The middle-aged patient with a dentofacial deformity complicated by partial edentulism and underlying medical prlbems presents a challenge to the orthodontic-surgical team. The clinical management of a 51-year-old man with maxillary deficiency and chronic atrial fibrillation is presented. Preoperative evaluation and planning, and a scheme and rationale for perioperative anticoagulation, are crucial. The etiology and risks of chronic atrial fibrillation are reviewed along with anticoagulation therapy