Oral Rehabilitation with Implant-Retained Overdenture in a

Patient with Down Syndrome

Nuray Yilmaz Altintas, DDS, PhD,1 Serdar Kilic, DDS, PhD,2 & Subutay Han Altintas, DDS, PhD3
1
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey
2
Private Practice, Kocaeli, Turkey
3
Department of Prosthodontics, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey

Keywords
Implant-supported prosthesis; intellectual
disability; chromosome disorder.
Correspondence
Nuray Yilmaz Altintas, Department of Oral
and Maxillofacial Surgery, Faculty of
Dentistry, Karadeniz Technical University,
61080 Campus Trabzon, Turkey.
E-mail: dtnurayilmaz@yahoo.com
Previously presented at the 7th International
Oral & Maxillofacial Surgery Society Congress
(ACBID), 2013, Turkey.
The authors deny any conflicts of interest.
Accepted December 1, 2016
doi: 10.1111/jopr.12596
Abstract
Down syndrome, known as trisomy 21, is the most common chromosomal disorder.
The disorder affects mental and systemic development as well as oral structure,
including dental anomalies, high susceptibility of periodontal disease, and poor
quality of alveolar bone. This report presents a case of dental rehabilitation by
means of dental implants of a patient with Down syndrome. Two titanium dental
implants were placed in the maxilla, and three titanium dental implants were
installed in the mandible. One implant was lost during the osseointegration period.
The prosthetic rehabilitation was performed with implant-retained maxillary and
mandibular overdentures with the Locator attachment system. After a 2-year
follow-up period, the patient was doing well, and all implants were clinically stable
with no signs of bone loss or inflammation. The present study emphasizes that
implant-retained overdentures with Locator attachment system could be a
therapeutic option even for patients with Down syndrome. This therapy prevents
crestal bone loss around the implants, improves functional and esthetic outcomes,
and provides optimum oral hygiene for patients with mild mental impairment.
Careful patient selection and education of patients and caregivers are essential
considerations for a successful and safe treatment with dental implants in Down
syndrome patients.

Down syndrome is a genetic disorder also known as trisomy patients, this is not associated with poor oral hygiene alone.
21 and is the most common aneuploid condition.1 It is charac- The etiology of periodontal disease in Down syndrome differs
terized by various physical, mental, and medical features such
as intellectual disability, motor disorder, and
dysmorphologies, and cardiovascular, immunological,
hematological, respiratory, neurological, and musculoskeletal
abnormalities.2 The degree of intellectual disability in Down
syndrome patients is variable, ranging from mild (IQ: 50 to
70) to moderate (IQ: 35 to 50) to severe (IQ: 20 to 35).3 Oral
traits of Down syndrome can man- ifest as a hypoplastic
maxilla with a high, short, and narrow palate; mild
mandibular prognathism, macroglossia, and dental anomalies
such as taurodontia, hypodontia, or partial anodontia; and a
delayed or abnormal sequence of eruption.4 Several stud- ies
have demonstrated that individuals with Down syndrome
exhibit an increased prevalence and greater severity of peri-
odontal disease compared with age-matched healthy controls
or other groups of special-care patients. 5-7 Moreover, alveo-
lar bone loss, especially in the mandibular anterior region, has
been reported at early ages in patients with Down syndrome. 8
Although patients with Down syndrome experience more fre-
quent and more severe periodontal disease compared to other
Journal of Prosthodontics 00 (2017) 1–5 ⓍC 2017 by the American College of 1
Prosthodontists
from that in healthy subjects, and it has been suggested that
im- munological deficiency contributes to the etiology of
this rapid progressive disease.9,10 This chronic progression of
periodontal disease results in spontaneous loss of teeth.4
The basic dental treatment of patients with Down
syndrome should be the same as that of healthy individuals,
with prevent- ing the loss of remaining teeth as the first
priority.6 Edentulism is frequently observed among disabled
patients, and prosthetic treatment is more complicated in
these compared to healthy patients, because of anatomic
variations and problems with pa- tient cooperation.11,12 In the
last few decades, the use of dental implants has become a
common treatment modality for replac- ing missing teeth in
both fully and partially edentulous patients and also in
disabled individuals.12-14 Dental implant therapy can also be
an alternative rehabilitation procedure in cooper- ative
patients with Down syndrome and moderate mental im-
pairment. The use of implants in patients with Down
syndrome has previously been reported, and the results
indicate that these patients can be successfully treated with
dental implants.15-20
In recent reports, Down syndrome patients were
rehabilitated with dental implants for single crown
restorations, full-arch fixed implant-supported prostheses,
and overdentures with bar attachments.15-20 Lustig et al
described the oral rehabilitation

2 Journal of Prosthodontics 00 (2017) 1–5 ⓍC 2017 by the American College of

Prosthodontists
 Altintas et al Implant Therapy in a Patient with Down Syndrome

of a 16-year-old patient with Down syndrome with three rehabilitation with an implant-retained overdenture prosthesis.
single crowns supported by dental implants. They mentioned In addition to
that the dental implant therapy could be a promising
beginning in pa- tients with Down syndrome.15 Oczakir et al
presented a special- care patients case series study, in which
three patients with Down syndrome were treated with
implant-supported overden- tures with bar attachments. The
survival rate of the loaded implants in all special-care patients
was 100%.16 Soares et al presented an immediately loaded
single dental implant ther- apy with 4 years of follow-up in a
Down syndrome patient. 17 Van de Velde et al treated a patient
with Down syndrome with immediately loaded fixed dental
prostheses (FDPs); however, two of five implants were lost
within 3 months.18 Riberio et al stated that Down syndrome
patients could be considered candidates for dental implant
therapy according to the suc- cessful treatment outcome of a
Down syndrome patient with full fixed implant-supported
prostheses.19 In another report, Saponaro et al described a
successful prosthodontic therapy with an implant-supported
partial FDP for a patient with Down syndrome without any
surgical and prosthetic complication.20
Examining all the above-mentioned literature leads us to
believe that treatment with dental implants in Down syn-
drome patients can be successful; however, maxillary and
mandibular implant-supported overdentures with Locator at-
tachment system therapy were not described in the literature
for Down syndrome patients. Therefore, the present report
de- scribes the use of osseointegrated implants in a patient
with Down syndrome with an implant-retained overdenture
prosthe- sis with Locator attachment.

Clinical report
In March 2012, a 37-year-old female patient was referred to
the Department of Prosthodontics and Department of Oral
and Maxillofacial Surgery at the Karadeniz Technical
University, Trabzon, Turkey, with a principal symptom of
tooth mobility. Her medical history included moderate Down
syndrome and mild mental impairment; however, she was
cooperative, able to speak, sat for the dental examination
without needing se- dation, and was able to perform daily
tasks. She exhibited no medical problems associated with
Down syndrome. At physi- cal examination, skeletal features
included a flattened back of the head, with one eyelid slightly
droopy, maxillary hypoplasia, mandibular prognathism, and
pseudo class-III malocclusion.
Intraoral examination revealed that the maxillary
permanent teeth were lost. Generalized periodontitis and
severe mobil- ity were assessed in the remaining teeth in the
mandible. The patient exhibited pseudomacroglossia due to
hypotonic tongue. Oral mucosa exhibited a normal
appearance. Radiolog- ical examination revealed severe bone
loss around the teeth and generalized advanced bone loss
with an atrophic maxilla and mandible (Fig 1). Laboratory
examinations including complete blood cell count and blood
chemistry produced results within normal limits.
A multidisciplinary approach was adopted to manage the
case successfully. A comprehensive treatment plan was
formulated that included extraction of all remaining teeth and
 Implant Therapy in a Patient with Down Syndrome Altintas et al

Figure 1 Preoperative panoramic radiograph with generalized

periodon- titis and alveolar bone resorption.

Figure 2 Postoperative panoramic radiograph after implant placement.

panoramic radiographs, cone beam computerized

tomography (CBCT) was used to analyze and plan the future
implant sites. The patient’s caretakers were informed about
the risk of treat- ments. The patient and her caretaker signed
a written informed consent form. In the first procedure of
the treatment plan, all teeth were extracted under local
anesthesia. Three implants in the mandible and two implants
in the maxilla were planned due to the insufficient bone as
detected by CBCT. Three months later, three dental implants
(Zimmer Dental, Inc, Carlsbad, CA) were placed with an
insertion torque of 35 Ncm in the mandibu- lar canines and
left first incisor regions under local anesthe- sia. All
surgical procedures were performed in two sessions. Two
dental implants in the canine region in the maxilla were
placed stable 2 weeks later (Fig 2). No bone augmentation
was needed. Antibiotic therapy (Augmentin;
GlaxoSmithKline, Re- search Triangle Park, NC) and
chlorhexidine mouth rinse were started and maintained after
surgery for 7 days. The patient did
not use any interim prostheses during the healing period.
After a submerged healing period of 3 months, the
implants were uncovered. All implants were stable except
for one in the midline of the mandible. Due to the lack of
osseointegration, this implant was removed, and curettage
was performed; how- ever, it was not replaced with a new
implant, as the existing alveolar bone was insufficient for
implant placement. Together with prosthetic consultation,
the authors decided that two dental implants would provide
adequate retention.
Healing abutments were removed as soon as the adjacent
soft tissues had healed. Locator abutments were inserted
(Zest Anchors) with the help of an abutment driver and
tightened to 30 Ncm with a torque wrench. Preliminary
impressions were

Figure 3 Extraoral views of dentures.
made for a custom-made tray using irreversible hydrocol-
loid. Definitive impressions of both arches were made using
polyether impression material (Impregum Duo Soft; 3M
ESPE, St. Paul, MN) with custom trays after placement of
Locator impression copings. The black processing patrix caps
with the metal housing were processed into the denture base
using the indirect laboratory technique, and maxillo-
mandibular relationship records were obtained. The casts
were mounted in an articulator, and the artificial teeth were
arranged in wax for trial evaluation. The positions of the
artificial teeth and occlusal vertical dimension were evaluated
intraorally, and the neces- sary corrections were made. The
waxed trial dentures were processed in a heat-polymerized
denture base resin, and the patient was given blue patrix
inserts for the initial few months. The prosthetic treatment
was performed with implant-retained maxillary and
mandibular overdentures (Fig 3). The patient and her
caretaker were highly satisfied with the results. They were
instructed about the importance of good oral hygiene and
educated in the care of dental implants and removable
prosthe- ses. Dental water jet was recommended instead of
conventional toothbrush and cleaning the prosthesis using a
soft brush with a denture cleaning agent. The patient and
caregiver were advised to remove the prostheses while
sleeping and store in a cleaning solution.
Two-year follow-up revealed an optimal functional and es-
thetic rehabilitation with continued success (Fig 4). No fun-
gal or bacterial infections were detected in this patient with
Down syndrome. The patient continues to be seen at regular
Journal of Prosthodontics 00 (2017) 1–5 ⓍC 2017 by the American College of
Prosthodontists
Figure 4 Panoramic view of patient at 2-year follow-up.
follow-up visits. In her recall visits, the radiologic and
intraoral examinations are conducted, and implants,
prostheses, and oral hygiene maintenance assessed.
Discussion
Partial or complete edentulism may be diagnosed due to prob-
lems such as severe periodontal disease and congenitally
miss- ing teeth in patients with Down syndrome. 4-6 We
observed severe periodontitis and bone loss in our patient at
initial ex- amination, as expected from the dental literature.
The patient had mild mental impairment but was very
enthusiastic about dental implants and reported that she
wished to be attractive with her new prosthesis. The final
treatment option was extrac- tion of all teeth and
rehabilitation with dental implants. Due to the inadequate
alveolar bone height, width, and lip support, an implant-
retained overdenture was selected. Inadequate soft and hard
tissue would cause esthetic and biomechanical problems for a
full-arch implant-retained fixed prosthesis. An implant-
retained overdenture may be more esthetic than an implant-
retained FPD, especially in the maxillary arch when the soft
tissues of the face need additional support as a result of bone
loss.21 Bone loss affects the appearance of the lower third of
the face. Implant-retained overdentures often provide lip and
soft tissue supports compared with an implant-retained fixed
pros- thesis. For the laboratory, to replace the soft tissue drape
and also to create pink interdental papilla is easier with an
implant- retained overdenture than with a fixed restoration.
Therefore, when there is lack of soft and hard tissues to
support the fa- cial tissue by the buccal denture flange, a fixed
prosthesis is less preferable.22 After severe bone loss,
biomechanical prob- lems are more unfavorable due to the
increased interocclusal space. An increase in interocclusal
space increases the forces on restoration and implants, as
cantilevered or angled loads.23 An implant-retained
overdenture may limit lateral movements and direct more
longitudinal forces. This may prevent crestal bone loss
around the implants.23 Furthermore, removable overden- ture
treatment with Locator attachment systems might be more
comfortable for oral hygiene, compared with a fixed implant
prosthesis and implant-retained overdenture with bar systems,
for patients with Down syndrome.
As described previously, using dental implants not only
provides function but also preserves existing bone and plays
an important role in resorbed alveolar bone in particular. 14
High patient satisfaction was obtained with an implant-
3
retained mandibular maxillary overdenture in this case. To
the authors’

4 Journal of Prosthodontics 00 (2017) 1–5 ⓍC 2017 by the American College of

Prosthodontists
knowledge, the case is the first in the English-language lit- fissure that weakens the prosthetic material. Denture fractures
erature using an implant-retained overdenture with a Locator usually occur outside the
attachment system in Down syndrome patients.
The outcome of our treatment corresponded with isolated
clinical reports in the literature concerning patients with
Down syndrome.15-20 Lustig et al published the first clinical
report of rehabilitation of a Down syndrome patient with
dental implant in 2002. A 16-year-old boy was successfully
rehabilitated with dental implants, and the case represented a
promising beginning for patients with Down syndrome.15 The
osteoporotic bone type observed in patients with Down
syndrome has been reported to affect the success of the
implant compared with healthy indi- viduals. One of the four
implants was loosened in that report, similar to our patient
and other published studies.18,19,24
Oral health education and motivation of patients with
Down syndrome, and as well as parental education, are very
important. These patients should be examined at least every 6
months, or more often, if specific problems arise. 4 Sakellari et
al reported that patients with Down syndrome were unable to
perform proper and adequate plaque removal despite good
personal and parental levels of cooperation and compliance
with frequent visit schedules.6 Interestingly, Zigmond et al
pointed out that a preventive dental program was insufficient
to slow the progres- sion of periodontitis in Down syndrome
patients.25 Another study concluded that periodic dental care
was not effective in controlling further periodontal disease in
special-care patients with Down syndrome.26 Therefore, risk
factors concerned with tendencies to periodontal disease
should be considered before making decisions about dental
implant therapy in patients with Down syndrome.
In the present report, dental implants were placed under lo-
cal anesthesia, because the patient had mild mental disability
and was very cooperative during the examinations. Soares et
al placed the implants in patients with Down syndrome un-
der sedation.17 However, intravenous (IV) sedation in a
patient with Down syndrome may involve a high risk of low
peripheral oxygenation. Yoshikawa et al investigated 1213
patients with disabilities after IV sedation. They determined
that the most problematic group with the highest risk of poor
sedation con- trol during dental treatment was patients with
Down syndrome, compared to patients with disabilities such
as cerebral palsy and mental retardation. Low SpO 2 during
sedation is associ- ated with sleep apnea and upper-airway
obstruction due to the presence of a large tongue.27 Careful
intraoral examination and close monitoring of patients with
Down syndrome is therefore very important during IV
sedation.
Poly(methyl methacrylate) is the most commonly used ma-
terial for fabrication of complete dentures. Despite its popu-
larity in satisfying esthetic demands, it is still far from ideal
in performing the mechanical requirements of a prosthesis,
and thus may cause prosthetic failure when there are
excessive parafunctional and/or functional forces.28 Fracture
in a den- ture often results from two different types of force:
flexural fatigue or impact. Failures due to the flexural fatigue
can be ex- plained by the development of microscopic cracks
in areas of stress concentration such as a large frenal notch or
the contact area between implant and overdenture. With
continued loading, these cracks fuse to an ever-growing
mouth from impact as a result of a sudden blow or acciden- microflora in adults with Down’s syndrome. J Clin
tal dropping while cleaning, coughing, or sneezing .28 Periodontol 2001;28:1004- 1009
Metals and metal alloys can be added in the form of wires,
plates, or fillers into the complete dentures to improve
fracture resis- tance, dimensional stability, weight, and
retention.29 Shimizu et al have described the use of cobalt–
chromium bases in max- illary dentures and indicated that
this approach reduces func- tional deformations.30
Furthermore, the internally suspended metal framework is
indicated for implant overdentures and can be readily
designed to accommodate individual attachments.29 The
present study involved dental implant-retained over-
dentures with cobalt–chromium framework, which
minimize the denture fracture risks, and maximize the
prosthetic re- tention in a Down syndrome patient with
mild mental impairment.

Conclusion
This report has shown a successful 2-year follow-up of im-
plant osseointegration and prosthodontic therapy in a
patient with Down syndrome wearing a functional implant-
retained overdenture with Locator attachment system. The
final result indicates an improvement of hygienic
conditions and preven- tion of postrestorative crestal bone
loss with functional and esthetic optimization owing to the
overdenture treatment with the Locator system in a patient
with Down syndrome; however, special care and short-term
follow-up is needed in these patients due to the complex
nature of Down syndrome.

References
1. Khocht A, Janal M, Turner B: Periodontal health in
Down syndrome: contributions of mental disability,
personal, and professional dental care. Spec Care Dent
2010;30:118-123
2. Abanto J, Ciamponi AL, Francischini E, et al: Medical
problems and oral care of patients with Down syndrome: a
literature review. Spec Care Dent 2011;31:197-203
3. Bull MJ: Committee on genetics. Health supervision for
children with Down syndrome. Pediatrics 2011;128:393-406
4. Hennequin M, Faulks D, Veyrune JL, et al: Significance of
oral health in persons with Down syndrome: a literature
review. Dev Med Child Neurol 1999;41:275-283
5. Genco RJ, Loe H: The role of systemic conditions and
disorders in periodontal disease. Periodontol 2000
1993;2:98-116
6. Sakellari D, Belibasakis G, Chadjipadelis T, et al:
Supragingival and subgingival microbiota of adult patients
with Down’s syndrome. Changes after periodontal treatment.
Oral Microbiol Immunol 2001;16:376-382
7. Sakellari D, Arapostathis KN, Konstantinidis A:
Periodontal conditions and subgingival microflora in
Down syndrome patients. A case-control study. J Clin
Periodontol 2005;32:684-690
8. Modeer T, Barr M, Dahllof G: Periodontal disease in
children with Down’s syndrome. Scand J Dent Res
1990;98:228-234
9. Morgan J: Why is periodontal disease more prevalent and
more severe in people with Down syndrome? Spec Care
Dentist 2007;27:196-201
10. Reuland-Bosma W, van der Reijden WA, van
Winkelhoff AJ: Absence of a specific subgingival
11. Ekfeldt A, Zellmer M, Carlsson GE: Treatment with
21. Misch CE: Mandibular and maxillary implant overdenture
implant-retained fixed dental prostheses in patients
design and fabrication. In Misch CE (ed): Dental Implant
with
Prosthetics (ed 2). St. Louis, Mo, Mosby, 2015, pp. 757-759
congenital and acquired neurologic disabilities: a prospective
22. Barao VAR, Delben JA, Lima J, et al: Comparison of
study. Int J Prosthodont 2013;26:517-524
different designs of implant-retained overdentures and fixed
12. Romero-Perez MJ, Mang-de la Rosa M, Lopez-Jimenez J, et
full-arch implant-supported prosthesis on stress distribution
al: Implants in disabled patients: a review and update. Med
in edent- ulous mandible—a computed tomography-based
Oral Patol Oral Cir Bucal 2014;19:e478-482
three- dimensional finite element analysis. J Biomech
13. Branemark PI, Hansson BO, Adell R, et al: Osseointegrated
2013;46:1312-1320
implants in the treatment of the edentulous jaw. Experience
23. Misch CE: Treatment planning: force factors related to patient
from a 10-year period. Scand J Plast Reconstr Surg Suppl
conditions. In Misch CE (ed): Contemporary Implant
1977;16:1-132
Dentistry (ed 2). St. Louis, MO, Mosby, 2015, pp. 105-129
14. Senel FC, Altintas NY, Bagis B, et al: A 3-year follow-up of
24. Ekfeldt A: Early experience of implant-retainedprostheses
the rehabilitation of Papillon-Lefevre syndrome by dental
in patients with neurologic disabilities. Int J Prosthodont
implants. J Oral Maxillofac Surg 2012;70:163-167
2005;18:132-138
15. Lustig JP, Yanko R, Zilberman U: Use of dental implants in
25. Zigmond M, Stabholz A, Shapira J, et al: The outcome of a
patients with Down syndrome: a case report. Spec Care
preventive dental care programme on the prevalence of
Dent 2002;22:201-204
localized aggressive periodontitis in Down’s syndrome
16. Oczakir C, Balmer S, Mericske-Stern R: Implant-
individuals.
prosthodontic treatment for special care patients: a case series
J Intellect Disabil Res 2006;50:492-500
study.
26. Agholme MB, Dahllof G, Modeer T: Changes of periodontal
Int J Prosthodont 2005;18:383-389
status in patients with Down syndrome during a 7-year
17. Soares MR, de Paula FO, Chaves M, et al: Patient with
period. Eur J Oral Sci 1999;107:82-88
Down syndrome and implant therapy: a case report. Braz
27. Yoshikawa F, Tamaki Y, Okumura H, et al: Risk factors with
Dent J 2010;21:550-554
intravenous sedation for patients with disabilities. Anesth
18. Van de Velde T, Collaert B, De Bruyn H: Immediate loading
Prog 2013;60:153-161
in the completely edentulous mandible: technical procedure
28. Jagger DC, Harrison A, Jandt KD: The reinforcement
and clinical results up to 3 years of functional loading. Clin
of dentures. J Oral Rehabil 1999;26:185-194
Oral Implants Res 2007;18:295-303
29. Balch JH, Smith PD, Marin MA, et al: Reinforcement of a
19. Ribeiro CG, Siqueira AF, Bez L, et al: Dental implant
mandibular complete denture with internal metal
rehabilitation of a patient with down syndrome: a case
framework. J Prosthet Dent 2013;109:202-205
report. J Oral Implantol 2011;37:481-487
30. Shimizu H, Tsue F, Obukuro M, et al: Fracture strength of
20. Saponaro PC, Deguchi T, Lee DJ: Implant therapy for a patient
metal-based complete maxillary dentures with a newly
with Down syndrome and oral habits: a clinical report. J
designed metal framework. Int Chin J Dent 2005;5:35-38
Prosthet Dent 2016;116:320-324