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Video: PAOO Adult Orthodontics

PAOO (Periodontally Accelerated Osteogenic Orthodontics) - Patient Story

Speedy adult orthodontics severe crowded upper and lower arches. PAOO: speedy orthodontics. Avoiding extrations in adults for tooth alignment and levelling. My chief concerns: improving the aesthetic apperance of her smile. Severe upper and lower crowding was a concern for Ms L. Her main concern was severe maxillary/mandibular crowding. In the past, this patient was advised extraction of all four premolar teeth (this was not an option for the patient preferring a different less invasive approach.

Initial Presentation

Crowded lower arch with spacing and wear. Note the blocked out upper left lateral incisor and lower right lateral incisor. The uneven gum levels and discrepancy between the dental and facial midline is quite obvious.

Our Aim was to improve the aesthetics: arch shape, teeth alignment and levelling. Provide optimal lip and facial support using minimal intervention.


We agreed to consider the best option: maxillary (upper jaw) arch expansion in combination with PAOO, TAD to create adequate space to level and align the teeth in both arches. Therefore, I would like to set out the treatment I feel appropriate in this case.


Unacceptable tooth colour and wear creating an aesthetic disturbance. Unacceptable tooth position and arch form creating an aesthetic disturbance.

Clinical examinations, x-rays, photos and study models, and Cephalometric Facial analysis has confirmed the following:

  1. Skeletal class II base, dental molarI and anterior Div-1
  2. Narrow upper arch with Crossbite 22/33
  3. Bilateral cross bite and severe lower arch crowding
  4. Profile straight/convex
  5. Symmetrical face, with slight chin deviation to the right. The upper jaw rotated to the left with midline shift 4mm. Due to high smile line and dental/facial midline discrepancy (to the left) this asymmetry is obvious
  6. Optimal lip outline and thickness
  7. Dental and skeletal midlines: considerable discrepancy due to missing 4mm dental midline to the facial midline (left)
  8. Frontally it is evident that maxillomandibular complex is rotated within the facial frame. The ideal treatment is orthodontic and orthognathic surgical correction. However, since Ms L has multiple orthodontic consultations in the past, and time factors, therefore prolonged surgical-orthodontic treatment at this stage in her life is not an option. Hence the reason for choosing the treatment mainly related to upper arch to compensation the dental-skeletal correction
  9. Periodontal health is mandatory and needs to be under control with good home care
  10. We need space 8-10mm per arch, therefore some interproximal reduction would be required as discussed
  11. We need TAD (temporary anchorage –mini implants) to distalise 43, 33, 13, 23
  12. PAOO to free up the system
  13. Initially developed the arches and retraction of 33, 43
  14. Improve buccal corridor and correct anterior cross bite


Once we have determined her needs and expectations and when the she is ready, we begin to restore her teeth to optimal function and aesthetics.

The treatment plan: Levelling and alignment with an orthodontic treatment. The primary aim is to correct the dental/facial midline, create space using small interproximal refinementsr canines for retracting canines and anterior crossbite 22/33 using TADs ( temporary anchorage device-miniimplant to be removed once the orthodontic treatment is completed).

The treatment will involve placement of clear orthodontic brackets, followed by forthnightly adjustment. To “speed up the orthodontic treatment, the procedure is PAOO: Periodontally Accelerated Osteogenic Orthodontics is advised, which involved selective incisions on the bone between the teeth being moved orthodontically (selective alveolar decortications). This concept is well tested. It improves the speed and result of orthodontic levelling and alignment. Treatment time less than one year but usually in severe crowding we need up to 18 months.

7 Months Post Op

When orthodontic treatment is complete we place permanent retention wire on the palatal aspect of upper front teeth as well as back of the lower front teeth, since we have better control with fixed compared to wearing removable retainers. Latest research suggests that retention should be as long as possible.

The Aesthetic Effect

Should establish harmony and balance between dentition and surrounding soft tissues. Final treatment outcome and we have a happy patient. We have restored aesthetics comfort and function. However most importantly we have complemented our lovely patient’s facial aesthetics. Hence I use the term: dentofacial rejuvenation.

Thank you for taking the time to explore this patient's story. I hope this gives you an idea of what I can do for you if you are having difficulty and need help, because there is always hope.

Dr. Sarkis Nalbandian
Visiting Professor YSMU
Specialist Prosthodontist & Implant Surgeon
B.D.S. (Hons), Dip. Clin. Dent. (Oral Implants) Uni Syd, M. Clin. Dent (Prosth) King’s College, Uni London
D. Clin. Dent (Prosth) Uni Syd, FRACDS, MRACD (Prosth) FIADE, FPFA

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