From practitioner to practitioner - ZZI 01/2017

Dental implant rehabilitation of a patient with Down syndrome – interdisciplinary workflow

Introduction: Implant-supported prosthetic restorations exhibit greater patient satisfaction compared to removable prosthetic restorations. Systemic diseases such as Down syndrome can affect the treatment planning and therapy. Typical oral manifestations of this syndrome include macroglossia, dysplasia of maxilla, malocclusion of the teeth, crossbite, shortened roots and anterior open bite.

Material and methods: This case report describes therapeutic treatments of implant surgery and prosthetic rehabilitation in a patient with Down syndrome using digital treatment concepts.

Results: A complex treatment with dental implants in combination with a prosthetic restoration can be successfully carried out at a Down syndrome patient.

Discussion: It has been shown in this case study, the digital workflow and in particular digital impressions can facilitate treatment procedures in compromised patients.

Keywords: dental implants; implant prosthetics; digital impression; Down syndrome

Cited as: Theisen K, Lorenzoni M: Dental implant rehabilitation of a patient with Down syndrome – interdisciplinary workflow. Z Zahnärztl Implantol 2017; 33: 56–65

DOI 10.3238/ZZI.2017.0056–0065

Introduction

Down syndrome is the most frequently occurring chromosomal syndrome in neonates and the most frequent genetic reason for mental retardation [12]. It is a genetic disorder caused by the presence of all or part of a third copy of the complete chromosome 21. This syndrome is therefore also typically known as trisomy 21.

In 2013 approximately 10.2 million people with a manifested handicap were living in Germany, thus corresponding to 13 % of the total population [20]. At present precise data on the frequency of patients with Down syndrome cannot be found in current literature. According to an article published in 2011 about 60,000 persons with Down syndrome live in Great Britain [22].

Typical physiognomic and oral symptoms of the Down syndrome are multifaceted and include diverse manifestations. Macroglossia, dysplasia of maxilla, malocclusion of the teeth, crossbite, shortened roots and anterior open bite are found [16, 17]. Compared to the average population showing in 1–9 % the dental aplasia of at least one permanent tooth (with the exception of the third molars) [4], agenesis is a frequent symptom amongst Down syndrome patients. McMillan und Kashgarian report of an agenesis prevalence of 48 % [11], Orner of 53 % [14].

Further characteristics are a reduced dental melt and dentin strength in permanent dentition [5, 25] and hypocalcification [11, 14].

Down syndrome patients, compared with patients with or without mental retardation, exhibit a 60–100 % prevalence rate for periodontal diseases [1]. The occurrence of plaque-induced gingivitis can be raised by genetic combinations with a similar plaque accumulation [21]. The reason for the degeneration of tooth-supported structures is thus not exclusively insufficient oral hygiene [15], but moreover a generic disposition and immunological dysfunction are responsible for such a development [7, 24].

Contraindications for inserting dental implants include a variety of the symptoms, such as macroglossia, bruxism, and restricted ability to ensure oral hygiene or parafunctions. The faulty communication can also lead to non-observance of postoperative instructions. In the case of immediate treatment excessive stress may arise and favour a failure of the implant [23]. In various studies it is therefore discussed whether implants for this group of patients represent a promising therapy option. It was shown that Down syndrome patients have a reduced bone density in comparison with the average population which is most probably due to muscular hypotension [2, 3]. Ekfeldt et al. report of a 5- to 10-year survival rate of implants corresponding to 85.8 % in patients suffering from neurological and congenital impairments [8]. Clear advantages are seen in this group of patients by avoiding removable prostheses [13, 18].

According to Sadie et al. there are no universal treatment methods for all patients with or without Down syndrome so that a therapy should be aligned to the individual case taking all influencing factors into consideration [22]. Access to dental treatment is essential for people with Down syndrome and should be performed adopting a non-discriminating approach [9].

Case report

Diagnosis

The patient (27 years of age, Down syndrome) presented within the scope of an interdisciplinary consultation at the Medical University Graz, Division of Oral Surgery and Orthodontics (Austria). She suffers from mental retardation on the grounds of her underlying disease, is, however able to speak and perform simple daily tasks. The patient lives with her family and works at a special establishment for handicapped persons. No other physical diseases have been diagnosed. Tooth-maintaining measures were performed in the past at larger intervals.

The clinical intra- and extra-oral examination reflects symptoms which are typically seen in patients with Down syndrome. Insufficient oral hygiene and the resulting raised accumulation of plaque with loss of the periodontal attachment as well as moderate gingivitis were diagnosed. In addition, hypoplasia within the area of the midface and a visible macroglossia were identified. In addition the patient exhibited a hypersensitivity in the area of the palate triggering an excessive faucial reflex when gently touched besides hypersalivation which has already been described in the case of Down syndrome patients [10].

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