From practitioner to practitioner - ZZI 01/2017

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

The teeth in regio 11, 12, 15, 21, 22, 24, 25, 26, which required prosthetic-restorative treatment in the concept, had to be prepared and impressed in several sessions, as the patient was not able to tolerate treatment sessions lasting longer than approx. 60 minutes in each case. A special challenge was to produce the impression due to the unusual impression mould as well as the excessive faucial reflex. In order not to endanger the patient’s confidence in the dental team, the process of taking impressions was carried out in several sessions with interim interruptions. The temporary dentures were incorporated with cemented plastic crowns for these teeth.

Clinical and radiological check-ups were performed at regular intervals. In 2 of these check-ups the patient presented without her temporary dentures which she had lost. The patient subjectively stated that she did not feel any pain at the vital teeth, which coincides with the general disease situation.

For the supra-constructions (13, 14, 16, 23, 35, 45) a model scan with following transmission of data to the GC Tech Millingcenter (Belgium) requiring precise milling was performed. Based on these data the one-piece screw-retained chromium-cobalt crowns were manufactured in the laboratory (Neubauer & Ebenberger zahntechnisches Labor GmbH, Graz, Austria) and blended with GC MC ceramic. The material selected in combination with milled crowns offers a higher stability and resistance to stress in comparison with full-ceramic supra-constructions. Due to the patient’s existing parafunctions the risk of fractures is visibly reduced. In comparison with a cemented treatment the screwed supra-constructions are additionally easier to remove and clean in later recalls. When inserting the supra-construction in regio 23 the patient suffered a tussive irritation and swallowed this supra-construction, so that it had to be produced anew. In further consultations the crowns were inserted in regio 11, 12, 15, 21, 22, 24, 25, 26 (e.max, Ivoclar Vivadent, Liechtenstein) (Fig. 9–11). Here, too, it was noticed that the patient initially had difficulty in tolerating unusual treatment steps, but accepted the treatments after adapting.

The teeth in regio 36, 46 were filled with temporary filling material. It was planned to insert one onlay (regio 36) as well as one endocrown (regio 46). Due to the patient’s excessive faucial reflex the dental team refrained from making conventional impressions. Instead a digital intraoral scan (Cerec Omnicam, Sirona Dentsply) was performed (Fig. 12, 13), which the patient tolerated without any problems. No faucial reflex or subjective impeded breathing were registered. According to the scan data the dental restorations (36, 46) were manufactured in hybrid ceramic (Vita Enamic, VITA Zahnfabrik, Bad Säckingen, Germany) on the chair side and positioned intraorally with RelyX Unicem (3M ESPE Dental Products, St. Paul, USA).

Figure 14 exhibits the final radiological diagnosis after inserting the dental restorations in regio 11, 12, 13, 14, 15, 16, 21, 22, 23, 24, 25, 26, 35, 36, 45, 46 as well as the clinical end situation (Fig. 15, 16).

The patient and her relatives were highly satisfied with the aesthetic appearance and functionality of the new dental prosthesis.

Summary

As in the case of other systemic diseases Down syndrome patients suffer from impaired oral health. Due to the increased life expectancy of impaired persons [19] in the last decades, it is among others, important that these patients are granted discrimination-free access to medical and dental therapies. Down syndrome patients with or without mental retardation should be able to benefit from high-quality treatments in aesthetic and functional aspects [9].

Based on the case report it is shown that a complex therapy with dental implants in combination with a prosthetic restoration can be performed at a Down syndrome patient.

The risk-benefit ratio shall be assessed upfront. In particular the oral symptoms of Down syndrome patients as well as their cooperation must be taken into account. Compliance can be tested during initial control examinations with an increased duration of treatments. In planning the therapy options it is also necessary to clarify whether hygiene measures can be assumed by patients with support from their social environment.

Due to increasing acceptance and willingness to cooperate among these patients in dental procedures and the positive development of oral hygiene it was possible to plan and implement a complex therapy form under primary consideration of the oral manifestations.

The shorter therapy sessions as against patients without impairments require a longer treatment period and higher personnel costs. It is furthermore necessary to adapt treatments individually to the patient’s respective constitution, thus making it difficult to plan the respective appointments in the long-term.

According to Holthaus a treatment in general anaesthesia or sedation is often required and general anaesthesia is administered in 40 of 100 cases [6]. By gently familiarising the patient with therapy procedures it was possible to omit anaesthesia despite the complexity.

In comparison between conventional impression technique (material: Polyether, Impregum Soft, 3M ESPE) and digital impression (Cerec Omnicam, Sirona Dentsply) it was shown that the digital scan is complication-free and required no adaptation phase. In contrast to conventional impression techniques the scan can be interrupted and continued at any time. Faulty scans which may arise by a moving tongue, coughing reflex, unrest etc. during recording can be subsequently deleted and do not play a role in calculating the digital impression. In our opinion, a digital intraoral scan should thus be given preference in particular in the case of impaired persons.

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