Prosthodontic Rehabilitation for a Patient with Down

Syndrome: A Clinical Report

Nasser M. Alqahtani, BDS, MSD, FRCD(C),1 Hussain D. Alsayed, BDS,2,3 John A. Levon, DDS,
MS,3 & David T. Brown, DDS, MSD4
1
Department of Prosthetic Dental Sciences, King Khalid University College of Dentistry, Abha, Saudi Arabia
2
Department of Prosthetic Dental Sciences, King Saud University College of Dentistry, Riyadh, Saudi Arabia
3
Department of Prosthodontics, Indiana University School of Dentistry, Indianapolis, IN
4
Department of Comprehensive Care and General Dentistry, Indiana University School of Dentistry, Indianapolis, IN

Keywords
Occlusal vertical dimension; dental implant;
overlay removable partial dental prosthesis;
implant-assisted removable dental prosthesis;
Down syndrome.
Correspondence
Nasser M. Alqahtani, King Khalid University
College of Dentistry - Prosthetic Dental
Science, Guraiger Abha 62529, Saudi
Arabia. E-mail:
dr.nasser.m.alqahtani@gmail.com.
The authors deny any conflicts of interest.
Accepted December 9, 2016
doi: 10.1111/jopr.12595
Abstract
Patients with Down syndrome can present with a variety of oral manifestations such
as hypodontia, periodontal disease, premature tooth loss, reduced salivary flow,
crowding of teeth in both arches, and decreased occlusal vertical dimension. The
intellectual ability of people with Down syndrome varies widely. They present with
a mild-to- moderate intellectual disability that restricts their ability to communicate
and adjust to their environment, which can add complexity in the overall dental
treatment. There is little information in the literature regarding the prosthodontic
rehabilitation for patients with Down syndrome in combination with dental implant
placement. An implant-assisted removable partial dental prosthesis can be a cost-
effective treatment alternative for carefully chosen patients with Down syndrome.
This article presents the treatment of a 44-year-old male patient with Down
syndrome and a moderate intellectual disability who presented with congenital and
acquired tooth loss with significant occlusal discrepancies. The treatment included a
prosthodontic approach that used a single dental implant, which will be described
and illustrated in this article.

Down syndrome, also known as trisomy 21, is an autosomal techniques and approaches have been proposed to manage
chromosomal anomaly that is mostly due to carrying an extra common oral problems of patients with Down syn-
chromosome 21.1 Approximately 14.47 per 10,000 live births
occur with this condition.2
Several common medical and dentofacial manifestations
are reported for individuals with Down syndrome. The
common dentofacial manifestations are tooth structure
anomalies, hy- podontia, malocclusion, tooth wear due to
bruxism, decreased occlusal vertical dimension (OVD),
periodontal disease, hypo- tonic orofacial musculature,
reduced salivary flow, and a high incidence of dental caries.
In addition, an underdeveloped max- illary arch and
mandibular prognathism are common skeletal defects in
patients with Down syndrome.3-7 All these dentofa- cial
manifestations can result in masticatory dysfunction.8,9
The intellectual disability of people with Down syndrome
varies widely and may have an effect on their overall
behavior during any dental procedures. The dental
management mostly depends on the level of this disability.
In addition to the oral manifestations, compromised
cooperation may add to the com- plexity of the treatment.
Thus, the trust relationship between pa- tient and dentist is
very important to the treatment outcome.4,10 Several
Journal of Prosthodontics 00 (2017) 1–7 ×C 2017 by the American College of 1
Prosthodontists
drome. The type of the treatment depends on the age, intel-
lectual disability, severity of the oral manifestations, and the
dentist’s skills and knowledge.4,8,9 Early interdisciplinary
inter- vention benefits the treatment outcome and improves
the quality of life in such cases; however, for older adults
with Down syn- drome who have not received adequate
early intervention, sig- nificant oral problems and marked
malocclusion are common.9 Treatment of hypodontia and
malocclusion may be achieved by either fixed or removable
dental prostheses.11-13 In addi- tion, increasing the OVD
might be necessary to gain restorative space, improve facial
esthetics, treat anterior cross bites, and to reestablish tooth-
tooth relations in malocclusions.14-16
In general, dental implants can provide stability, retention,
and support for removable partial dental prostheses (RPDPs)
with high success rates,17,18 and dental implants can also help
to establish a more favorable RPDP design.17 However, most
dentists do not consider implant placement as a restorative
option for patients with Down syndrome because of
concerns about their cooperation with the overall treatment,
compliance with the dental maintenance, and the quality and
the quantity of the existing bone. Thus, the literature
includes only a few documented cases of rehabilitation with
dental implants for patients with Down syndrome.19-25
Furthermore, individuals

2 Journal of Prosthodontics 00 (2017) 1–7 ×C 2017 by the American College of

Prosthodontists
 Alqahtani et
al
Figure 1 Pretreatment extraoral frontal view.
Figure 2 Pretreatment extraoral lateral view.
with intellectual disabilities may exhibit low levels of self-
care and maintenance that can jeopardize their oral
environment and compromise the longevity of implant
restorations.19,22
Prosthodontic Rehabilitation for a Patient with Down
Syndrome
Figure 3 Pretreatment extraoral frontal smile.
Figure 4 Pretreatment intraoral frontal view.
Figure 5 Pretreatment intraoral right lateral view.
Figure 6 Pretreatment intraoral left lateral view.
Clinical report
A 44-year-old Caucasian male with Down syndrome was re-
ferred to the advanced graduate prosthodontic clinic at
Indiana University School of Dentistry with chief complaints
of an in- ability to chew and an unpleasant smile. His
medical history
Figure 7 Pretreatment panoramic radiograph.
Figure 8 Diagnostic wax-up.
Figure 9 Immediate implant placement in the area of tooth #9.
included a diagnosis of controlled type 2 diabetes mellitus,
hypercholesterolemia, and obstructive sleep apnea. There was
no history of allergic reactions to medication, local
anesthetics, or food. He had a moderate intellectual disability
and interacted well with dentists in general; however, he was
afraid of any pain induced by dental treatment. His dental
history disclosed that he regularly visited his dentist, had
undergone dental extractions, and had tooth cleaning
performed every 6 months. Moreover,
Journal of Prosthodontics 00 (2017) 1–7 ×C 2017 by the American College of
Prosthodontists
Figure 10 Intraoral frontal view of the maxillary interim overlay RPDP
and the mandibular interim FPDP #22-27.
Figure 11 IAORPDP framework and custom Locator abutment.
Figure 12 Frontal view of the IAORPDP framework, metal-ceramic
FPDP, and custom Locator abutment.
he mentioned a severe gag reflex and exhibited some
difficulty in breathing in a supine position.
The patient presented with square face and concave lateral
profile (Figs 1 and 2). The extraoral examination revealed no
palpable nodes. He had no symptoms of any
tempromandibular joint (TMJ) discomfort or masticatory
muscle pain. Examina- tion of the TMJs revealed no clicking,
pain, or crepitus at rest or in function. He had a full range of
mandibular movements with a maximum opening of 50 mm,
with no deviation on opening or closing. In addition, he had a
very low smile line, with less than
3
 Figure 17 Intraoral Locator housing direct pick-up with a chemically
activated acrylic resin material.

Figure 13 Lateral view of the custom Locator abutment.

Figure 14 IAORPDP at try-in.

Figure 18 Posttreatment extraoral frontal view.

Figure 15 Cameo surface of the definitive IAORPDP

75% of the maxillary central incisor showing at the maximum
smile (Fig 3).
Intraoral examination revealed a negative cancer screening,
an anterior cross bite, generalized mild tooth wear,
congenitally missing teeth (#1, 6, 7, 10, 11, 16, 17, 23, 26,
32), and teeth
missing due to periodontal disease (#2, 5, 12, 13, 18, 24, 25,
31). In addition, 2 weeks prior to his evaluation, teeth #5, 12,
and 13 were extracted due to a poor periodontal prognosis
(Figs 4–6). Teeth #8, 9, 22, and 27 were mildly supraerupted
because of a long-term situation with no opposing teeth. In
addition, the distal third of the maxillary central incisal edges
were mildly worn due to heavy and premature contact with
Figure 16 Intraoral frontal view of the definitive treatment.
the mandibular canines. Tooth #29 was inclined lingually and
contacted the maxillary teeth on the buccal incline of the
buccal cusp. The patient presented with no dental caries.

Figure 19 Posttreatment smile.
Panoramic and full-mouth radiographs had been taken be-
fore the most recent tooth extractions (Fig 7). The periodontal
examination showed the presence of plaque and gingival in-
flammation with bleeding on probing, and teeth #8 and #9
showed class III mobility. Clinical attachment loss was gen-
erally between 3 to 4 mm with the exception of teeth #8 and
#9, which showed deeper probing depths. Generalized,
moder- ate horizontal bone loss was identified with localized
angular defects on the mesial aspect of the maxillary central
incisors.
Irreversible hydrocolloid impressions (Jeltrate Plus;
Dentsply, York, PA) of the maxilla and mandible were made,
and study casts were fabricated. A facebow record was made,
and the maxillary study cast was mounted in a Whip Mix
2240 semi-adjustable articulator (Whip Mix, Louisville, KY).
The mandibular cast was mounted in centric relation using
a polyvinyl siloxane (PVS) interocclusal registration material
(EXABITE II NDS; GC America, Alsip, IL). The mounted
diagnostic casts showed that centric occlusion coincided with
maximum intercuspation.
Based on the medical, clinical, radiographic, and mounted
cast records, the patient revealed no contraindications to den-
tal treatment. He was diagnosed with American College of
Prosthodontists (ACP) class IV partial edentulism, a low
smile line, anterior cross bite with prognathic mandible,
localized scissor-bite malocclusion at the area of teeth #4 and
#29, abnor- mal posterior cusp-to-fossa relationship, localized
mild attrition with facet wear, generalized moderate severe
chronic periodon- titis, localized severe chronic periodontitis
around teeth #8 and #9 with class III mobility with
supraeruption, and a Kennedy class IV maxillary arch.
Treatment options were discussed with the patient and his
mother. Due to the financial situation of his family, the fi-
nal treatment plan included: reinforcement of oral hygiene in-
struction, extraction of teeth #8 and #9 due to the poor peri-
odontal prognosis, immediate dental implant placement in the
area of tooth #9, a mandibular metal-ceramic fixed partial
den- tal prosthesis (FPDP) on teeth #22 and 27, and a
maxillary implant-assisted overlay removable partial dental
prosthesis (IAORPDP) to reestablish the occlusal relation
with increasing OVD and to correct the anterior cross bite.
This would convert the Kennedy class IV maxillary arch to an
implant-corrected Kennedy class IV maxilla. 26 Moreover, the
dental implant at #9 would help to improve the IAORPDP
design through use of a U-shaped major connector to help
reduce the potential for a gag reflex. The dental implant
would act as an indirect retainer for the U-shaped IAORPDP
by using a resilient attachment. Periodontal therapy would
include scaling and root planing in all four quadrants.
A cone beam computed tomography scan was taken of the
maxilla. After a diagnostic wax-up was completed, and an im-
plant surgical guide was fabricated (Fig 8), the patient was
referred to the graduate periodontics program for periodon-
tal therapy, extraction of teeth #8 and #9, and implant place-
ment in the area of tooth #9. An SLActive implant (4.1×10
mm) (Straumann, Basel, Switzerland) was placed
immediately after extraction of tooth #9 (Fig 9). Because of
the patient’s concern for pain, an interim overlay RPDP and
mandibular interim FPDP from #22 to #27 were delivered 2
weeks after the surgery (Fig 10). During the 4 months of
implant heal- ing, esthetics, phonetics, OVD, and function
were evaluated. Periodontal treatment was also completed
during the healing period. The patient showed a positive
response to the interim prosthesis, and the decision was made
to reproduce the same OVD and tooth positions in the
definitive prosthesis.
Final impressions were made using custom trays (Triad;
Dentsply) made from light-activated acrylic resin material
and PVS impression material (Examix NDS; GC America).
The impressions were poured in type IV dental stone (Silky
Rock; Whip Mix). A facebow record was made, and the
maxillary master cast was mounted in a Whip Mix 2240
semi-adjustable articulator. The mandibular master cast was
mounted at the same vertical dimension obtained by the in-
terim prosthesis by using PVS interocclusal registration ma-
terial (EXABITE II NDS). The mounted casts were sent
to a local dental laboratory to fabricate a maxillary over-
lay removable partial metal framework with a chromium-
cobalt alloy (Vitallium 2000; Dentsply) and mandibular
metal- ceramic FPDP on teeth #22 and 27 (Figs 11 and
12). A custom Locator abutment (Zest Anchors, Escondido,
CA) was fabricated for the maxillary implant in conjunction
with a UCLA abutment (Ceramicor; Cendres & Metaux, Biel-
Bienne, France) and cast in type IV gold alloy (J.F. Jelenko &
Co, Armonk, NY). The custom Locator abutment was used to
im- prove the position of the attachment system in relation to
the mandibular metal-ceramic FPDP, allow for favorable
restora- tive space for the maxillary IAORPDP acrylic teeth,
and follow the same path of insertion of the IAORPDP (Fig
13).
The maxillary IAORPDP framework, mandibular metal-
ceramic FPDP from #22 to #27, and custom Locator
abutment
were tried in and adjusted. The artificial denture teeth needed to treat such individuals with prosthodontic
(Trubyte Portrait IPN; Dentsply) were arranged in a type II
baseplate wax (TruWax; Dentsply) (Fig 14). The maxillary
IAORPDP was tried in, and the esthetics and phonetics were
evaluated. The prosthesis was processed with a heat-activated
acrylic resin material (Lucitone 199; Dentsply). After the
deflasking procedures, the occlusion was adjusted, and the
prosthesis was finished and polished (Fig 15).
The mandibular metal-ceramic FPDP was cemented with
a resin-modified glass-ionomer cement (Fuji II LC, GC Int,
Tokyo, Japan). The custom Locator abutment was placed and
torqued to 35 Ncm2. The maxillary IAORPDP was delivered
with minor occlusal adjustments, and the Locator aluminum
housing (Zest Anchors) was picked up intraorally with a
chem- ically activated acrylic resin (ERA PickUp; Sterngold,
Attle- boro, MA) (Figs 16–19).
Oral hygiene instructions were given, and the patient was
instructed to remove the prosthesis at night and clean his
teeth and the IAORPDP with a nonabrasive paste and soft-
bristled brush. Daily applications of a nonaqueous solution of
topical 0.4% stannous fluoride gel27 were prescribed, and the
patient was scheduled for a 6-month follow-up appointment.

Discussion
Careful patient selection is very important for successful den-
tal implant treatment. The indications of dental implant treat-
ment are based on several local and systemic factors, which
impact bone or soft tissue health. These factors should be
care- fully evaluated before proceeding to any dental implant
ther- apy to predict the success of the overall treatment
outcome.20,22 Prosthodontic rehabilitations with implant
therapy have been successful treatments for special care
patients, including in- dividuals with Down syndrome. 19,21-25
Oral hygiene and the level of intellectual disabilities should
be assessed.3,4,7-9 For patients with Down syndrome,
increasing the OVD with an IAORPDP has been achieved
successfully to compensate for malocclusion.13-16 It shows a
clinically acceptable degree of comfort and esthetic
improvement, which can change their quality of life.9,11,12,28
People with Down syndrome should be treated as
nonsyndromic patients based on the available re- cent
evidence. Reinforcement of oral hygiene instructions for
individuals with Down syndrome is also a key factor in the
treatment outcome.3,4,7

Conclusion
Patients with Down syndrome should be carefully assessed
and treated accordingly. This report is presented to
demonstrate that dental implants should not be eliminated
from the treatment op- tions for them. In such cases, good
oral hygiene and long-term maintenance are essential to the
overall success. In addition, RPDPs are a valid treatment
option for mildly to moderately intellectually disabled
patients with Down syndrome. This pa- tient tolerated his
new OVD and followed every instruction given to him, which
should allow for an acceptable long-term outcome and
prognosis. Although special care and more expe- rience are
rehabilitation in conjunction with dental implant placement, Prosthodont 2005;18:132-138
this report shows a promising outcome can be achieved.

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