CLINICAL REPORT

Implant therapy for a patient with Down syndrome and oral

habits: A clinical report
Paola C. Saponaro, DDS, MS,a Toru Deguchi, DDS, MS, PhD,b and Damian J. Lee, DDS, MSc

Down syndrome (DS) is a ge- ABSTRACT

netic condition that results
This clinical report describes prosthodontic therapy with an implant-supported partial fixed dental
from a chromosomal abnor- prosthesis for a patient with Down syndrome and concomitant oral habits, including tongue
mality, especially chromosome thrusting and thumb sucking. (J Prosthet Dent 2016;-:---)
21, which results in physical
and dental challenges.1 Orofacially, features such as a
flattened face and occiput, slanting eyes with prominent
epicanthic folds, underdevelopment of the middle third
of the face, and prognathism exist.2 Dental characteristics
such as delayed development and eruption of both
dentitions, hypodontia, microdontia, short roots, hypo-
calcification and hypoplastic defects, and occlusal prob-
lems exist for patients with DS, along with mouth
breathing.3 High incidences of severe early onset peri-
odontal disease with reduced resistance to infection and
healing have also been reported for patients with DS.1
Despite their physical and mental disabilities, life ex-
pectancy of individuals with DS ranges from 50 to 60
years of age, posing new challenges for dental providers
to maintain optimum oral health care and restore func-
tion when the need arises. Because of their prevalence for
periodontal disease,4 DS patients’ need for tooth
replacement may be a common clinical situation, and
dental implants may be used as a restorative option.5
However, documentation for dental implant therapy for
patients with special needs such as those with DS has
been limited.6-12
Oral habits and malocclusion are common in those
with DS. Soares et al13 described a high incidence of
open occlusal relationships and anterior and posterior
reverse articulation associated with sucking habits among
patients with DS. One oral habit that has rarely been
described for patients with DS is tongue thrusting. This is
a habit reported mainly in the orthodontic literature,
where reverse articulation by flaring of the mandibular,
anterior teeth and/or open anterior relationships occur
due to prolonged and constant intermittent forces of the
tongue pushing against the dentition.2,14 This type of
malocclusion can be corrected with conventional ortho-
dontic therapy and incorporation of habit-changing de-
vices, such as a tongue crib, to prevent protruding the
tongue against the teeth. However, when periodontal
disease is involved, the consequence of such a habit can
be more detrimental, causing severe mobility and accel-
erated bone loss and is not conducive to orthodontic
therapy for correcting the flaring.14 To replace these
teeth, dental implant therapy may be needed; however,
the long-term effects of oral habits on dental implant
restorations where nonaxial forces maybe loaded15 have
not been widely documented or available in the dental
published reports.
This clinical report describes an implant therapy
provided for a patient with DS and oral habits.
CLINICAL REPORT
A 27-year-old white woman with DS presented with
her mother to the Advanced Prosthodontics Clinic at
The Ohio State University College of Dentistry. They

a
Clinical Assistant Professor, Division of Restorative Science and Prosthodontics, The Ohio State University College of Dentistry, Columbus, Ohio.
b
Associate Professor and Director, Advanced Education in Orthodontics Program, Division of Orthodontics, The Ohio State University College of Dentistry, Columbus, Ohio.
c
Assistant Professor and Director, Advanced Education in Prosthodontics Program, Division of Restorative Sciences and Prosthodontics, The Ohio State University College
of Dentistry, Columbus, Ohio.

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Figure 1. Patient. A, Frontal view. B, Profile view.

complained that “her front teeth are so loose we are

afraid that they’ll fall out or get infected”. The patient had
a history of hypothyroidism, gastroesophageal reflux
disease, depression, obsessive-compulsive disorder, and
sleep apnea. Her dental history included a thumb-
sucking habit that developed during her teenage years,
a tongue thrusting habit, and a history of orthodontic
treatment completed approximately 10 years earlier. The
patient reported brushing her teeth twice a day and did
not floss. Extraorally, the patient displays a short middle
face with a prognathic mandible (Fig. 1). Intraorally, the
patient had macroglossia, missing the maxillary third
molars, maxillary right lateral incisor, and mandibular
first premolars (oligodontia), anterior open relationships,
and posterior reverse articulation (Fig. 2). The anterior 6 Figure 2. Frontal view, maximum intercuspation position.
teeth on the mandibular arch showed severe root
resorption with mobility grade 3, according to Miller’s uncovering the implants, a definitive impression was
classification16 (Fig. 3). Periodontally, she exhibited made using the closed tray transfer technique with light-
generalized chronic plaque-induced gingivitis with min- and heavy-body polyvinyl siloxane and a customized tray.
imal bone loss overall. A working cast was fabricated, and a metal ceramic partial
After the examination was completed and diagnostic fixed dental prosthesis was fabricated using screw reten-
casts obtained, it was determined that the patient’s tion. However, because of the angulation of the right
mandibular anterior dentition had a poor prognosis, and a central implant, screw retention was not possible, and a
treatment plan that included implant-supported partial customized milled abutment in titanium was fabricated to
fixed dental prosthesis with 3 implants was presented. allow cement retention for the center implant (Fig. 5). The
After extractions of the mandibular incisors and left metal framework was tried for passivity, and feldspathic
mandibular right canine, 3 endosseous implants (TSV porcelain was applied. An anterior open relationship was
3.7×13 mm; Zimmer Dental) were placed immediately on maintained for the prosthesis, and no protrusive in-
the mandibular left lateral, right central, and right canine terferences were present (Fig. 6). The abutment and
sites under local anesthesia (Fig. 4). The surgery was prosthesis was tightened to 25 Ncm, and medical silicone
performed using a 2-stage approach, and the sites were adhesive (Factor II, Inc) was used for the center implant
allowed to heal for a period of 4 months. Two weeks after (Fig. 7). The patient was very satisfied with the appearance

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Figure 3. Periapical radiographs of mandibular anterior dentition.
Figure 4. Implant surgery.
of the prosthesis, and oral hygiene instruction was given
to the patient and her mother.
At presentation, this patient exhibited high-
functioning motor and social skills; therefore, providing
care for this patient did not present any difficulties. The
patient’s parents were present at all appointments;
however, during clinical procedures, the patient felt
comfortable without her parents chairside. The patient
exhibited sufficient maturity and understanding to
effectively cooperate during all surgical and prosthetic
phases of her treatment. However, instructions and
reinforcement for the maintenance and success of her
treatment were emphasized to all parties at the end of
each appointment. The patient was evaluated at 2 weeks
and at 6 months (Fig. 8), and the prosthesis showed
excellent stability and periimplant gingival condition.
After 21 months in function, the patient did not exhibit
any prosthetic complication and had followed the hy-
giene and maintenance protocols as established.
Saponaro et al
3
Figure 5. Framework evaluation.
DISCUSSION
Reports of implant therapy in individuals with DS are
limited mainly to case reports and case pre-
sentations.6,10-12 Several authors have described the use
of implant therapy to restore defects ranging from
single-tooth to complete arch restorations for the
maxilla and mandible, with favorable functional, pho-
netic, and esthetic outcomes.3,11 However, maintaining
meticulous oral hygiene and patient compliance are
challenging. Informed caregivers must aid the patient in
their daily oral hygiene practices and raise the patient’s
awareness of their role in overall dental rehabilita-
tion.1,6,10-12 An increased risk of implant failure in pa-
tients with DS8 and the suitability for implant placement
in these patients have been widely questioned because
of osteoporotic alveolar bone quality, delayed wound
healing, reduced resistance to infection, macroglossia,
and a tendency to poor compliance.10,11 In contrast,
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Figure 6. Definitive prosthesis frontal view. Figure 7. Definitive prosthesis occlusal view.

another study of patients with special needs, including 3

patients with DS, reported no implant failures.12 The
risks of soft tissue complications are higher among pa-
tients with neurological disabilities.3 However, no dif-
ferences in degree of soft tissue inflammation between
patients who could not maintain ideal oral hygiene and
a group that could provide for their own oral care have
been reported.3 Ekfeldt et al6 reported the cumulative
survival rate of 85.8% for implants placed in individuals
with congenital and neurological disabilities after 5 to 10
years. Even though the 10-year results are lower than
the outcomes described for healthy, nonsyndromic pa-
tients in other systematic clinical reviews, this type of
treatment can be properly planned and offered with
relatively favorable outcomes. However, additional
documentation of long-term follow-up is imperative for
this population subset.
The long-term effect of oral habits such as tongue
thrusting on dental implants and restorations is un-
known. Previous reports of screw loosening and loss of
preload may have been associated with nonaxial loading,
Figure 8. Frontal view of restored patient.
and tongue thrusting can place repeated, intermittent
force on the restoration.15 For this particular patient, the
restoration was designed to be retrievable and allow for Simple guidelines and protocols for treating and
periodic removal and examination. However, the labial educating patients with special needs with dental im-
inclination of the mandibular bone in the anterior region plants must be established. Caretakers must be fully
with prognathism may complicate the alignment of the involved in the reinforcement of oral hygiene, as the
implant to allow screw access. Use of cement- and screw- dental practitioners cannot verify whether postoperative
retained methods combines the advantages of retriev- instructions are followed appropriately. Easily compre-
ability and optimum esthetics,17 and for this patient, the hendible materials and methods can benefit both patient
design of the 5-unit partial fixed dental prosthesis and caregiver education.
allowed for the screw retention of the terminal abut- Concomitant orofacial stimulation or myofunctional
ments and cement retention of the center abutment, therapy has been suggested as early onset dental inter-
where flexing is predicted the most, and the prosthesis vention for patients with DS to improve tongue position
was kept out of occlusion and without any protrusive and protrusion, reduce mandibular prognathism and
interferences to minimize the possibility of prosthetic correct the anterior open mouth habit.5 Other benefits of
complications. New developments in angled18 screw- this type of intervention include improved swallowing
access locations may help patients with DS if retrieval and mastication. Severe malocclusion and oral dysfunc-
becomes necessary. tion are common in patients with DS who did not receive

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early corrective postural intervention. The use of orthotics
has been suggested to improve comfort, ameliorate
dyskinetic movements and bruxism, and provide orofa-
cial stimulation to strengthen perioral and oral muscu-
lature.5 One difficulty the clinician could experience while
treating a patient with DS with implant therapy is
providing even occlusal contacts with anterior guidance.
In terms of skeletal development, swallowing is
compromised as the tongue must protrude to generate
an oral seal, and in conjunction with mouth breathing,
disruption of the respiration-deglutition sequence leads
to tongue thrusting.1 In addition, it may occur that the
patient easily protrudes the mandible because of the
laxity of the temporomandibular joint ligaments to avoid
the discomfort associated with the severe malocclusion.
In this report, the patient presented with an anterior
open relationship, which eliminated any protrusive in-
terferences; however, the patient did demonstrate lateral
excursive interferences on her natural dentition.
SUMMARY
This report described a successful prosthodontic therapy
for a patient with DS with oral habits, suggesting that
these patients should be treated with appropriate care,
regardless of their physical or neurological condition.
However, because of the complex nature of patients with
DS, further long-term investigation in implant therapy
and oral rehabilitation is needed.
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Corresponding author:
Dr Damian J. Lee
Division of Restorative Sciences and Prosthodontics
The Ohio State University College of Dentistry
305 W. 12th Ave, Rm 2039L
Columbus, OH 43210
Email: lee.6221@osu.edu
Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
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