be harvested under local anaesthesia, which might be advantageous for outpatient surgeries.

Clinical feasibility evaluation of a digital workflow of prosthetically oriented onlay bone grafting for horizontal alveolar augmentation: a prospective pilot study

BackgroundOnlay bone grafting is considered highly reliable for reconstructing severe horizontal bone defects. A critical problem is how to achieve precise position of the bone block to control alveolar ridge dimensions. This research aims to establish a digital workflow for prosthetically oriented onlay bone grafting and evaluate its accuracy and efficiency.MethodsThis prospective pilot study investigated eight patients who required implant restoration in the esthetic area with horizontal alveolar bone defects. The workflow includes preoperative virtual planning, design and manufacture of patient-specific templates, bone grafting surgery, and implant insertion. Primary outcomes were graft accuracy, defined by root mean square estimate (RMSE) values between preoperatively designed and actual implanted outer contours of bone blocks. Secondary outcomes were bone graft and implant success rates. Besides, the surgeons used the visual analog scale (VAS) to rate the intuitiveness, ease of understanding, and helpfulness of the workflow.ResultsNo bone grafts or implants failed in any of the eight patients, resulting in a 100% success rate. The RMSE values between the preoperative design and the implanted outer contour of bone blocks were 0.41 ± 0.15 mm. The digital approach showed advantages in intuitiveness (9.3 ± 0.5), understanding (9.0 ± 0.5), and helpfulness (8.4 ± 1.1) according to surgeons' VAS scores.ConclusionsA digital workflow provided encouraging results, in terms of accuracy and efficacy, for horizontal bone augmentation.Trial registrationThis study was registered in the National Clinical Trials Registry in 16/02/2023 under the identification number ChiCTR2300068361.

Physicochemical Properties and Surface Characteristics of Ground Human Teeth.

Enamel, dentin and cementum apatite has a complex composition. The lack of complete reports on the chemical composition of all tooth tissues together and the need to create a modern biomaterial that reproduces the correct ratio of individual tooth mineral components prompted the authors to undertake the research. A detailed evaluation of the micro- and macro-elements of tooth powder, using various methods of chemical analysis was conducted. All four groups of human sound teeth were crushed using the grinder. A fine powder was implemented for the FTIR (Fourier Transform Infrared Spectroscopy), ICP (Inductively Coupled Plasma Optical Emission Spectometry) and for the potentiometric titration, SEM and mercury porosimetry analyses. The obtained studies indicate that there is no significant correlation in chemical composition between the different teeth types. This proves that every removed, crushed tooth free of microorganisms can be a suitable material for alveolar augmentation. It is essential to know the chemical profiles of different elements in teeth to develop a new class of biomaterials for clinical applications.

Radiological and Microbiological Evaluation of the Efficacy of Alveolar Bone Repair Using Autogenous Dentin Matrix—Preliminary Study

Dental procedures for alveolar bone augmentation may be carried out using autologous bone graft material derived from the patient’s own tooth. The material obtained is subjected to strict procedures aimed at reducing the amount of bacteria in the autograft. The aim of this study was the evaluation of the efficacy of the autogenous dentine matrix produced by grinding the patient’s own tooth for the augmentation of maxillary bone defects and the evaluation of the microbiological status of the material obtained. Alveolar bone repair was performed with an autogenous dentin matrix in four patients. In each case, an autogenous bone graft substitute obtained by grinding the patient’s own tooth was used. The tooth-derived material was then used for alveolar augmentation. The obtained material was tested to assess its microbiological profile. For the purpose of comparison, other materials and tissues were also subjected to microbiological testing. Bone healing was assessed by CBCT (cone beam computed tomography) scanning before and 6 months after surgery using the Hounsfield scale and the ImageJ software. Analysis of the bone regeneration process based on the bone density score in Hounsfield units showed significant differences in measurements on CBCT scans carried out on the treatment site, before surgery, and 6 months after it, using ImageJ software. All bacteria detected in the bone augmentation material constituted the patient’s bacterial flora. The microorganisms present in the augmentation material were also present in the patient’s bone and soft tissues. The use of an autogenous dentin matrix for alveolar bone repair ensures that the proper volume is obtained and that alveolar bone shape is preserved and does not introduce pathogenic microorganisms into the patient. The procedure for preparing and using an autogenous dentin matrix is described based on one clinical case.

Comparison of Particulate, Block and Putty Forms of β-tricalcium Phosphate-Based Synthetic Bone Grafts on Rat Calvarium Model.

Bone augmentation is a necessity for atrophied alveolar ridge prior to dental implant placement. Various bone graft types and forms with different characteristics are available in the market for alveolar augmentation. Beta tricalcium phosphate (β-TCP) is a synthetic biomaterial known as the oldest type of calcium phosphate. Studies comparing particulate, block or putty grafts are very limited. The aim of this study was to compare the particulate, block and putty forms of the same β-TCP bone graft and analyze the efficiency in critical size calvarium defects. Twenty male Wistar-Albino rats were employed for the study. Four bicortical bone defects with 5mm diameter were created on each rat calvarium, and three defects were filled with particulate, block or putty β-TCP graft and one defect was left empty. The animals were killed after 8weeks. New bone formation, residual graft, loose connective tissue, condensed mesenchyme, alkaline phosphatase, proliferating cell nuclear antigen, osteocalcin were measured on the specimens. Compared to block and putty forms, significantly higher new bone formation and least residual graft were observed in the particulate graft group. The residual graft was significantly higher in the block graft group than both the particulate and the putty groups. The cellular immunoreactivity of the samples in the particulate graft group was significantly higher. There was no significant difference between putty and block graft groups. Bone regeneration is significantly affected by the form of β-TCP bone graft, and the particulate form was the most successful in our study.

Endonasal sinus lift as a new way of augmenting the alveolar process of the upper jaw

Aim to develop a new method of endonasal augmentation of the alveolar process of the upper jaw to reduce postoperative risks.&#x0D; Material and methods. The study involved 10 patients during the period of December, 2019, and June, 2021. The examination methods were: computed tomography of the nose and paranasal sinuses, upper and lower jaw, and video-endoscopy of the nasal cavity. The patients received the indonasal sinus inlay with the use of allogenic bone chips.&#x0D; Results. The surgical access through the lower nasal passage, under the lower nasal concha, allows to expose the maxillary sinus floor with preservation of mucous membrane integrity and to fill in the space between them with the allogenic bone material. Formation of a bone window in the lateral nasal wall using a piezotome prevents the rupture of the sinus mucous membrane. A bony fragment of the lateral nasal cavity wall transferred into the cavity of the maxillary sinus as one block with the mucosa creates additional protection for the Schneiderian membrane. Allogenic material introduced by endonasal method is substituted by the own organotypic tissue, restoring the lost volume of the maxillary sinus alveolar process.&#x0D; Conclusion. The endonasal method of alveolar augmentation may be used in clinical practice as an alternative to the classic methods.

A Porcine Model Using Adipose Stem Cell-Loaded Scaffolds for Alveolar Ridge Augmentation.

Tooth loss greatly affects a person's quality of life and many turn to dental implants to replace lost teeth. The success of a dental implant depends on the amount of alveolar bone supporting the implant, and thus, bone augmentation is often necessary to preserve or build up bone volume in the alveolar ridge. Bone can be augmented with autogenous bone, allografts, or xenografts, but the limitations of such natural bone grafts prompt researchers to develop synthetic scaffolds supplemented with cells and/or bioactive agents as alternative bone grafts. The translation of these combination scaffolds from the laboratory to the clinic requires reliable experimental models that can simulate the clinical conditions in human patients. In this article, we describe the use of a porcine alveolar defect model as a platform to evaluate the efficacy of a novel combination of a three-dimensional-printed polycaprolactone-tricalcium phosphate (PCL-TCP) scaffold and adipose-derived mesenchymal stem cells (AD-MSCs) in lateral alveolar augmentation. The surgical protocol for the defect creation and regenerative surgery, as well as analytical methods to determine the extent of tissue regeneration, are described and discussed.

A fully digital workflow for prosthetically driven alveolar augmentation with intraoral bone block and implant rehabilitation in an atrophic anterior maxilla

A fully digital workflow for prosthetically driven alveolar augmentation and implant rehabilitation in the esthetic zone was planned and executed by using a bone harvest guide, trim guide, graft guide, and implant guide. A controllable procedure and predictable results can be realized by adopting this digital workflow.

Wilkodontics: A Meteoric Rise to Faster Orthodontic Treatments

A tremendous amount of advances has been made in the field of dentistry in the past few decades. In spite of these advances, the average orthodontic treatment lasts 1.5 to 3 years. "Wilkodontics," often called Periodontally Accelerated Osteogenic Orthodontics (PAOO) is a procedure that helps in accelerating tooth movement as well as in providing an increase for rendering extensive dental services and care to the patients in bone activation through selective decortication and osteotomies as well as alveolar augmentation using a particulate bone graft. Thus, thisThis article attempts to review the main indications, contraindications, and modifications of wilkodontics.

One stage surgery and full-mouth reconstruction- A case report

Nowadays patients demand implant-prosthetic therapy with optimal function and esthetics. Definition of success also implies dental implants osseointegration as well as optimal recovery of facial aspect. To reach these objectives an effective collaboration must take place between implantology specialist, oral surgery specialist, laboratory technician, and patient. A 52-year-old male patient presented with a full arch maxillary restoration with periodontal mobility and prosthetic issues. A decision was made for maxillary full arch implant-supported fixed bridge with one stage surgery and immediate implantation. The treatment plan sequence used for this patient was as follows: (1) manufacturing of interim removable prosthesis and discussion with patient of future esthetic requirements; (2) digital evaluation and planning of implant system selection, pro-implant surgical procedures and implant surgical stage; (3) digital planning of implant placement guide and its fabrication; (4) sinus lifting and alveolar augmentation; (5) immediate implantation; (6) provisional restoration; (7) early loading with definitive implant-supported fixed bridge at 4 weeks. Immediate implantation and interim provisional restoration ensure recovery of aesthetics, phonetics and function and confidence of patient as fast as possible. This stage also helped to check up the osseointegration of the implants and oral hygiene maintenance as well as to help patient to adjust from the provisional restoration to the definitive full-arch implant-supported bridge. One stage surgery, immediate implantation and early loading are valid therapeutic solutions for the patients’ acceptance of implant-prosthetic therapy.

Implant Placement Using Alveolar Ridge Split in Atrophic Maxillary Alveolar Bone

If the volume of the horizontal alveolar bone is insufficient during the implant procedure, it is difficult to establish a fixture of the required diameter without surgical procedures such as block bone graft, lateral bone graft, and ridge split. Among them, alveolar ridge split is known as an effective technique to increase the volume of the horizontal alveolar bone using maxillary bone elasticity. The theoretical background of this technique is to provide a basis for maintaining the implant with the expectation that new bone will form when the implant and bone graft material are operated, forming a space surrounded by the bone and periosteum. In two cases reported herein, there was no postoperative inflammatory reaction and normal healing was observed. Since then, the follow-up radiograph has shown good outcomes, and ongoing progress is being observed. Alveolar ridge split and bone graft are effective techniques for horizontal alveolar augmentation. In these cases, it was actually possible to form a stable alveolar ridge for implant placement through a successful procedure in the maxillary edentulous region.

Evaluation of deformation in the buccal lamellar bone with finite element analysis in alveolar ridge-splitting/expansion technique

PurposeThe aim of this study was to investigate deformation and stress distribution in the buccal lamellar bone via finite element analysis (FEA) in the application of alveolar ridge-splitting/expansion technique (ARST) in atrophic maxilla and mandible. Material and methodThree-dimensional (3D) solid models of maxilla and mandible were formed using computer software, with an alveolar ridge thickness of 4 mm in the right first molar region. In both models, one horizontal and two releasing vertical osteotomies were made in the atrophic region. Vertical forces varying from 50 N to 1000 N were continuously applied on the midpoint of the horizontal osteotomy and then the axial and total deformation and von Mises stress distribution in the buccal lamellar bone was assessed by FEA. ResultsThe degrees of axial deformation and total deformation and the maximum von Mises stress value under a 50 N force were 0.22 mm, 0.23 mm, and 4.52 MPa in the maxillary buccal lamellar bone and were 0.04 mm, 0.06 mm, and 5.90 MPa in the mandibular buccal lamellar bone, respectively. Similarly, under a 1000 N force, the values were 4.44 mm, 4.75 mm, and 90.49 MPa in the maxillary buccal lamellar bone and were 0.96 mm, 1.1 mm, and 118.02 MPa in the mandibular buccal lamellar bone, respectively. ConclusionThese findings implicate that the ARST used for implant placement or alveolar augmentation can be achieved with the application of lower amounts of force in the maxilla compared to the mandible. It was also revealed that in ARST, the maximum von Mises stress value was lower in the maxillary buccal lamellar bone than in the mandibular buccal lamellar bone. Based on these findings, we consider that the administration of ARST could be biomechanically more stable in the maxilla than in the mandible.

Strategies of periodontal surgery to promote orthodontic treatment: the clinical application of periodontally accelerated osteogenic orthodontics

Orthodontic moving teeth are closely related to the health of periodontal support tissues, and the combined periodontal orthodontic treatment is becoming more and more normalized. Inflammation control is the prerequisite for orthodontic treatment in patients with periodontitis. For many adult patients, the long course of treatment and the risk of periodontal tissue damage during orthodontic treatment have gradually attracted the clinicians' attention. Periodontally accelerated osteogenic orthodontics (PAOO) is one of the surgical strategies by combining selective decortication with alveolar augmentation to promote orthodontic treatment. It is aiming to accelerate the movement of teeth for shortening the treatment course, to increase the bone volume for reshaping the alveolar bone and expanding the range of tooth movement and to reduce the risk of tooth movement beyond the "alveolar bone boundary" during orthodontic treatment. Based on the retrieve and review of current literature, this article will focus on how to design and implement PAOO surgery so as to maximize the effectiveness in clinical practice.

Patient experience following iliac crest-derived alveolar bone grafting and implant placement

BackgroundThe objective of this study was to assess patient-reported outcomes such as satisfaction and quality of life after advanced alveolar bone augmentation with anterior iliac crest grafting and implant treatment in orally compromised patients.MethodsThis cross-sectional retrospective cohort study included 59 patients (29 women and 30 men) with major functional problems, who underwent advanced alveolar augmentation with autologous iliac bone grafts during a 10-year period (2002–2012).The self-administered questionnaire included 36 validated questions related to (1) demographics, (2) perceived general and oral health, (3) donor site and hospitalization, (4) status of implants and/or prosthesis, and (5) oral health-related quality of life (OHRQoL).ResultsQuestionnaires were completed by 44 patients: 24 women and 20 men (response rate, 74.6%). Most patients reported good tolerance of the operative iliac bone harvesting (85%) and implant (90%) procedures. Post-operative pain at the donor site was reported by 38%, lasting 18.1 ± 16.1 days. An average of 4.3 ± 3.5 days of hospitalization and 20.2 ± 18.5 days of sick leave was reported. The overall satisfaction with prosthetic reconstruction was 90.5%. OHRQoL was reported with a mean Oral Health Impact Profile-14 (OHIP-14) score of 8.4.ConclusionFavorable OHRQoL and satisfaction were reported after advanced reconstruction of alveolar ridges with iliac crest-derived grafting and implants in severely compromised patients. However, this treatment requires substantial resources including hospitalization and sick leave.

Çekim Soketlerinin Ogmentasyonunda Primer Kapamaya Karşı Açık Membran Tekniği

Objectives: Funakoshi is the first one who reported 'Open Barrier Membrane' technique by using non-expanded, highdensity polytetrafluoroethylene(d-PTFE) membrane in 2005. d-PTFE membranes are impenetrable for bacteria invasion because of its surface characteristics and surgeon can leave the d-PTFE membrane intentionally exposed. The objective of this study was to investigate the clinical results of 'Open Barrier Membrane' technique in Guided Bone Regeneration (GBR) of the extraction sockets by using xenogenic bone graft and d-PTFE membranes. In this clinical study, open barrier membrane technique was compared to GBR technique. The comparison was made between the cases where the primary coverage of extraction site was obtained and the cases who completed the 6-month recovery period without exposure in terms of total bone gain. Material and Methods: Fifteen patients who were reported to have exposure in incision line during 6-month recovery period were included in open membrane group as study group (Group A). Fifteen patients who completed the 6-month recovery period without exposure were analyzed in primary coverage group as control group (Group B). The main groups were also divided into subgroups as horizontal and vertical augmentation. The amount of total bone gain was statistically compared between the groups based on the cone beam computerized tomography measurements. Results: Vertical and horizontal bone gain amounts (the main outcome variable) were statistically compared between Group A and B. There was no statistically significant difference between these groups in terms of bone gain (p=0.237 for comparison of vertical augmentation; p=0.482 for comparison of horizontal augmentation). Conclusion: Open barrier membrane technique can be considered as an alternative minimal invasive technique for both horizontal and vertical alveolar augmentation procedures.

Leukocyte- and platelet-rich fibrin is an effective membrane for lateral ridge augmentation: An in vivo study using a canine model with surgically created defects.

Leukocyte- and platelet-rich fibrin (L-PRF) has been suggested to enhance bone healing and the effects of L-PRF need to be evaluated in lateral residual alveolar bone augmentation. This in vivo study aimed to analyze the effects of L-PRF as a membrane on bone regeneration in lateral residual alveolar augmentation. Eight mongrel dogs were used; the mandibular premolars were extracted and then three lateral ridge defects were surgically created on each side of the arch. After 4 weeks, guided bone ridge augmentation was performed in each defect with the following treatment groups: N+D (nonresorbable membrane with deproteinized bovine bone mineral [DBBM]), N+B (nonresorbable membrane with β-tricalcium phosphate [β-TCP]), R+D (resorbable membrane with DBBM), R+B (resorbable membrane with β-TCP), and P+D (L-PRF with DBBM), and P+B (L-PRF and β-TCP). Following 4 weeks of bone healing, the new bone amount for each group was measured by light microscopy (primary outcome) and microcomputed tomography (micro-CT) (secondary outcome). The mean values were compared at the 0.05 significance level. The P+D group showed the most newly formed bone in histology and in micro-CT analyses. L-PRF was more effective in bone regeneration when compared to nonresorbable and resorbable barrier membranes. Additionally, this study indicated DBBM was the more favorable osseous graft material for bone regeneration than β-TCP when barrier membranes are used. From the results of this in vivo study using surgically created defects, L-PRF plays an effective role as a barrier membrane for lateral ridge augmentation. L-PRF may be an excellent barrier membrane in place of other nonresorbable and resorbable membranes.

Vertical Alveolar Augmentation Using BMP-2/ACS/Allograft with Printed Titanium Shells to Establish an Early Vascular Scaffold.

Traditional reconstruction of major alveolar ridge deficiency has required autogenous cortical cancellous particulate bone grafts, often augmented with particulate allogeneic components. Now there is a new concept to consider, that of orthoalveolar form. This paradigm shift involves components of the tissue engineering triad of inductive growth factors combined with a matrix and stem cells, together with osteotomies or devices designed for space maintenance. Reported here is early experience with computer technology used to redesign deficient alveolar ridges deriving ideal alveolar-shaped bone-forms made from powdered titanium, sintered by laser at high temperature using rapid prototype technology.

Vertical Ridge Gain with Various Bone Augmentation Techniques: A Systematic Review and Meta-Analysis.

The aim of this systematic review was to determine the most effective alveolar augmentation technique for vertical bone gain. A systematic search to select clinical trials and retrospective studies done on patients with reduced vertical bone height was conducted. The intervention of interest was autogenous block graft done compared to procedures such as distraction osteogenesis (DO), particulate grafting, block plus particulate grafting with titanium mesh, and tent pole technique in systematically healthy adult patients age 18 and older. The following electronic databases were explored: PubMed, CINAHL, and Dental and Oral Science. A supplementary manual search of published full-text articles from January 2005 to December 2017 was done using Google Scholar. Grey literature was also sought using greylit.org. The review protocol was registered at the Prospero registry (CRD # 42017072432). The risk of bias of the included studies was assessed using EPOC criteria. Meta-analysis was performed using Review Manager for studies with quantitative data on mean values of vertical bone gain and bone resorption achieved with various bone augmentation techniques. Random effect model was used. Heterogeneity among studies was evaluated using the I2 statistic. A total of 2322 articles were found. After excluding the irrelevant papers, only 8 papers were finally selected for the detailed evaluation. Of these 8, 5 were clinical trials, and 3 were retrospective studies. Four studies were on DO, 2 on particulate grafting, 1 on autogenous block grafting plus particulate grafting, and 1 on tent pole grafting. The control group in all studies were autogenous block graft. Meta-analysis revealed no significant difference between DO and autogenous block grafting for vertical bone gain (mean difference 0.82 [-1.28, 2.91]). Similarly, no significant difference was observed in the 2 techniques for bone resorption (mean difference 0.38 [-0.23, 0.99]). DO was not superior to autogenous block grafting for vertical bone augmentation. Both techniques were associated with a number of complications. There was no difference in the bone resorption observed in the 2 techniques. No conclusive results can be drawn on other techniques on account of limited data.

Periodontally accelerated osteogenic orthodontics: A boon in a severe periodontally compromised Class II division 1 malocclusion patient

Periodontally accelerated osteogenic orthodontics (PAOO) is a combination of a selective decortication facilitated orthodontic technique and alveolar augmentation. With this technique, one is no longer at the mercy of the preexisting alveolar volume, and teeth can be moved two to three times further than required for traditional orthodontic therapy. It is used to treat moderate-to-severe malocclusions in both adolescents and adults. PAOO technique increases alveolar volume which can provide a more intact periodontium, inturn decreases need for extractions, increases a degree of facial reshaping. This technique also increases the bony support for both the teeth and the overlying soft tissues. Here is a case report which highlights the above-mentioned uses with PAOO technique in a severe periodontally compromised Class II division1 malocclusion patient treated with nonextraction line of orthodontic treatment.