Down's syndrome (DS) is a genetic condition that involves trisomy of all or part of the 21st chromosome{{5 Pilcher,E.S.

2001;3 Quintanilla,J.S. 2002; }}. In all the above cases the problem is that there does not exist a stable occlusion. This is achieved when the teeth reach a point of maximum interdigitation. This allows functional movements of the mandible and optimum use of masticatory muscles. After each cycle masticatory cycle the mandible returns to the stable position{{2 Faulks,D. 2002; }}. The term malocclusion is used to refer to variations from normal occlusal development. Although it is accepted that most malocclusion represents variation from normal development for which there is no evident cause, genetic syndromes such as Downs have also been found to cause malocclusion {{1 Townsend,G.C. 1998; }}. It has also been observed that both genetic and environmental influences contribute to malocclusion{{1 Townsend,G.C. 1998; }}. Those with Down's syndrome are particularly susceptible to Class III malocclusion{{7 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001;8 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; 5 Pilcher,E.S. 2001; 11 Cohen,M.M. 1975; }}. The increased incidences of Class III malocclusion are due to the underdevelopment of the nose, bones of the midface and maxilla. The result is that these structures are relatively smaller in size than in individuals without Downs{{2 Faulks,D. 2002;7 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; 8 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; 5 Pilcher,E.S. 2001; }}. The size of maxilla relative to mandible makes it difficult for the teeth to interlock and often on closure there is only one interdental contact{{2 Faulks,D. 2002; }}. This Class III occlusal relationship can also itself contribute to an open bite{{6 Backman,B. 2003;5 Pilcher,E.S. 2001; }}. Another consequence of the Class III occlusion

problems result in tooth position that is unstable and does not allow any rest for the muscles of mastication. The individual will unconsciously try to find a comfortable position by grinding down the occlusal surface or adopting an abnormal mandibular position{{2 Faulks,D. 2002; }}. There are also reports of other types of malocclusion. According to {{7 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; }} all occlusion has been reported as follows: Class III, 32-70%;Class II, 3-32%; posterior unilateral and bilateral cross bites, 71%; and open bites, 5%. One of the principle ways of treating malocclusion is with the use of orthodontic treatment. This can be done in conjunction with palatal expansion and cross bite correction{{2 Faulks,D. 2002;8 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; }}. The goal of this treatment is to restore the dimensions of the lower face, to create a stable occlusion, to enable free movement of the jaw, and to eliminate mandibular protrusion. This treatment made up for the difference in size of the maxillary and mandibular arches and provides stable interdental position{{2 Faulks,D. 2002; }}. Sometimes none of the above treatments will work since the dentition is beyond restoration due to periodontal disease or carious attach and in these cases the best strategy is to extract the teeth and create a complete set of dentures{{2 Faulks,D. 2002; }}. One of the main symptoms of Down's syndrome is Facial dysmorphology. This refers to abnormal structural development either in utero or in later development. In this case it is caused by muscle hypotonia a common occurrence in Downs syndrome{{2 Faulks,D. 2002; }}. Hypotonia in the cheeks and lips contribute to an unbalanced force on the teeth while the force of the tongue is a greater influence. The clinical implication of this is that it often leads to an open bite{{6 Backman,B. 2003;5 Pilcher,E.S. 2001; }}. Tooth

mobility is another condition that affects stable occlusion. In Individuals with DS there is evidence that crowns and roots are shorter than normal creating an unfavourable crownroot ratio. This along with Taurodontism is expected to contribute to tooth mobility often seen in individuals with DS {{8 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; }}. Another more drastic treatment is the use of bone grafts. Here bone is removed from somewhere else in the body and surgically placed into the jaw. This is one way to deal with the congenital defects in those with Downs. Occlusal equilibration is often used to reduce the crown to root ratio making it more favourable. Also Radical occlusal equilibration can help reduce occlusal interference{{8 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; }}. There are also other consequences of Down syndrome that have implication for occlusion. Individuals with Downs have higher incidences of missing permanent laterals with incidences as high as 35-43% compared to 2% in the general personal population {{5 Pilcher,E.S. 2001;8 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; }}. Microdontia particularly mesiodistally is also common {{8 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; }}. To deal with the consequences of delayed or missing permanent teeth it is vital to try to keep the primary dentition as long as possible. To minimize the need to extract Primary teeth a suggestion is to use occlusal sealants. Also decay in the primary teeth should be treated promptly{{5 Pilcher,E.S. 2001; }}. Additionally those with Down syndrome may have Rotated teeth, spaced teeth, peg shaped teeth, anterior and/or posterior cross bite, over retained primary teeth, delayed

eruption of permanent teeth, more impacted teeth, and mandibular overjet {{6 Backman,B. 2003;2 Faulks,D. 2002; 7 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; 8 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; 9 Vigild,M. 1985; }}. Individually and especially collectively these variations from normal can have a large impact on dental occlusion. As mentioned above DS individuals are more susceptible to having over retained primary teeth these results in a crowded dentition. Selective extraction of primary or permanent teeth or even enameloplasty can be used to create interdental space {{5 Pilcher,E.S. 2001;8 SOUTHERN ASSOCIATION OF INSTITUTIONAL DENTISTS 2001; }}. In most cases there was generally agreement amongst the various studies about the symptoms of Downs syndrome and its subsequent effect on dental occlusion. In general I found that none of the studies had particularly large sample sizes. This is understandable since the group of Down's syndrome individuals who are in need occlusal correction is relatively small. In order to verify the claims of either symptoms or treatments it would be helpful to have a larger sample in the future In the end it seem that though DS individuals are genetically predisposed to suffer from occlusal disharmony the sooner treatment is given the better the health of the overall occlusion in these individuals.