Combining Clear Aligner Treatment With Bone Grafting for Comprehensive Care of Missing Teeth

Studies show that 69% of adults from ages 35 to 44 have lost at least one permanent tooth.¹ By age 50, people have lost an average of 12 teeth.² Moreover, one-fourth of school-aged children and one-third of adults experience dental trauma.³ In the past year, the author's office has seen a significant increase in emergency visits involving fractured teeth. The most common injury appears to be a fracturing of the central incisors caused by a range of incidents, including car accidents, falls, sports injuries, and bruxism. Patients also present with fractured teeth due to clenching and grinding, which may be a habitual and nocturnal reaction to stress.

Most dental practices offer many restorative options to treat their patients. For patients who want a fixed option, they often elect to have a bridge (ie, fixed dental prosthesis). Because the fractured or missing tooth is typically in the patient's smile line, and the patient would rather have a temporary tooth in that spot instead of no tooth, many patients choose this option out of convenience. Bridges are also more likely to be covered by insurance and require a smaller copay than dental implants. Another factor important to patients is that a bridge can be completed in fewer appointments than implants.

For patients who have mild to moderate malocclusion, however, achieving the optimal esthetic result will likely require minor movement of the abutment teeth. Clear aligner therapy is an economical and timely treatment used to accomplish this. For these cases, the author recommends SmileDirectClub through its Partner Network (smiledirectclub.com/partner-network/). With SmileDirectClub, patients receive doctor-prescribed and -monitored treatment that they can complete at home via a teledentistry platform. Patients do not have to disrupt their schedule with frequent in-person visits for treatment. With this system the abutment teeth are able to be moved safely and in a timely fashion, so the clinician can expedite a fixed replacement option for the patient.

Additionally, by presenting to patients an affordable clear aligner option, clinicians can fix issues that patients may have neglected to mention due to forgetfulness, embarrassment, or simply thinking their particular problem could not be fixed. While many adults have some form of malocclusion, they are often unaware of their options to correct this issue. Although some patients may opt to receive veneers or crowns, they may still need their malalignment corrected to achieve an ideal smile. A clear aligner system can be a suitable adjunct to enhance the cosmetic outcome for a patient. This option works well when combined with cosmetic treatment like veneers or crown-and-bridge restorations. The advantage of a clear aligner system is that patients are able to utilize an economical and convenient method to move their teeth while achieving their cosmetic goals.

Another key factor when replacing missing teeth is socket preservation. It is important for clinicians to inform patients of the significance of receiving bone grafting after extractions, especially if the patient is wanting to replace the missing tooth. A product that has worked well for the author with restorative cases that need bone augmentation is the OsteoGen^® Plug (Impladent Ltd., impladentltd.com). The product is a collagen plug filled with OsteoGen non-ceramic bone graft crystals. It combines bioactive resorbable calcium apatite with a bovine Achilles tendon collagen matrix. This matrix creates a structure that mimics bone.⁴ The product does not require the practitioner to mix or pack the graft and eliminates the issue of the grafting material washing out of the extraction site. OsteoGen is a bioactive and resorbable calcium apatite crystal that works by having a type I collagen stabilize the clot and provide a scaffold for keratinized tissue to develop over the extraction site.⁴ This is an important feature to initiate bone formation, and no membrane is needed for this product. The plug effectively fills the void of the recently removed tooth and works well in socket preservation.

If patients opt out of receiving a bone graft, they should know that they are increasing their chances of developing an atrophic ridge and having an unsatisfactory result with their final restoration. Without a bone graft after an extraction, the bone used to house the tooth will likely collapse, causing the patient to lose ridge height and width. It can take anywhere from 3 to 6 months for the patient's bone to begin regeneration.^5,6 However, a socket graft can add density to the extraction site and restore the site to close to its original form following trauma or tooth loss. Thus, bone graft is usually the recommended procedure.

By offering patients clear aligner therapy combined with bone grafting, clinicians are often able to produce a better esthetic result when replacing teeth. Fixing patients' malocclusion or malalignment and replacing missing teeth can go a long way toward helping patients find happiness and confidence through an improved smile. With the use of the OsteoGen Plug and clear aligner therapy that targets mild to moderate cases, like that available from SmileDirectClub, clinicians can help patients achieve their ideal smiles. With these tools and materials, tooth sockets can be preserved and mild to moderate malalignment can be fixed simultaneously.

Case 1

A 31-year-old male patient presented to the author's office after being in a car accident a week prior to his visit. His chief complaint was that he wanted his "front teeth fixed." The patient presented with tooth No. 8 fractured to the gingiva and a medium fracture to tooth No. 9 (Figure 1 and Figure 2). Tooth No. 8 had a class IV tooth fracture, where the complete clinical crown was missing and the root tip was retained. No mobility presented on any of the involved teeth (teeth Nos. 6, 7, 9, and 10).

In discussing options to replace the fractured tooth No. 8, the patient expressed that he wanted to finally "get my smile right." He expressed concerns about the esthetics of his smile and described improvements he wanted to make. Prior to the accident the patient had a large diastema between his maxillary central incisors that he disliked, and he was also concerned about the malalignment of his maxillary anterior teeth. While several options were presented to the patient to replace the missing tooth, he desired a fixed or permanent solution and wanted a replacement that could be completed in a short amount of time.

The patient chose to have a bridge completed. It was explained to him that in order to achieve the best esthetic result, a clear aligner system would need to be utilized to move his anterior teeth to a more ideal position. Because the patient was concerned with the malalignment of only his maxillary anterior teeth, he requested limited orthodontic treatment. Tooth No. 8 was extracted and an OsteoGen Plug was placed in the extraction site. One week later the patient presented for a scan that would be used to determine candidacy for clear aligners. The healing site looked excellent.

The patient was prescribed a 4-month SmileDirectClub treatment plan by a state-licensed doctor, all through the use of telehealth. The aligner system was able to move the anterior teeth to a more favorable position, closer to each other, to enable fabrication of a bridge. The patient thus was prepared for a bridge from teeth Nos. 7 through 9 and a single crown on tooth No. 10. The patient stayed in his temporary restoration for 4 weeks.

After 4 weeks, the final bridge and crown were seated (Figure 3 and Figure 4). The patient presented for a follow-up ex­am­in­ation after 2 months. The patient was happy with the outcome of the bridge and the alignment of his maxillary anterior teeth. There was no sign of recession or alveolar ridge atrophy. At 6 months the patient presented to the office for a follow-up visit and was still pleased with the esthetics of his restorations (Figure 5 and Figure 6). The alveolar ridge continued to uphold its shape.

Case 2

A 39-year-old female patient presented to the author's office with the chief complaint of wanting to "fix" her smile. She had recently moved to the area and wanted to know what options she had to address her concern. She had been seeing her previous dentist twice a year for dental cleanings and had now transferred into the author's practice. She had moderate malocclusion and a large diastema between her maxillary central incisors (Figure 7). She also had peg lateral incisors.

The patient expressed a desire to have her anterior teeth straightened but did not want to fully close the diastema, or "gap." Tooth No. 7 had class III mobility. She stated that the tooth had been mobile for at least a year.

After discussing treatment options with the patient, the treatment proceeded as follows: Tooth No. 7 was extracted and an OsteoGen Plug was placed in the extraction site. The patient was put in SmileDirectClub clear aligner therapy for 4 months to minimize the diastema between teeth Nos. 8 and 9 without eliminating it completely and to fix the malocclusion from teeth Nos. 6 through 11. The clinician then prepared a bridge from Nos. 6 through 8 and completed preparations for crowns on Nos. 9 through 11. The patient remained in temporary restorations for 2 months.

After 2 months the patient presented for a final scan for the bridge and crowns. The final restorations were seated, and there was no atrophy or recession of the alveolar ridge. The patient was very pleased with the outcome of the case. At 1-month follow-up healing looked excellent, as did her alveolar ridge. The patient was examined at her 6-month hygiene appointment (Figure 8) and 1-year hygiene appointment, and the alveolar ridge showed no signs of atrophy.

When replacing anterior teeth with a fixed restorative option, esthetics are highly critical. A key factor in accomplishing ideal esthetics is to maintain alveolar ridge height and width. Proper ridge maintenance can allow for the use of a pontic that successfully masks the edentulous area. Besides preservation of the ridge, proper positioning of the abutment teeth also helps accomplish ideal esthetics. The collagen plug used in the presented cases served as a convenient and effective option for ridge preservation. Additionally, SmileDirectClub clear aligners were utilized to accomplish the limited tooth movement that was necessary for the fabrication of esthetic restorations in the anterior region.

This article was commercially supported by SmileDirectClub.

Loray Spencer, DDS
Private Practice, Rock Hill, South Carolina