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Growth and development of hard tissues in Down syndrome is marked by retardation and increased phenotypic variability. Retardation in skeletal maturation and skeletal growth is most severe during early childhood. Skeletal maturation and growth during the circumpubertal years are associated in a normal way with other aspects of pubertal development. Various characteristics of dental development are abnormal in Down syndrome. The effect of the trisomic condition on dental eruption and teeth size is somewhat less severe than its effect on skeletal maturation and growth of stature. The concept of increased developmental instability in Down syndrome is discussed.