Dental Traumatology 2014; 30: 100106; doi: 10.1111/edt.

12081

Premature loss of primary anterior teeth

due to trauma potential short- and
long-term sequelae
REVIEW ARTICLE
Gideon Holan1, Howard L.
Needleman2,3
1
The Hebrew UniversityHadassah School of
Dental Medicine, Jerusalem, Israel;
2
Department of Developmental Biology, Harvard
School of Dental Medicine; 3Department of
Dentistry, Boston Childrens Hospital, Boston,
MA, USA

Abstract Traumatic dental injuries (TDIs) can result in the premature

loss of primary anterior teeth due to an immediate avulsion, extraction
later after the injury because of poor prognosis or late complications, or
early exfoliation. There are a number of potential considerations or
sequelae as a result of this premature loss that have been cited in the
dental literature, which include esthetics, quality of life, eating, speech
development, arch integrity (space loss), development and eruption of the
permanent successors, and development of oral habits. This article
provides a comprehensive review of the dental literature on the possible
consequences of premature loss of maxillary primary incisors following
TDI.

Key words: avulsion; child; deciduous;

dento-alveolar trauma; exarticulation; primary
tooth
Correspondence to: Dr. Gideon Holan, The
Hebrew UniversityHadassah School of
Dental Medicine, P.O. Box 12272, 91120
Jerusalem, Israel
Tel.: 972-2-6776124
Fax: 972-2-6431747
e-mail: holan@cc.huji.ac.il
Accepted 10 September, 2013

Premature loss of primary anterior teeth due to trauma

can be the outcome of an avulsion, extraction after the
injury because of poor prognosis (1), late complications
of the injury (2), or early exfoliation because of accelerated resorption of the root (3). The prevalence of avulsion out of all types of traumatic injuries to primary
teeth ranges between 5.8% (4) and 19.4% (5) (Table 1).
The prevalence of avulsion out of luxation injuries is
only 19.2% (13). Avulsion occurs more often in 2-4
year-old children (14) and it affects boys 1.21.5 times
more often than girls (15). The maxillary primary central
incisor is involved more than any other tooth (7, 15, 16),
followed by maxillary lateral incisors and mandibular
central incisors (7).
Extraction of traumatized primary incisors may be
necessary due to poor prognosis, the inability of the
child to accept complex dental treatment, the parents
not being in favor of treatment to maintain primary
teeth, the tooth imposing risk to the permanent successors, poor healing of surrounding soft tissues, and the
development of late complications. Such extractions
have been reported following intrusion (17), root fracture (18), and a variety of types of luxation injuries (2).
The sequelae resulting from premature loss of primary
incisors can affect esthetics, quality of life, eating,
100

speech development, arch integrity, development and

eruption of the permanent successors, and development
of oral habits.
The purpose of this comprehensive review is to present the dental literature published in English on the
possible consequences of premature loss of maxillary
primary incisors following traumatic dental injuries
(TDIs).
Esthetics/quality of life

The outcomes of traumatic dental injuries (TDI) to

permanent teeth can affect ones self-image and thus
ones quality of life (19). However, a PubMed search
of the dental literature published in English did not
reveal any publication on the effect of early loss of primary teeth on either esthetics or quality of life.
Impaired esthetics of the anterior maxillary primary
dentition in preschool children may be the result of
fracture, displacement, and/or early loss of one or more
of these incisors.
Most esthetic conditions develop slowly, for example, with dental caries, and allow for gradual adaptation to the change in the esthetic defects. Conversely,
TDI such as avulsion of a maxillary primary incisor
2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Premature loss of primary anterior teeth due to trauma

Table 1. Prevalence of defects to the permanent incisors
following avulsion of their primary predecessors

Author(s)

Year

Avulsed primary
teeth (n)

Affected
permanent
successors
n (%)

Ravn (5)
Andreasen and Ravn (6)
Ravn (7)
Brin et al. (8)
von Arx (9)
Christophersen et al. (10)
Da Silva Assunc~ao et al. (11)
de Amorim et al. (12)

1968
1971
1975
1984
1993
2005
2009
2011

20
27
85
23
26
33
126
14

17
14
63
12
9
10
48
6

(85)
(52)
(74)
(52)
(38)
(30)
(38)
(43)

results in a sudden change in the appearance of the

child. It is therefore not surprising that parents often
demand replantation of avulsed teeth (20, 21) to allay
any concerns they have about how this will affect their
childs appearance and thus the parents view of the
child. It has been our experience that this esthetic concern is generally limited to parents.
However, there is some data demonstrating that preschool children attribute behavioral characteristics to
other children based on their attractive or unattractive
appearance (2224). It was reported that children with
normal dental appearance were judged to be better
looking, more desirable as friends, more intelligent,
and less likely to behave aggressively (25). The oral
region proved to be of primary importance in determining overall facial attractiveness (25). Kapur et al.
(26) suggesting that children even as young as 3 years
of age are conscious of their appearance and are
prompting parents to report to dentists for esthetic reasons due to missing or discolored teeth. Moss (27), on
the contrary, stated that children do not become aware
of the loss of a primary incisor prior to age five or six.
It doesnt make a great deal of difference to them
because their classmates also lose their incisors. However, neither Kapur nor Moss cited any data or references to support their statements.
Another aspect of esthetics relates to parents who
may look for a way to cope with the impaired esthetics
caused by a sudden loss of a front tooth. Woo et al.
(28) evaluated parents perception of the esthetics of
maxillary primary incisors that were grossly carious
and infected or darkly discolored. Parents, primarily
mothers, found these conditions to be unattractive.
Several solutions have been suggested in the dental
literature for replacement of prematurely lost maxillary
primary tooth/teeth, which include replantation of an
avulsed tooth (29), placement of an anterior esthetic
fixed (30) or removable appliance, and even the use of
the natural crown of an exfoliated tooth of another
child (26).
Speech impairment

It has been well established that there exists a strong

relationship between the dentition and speech production, especially for the anterior teeth (3140). In 1985,
2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

101

Riekman and ElBadrawy (41) reported that 4 of 14 children who prematurely lost maxillary primary incisors
due to early childhood caries had some degree of speech
impairment with 2 being severe. All those with speech
impairment had the extractions prior to age 3, while
those with extractions at a later age were less likely to
do so. They concluded that minor residual effects may
occur if such extractions are performed in children
younger than 3 years of age. However, it is important to note that no controls were used in the study.
Moreover, it can be assumed that whether primary incisors reach the stage that they are no longer restorable
and need extraction, their crowns must have lost much
of their original form and thus their role in articulation.
Unlike the sudden loss of primary incisors due to
trauma, destruction of the crowns because of early
childhood caries is relatively slow and allows adaptation
of articulation to the gradual changing condition, which
may explain why there were less speech problems when
teeth were extracted after the age of three.
In 1990, Palviainen and Laine (42) examined the role
of the eruption stage and occlusal anomalies as etiological factors for articulatory speech disorders in 157 first
graders with articulatory disorders. They concluded
that articulatory speech disorders were not affected by
any type of occlusal anomalies during the first phase of
the mixed dentition. In addition, some spontaneous
correction of speech sound articulation occurs with
maturing of the articulators with age and with development of permanent teeth. Specifically, improvement
was most notable for the/s/sound for which the incisors
are critical.
In 1995, Gable et al. (43) performed a controlled
study with 26 children with premature extraction of the
maxillary incisors and 26 children with normal exfoliation of their primary maxillary incisors. All subjects
were subsequently tested for speech impairment after
the eruption of their permanent incisors. Interestingly,
at least half of the subjects tested in both groups had
articulation impairments with no statistical difference
between the groups. Both groups demonstrated a maturation effect with the number of articulation errors
decreasing with age.
Based on these few studies of various scientific qualities, one can advise parents of child who prematurely
lose anterior primary incisors due to trauma that any
potential resultant speech impairment such as lisping is
not likely to occur. However, if speech problems do
occur, they will likely be transient and should resolve
with the eruption of the succedaneous permanent teeth.
Space loss

When traumatized primary teeth are lost prematurely,

an important concern is the potential for space loss as
a result of spontaneous drifting of the adjacent teeth
into the edentulous space (Fig. 1). This loss of space
can cause intra-arch discrepancies during the primary,
mixed, and/or permanent dentition, which include
delay or ectopic eruption of the succedaneous teeth
with a resultant malocclusion. Even without space loss,
the early loss of primary teeth can affect the timing

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Holan & Needleman

(a)

(b)

Fig. 1. Radiograph (a) and clinical photograph (b)

demonstrating migration of primary teeth into space
previously occupied by a primary maxillary left central
incisor. This tooth was lost prematurely due to intrusion at
age 3 years 3 months; however, the intercanine distance
appears to be unchanged.

and path of eruption of their successors (see section

Effect on Development and Eruption of Succedaneous
Teeth).
When a permanent tooth is lost due to trauma,
maintaining the dimensions of the permanent tooths
edentulous space is critical to avoid migration of the
adjacent permanent teeth into this area. In an excellent
review, Alani et al. (44) described the contemporary
management of replacement of such teeth. However,
when primary teeth are lost prematurely, it is not clear
as to which primary teeth and at what age maintaining
the integrity of the edentulous space is necessary. There
exists a large body of evidence on this topic best summarized in both descriptive review articles (4548) and
more recently in evidence-based reviews (4951). The

vast majority of this evidence is limited to the issue of

maintaining space for prematurely lost primary molars,
which can result in space loss with resultant limited
malocclusions. However, there is little data regarding if
space is lost following the premature loss of primary
anterior teeth and those that do are primarily descriptive and suffer from very small sample sizes and lack
of controls (27, 5256).
Clinch and Healy (53) followed 29 children for
11 years who had lost either primary anterior teeth or
molars and reported no space loss in the few cases of
premature extraction of incisors or canines.
Kohn (54) made recommendations for space maintenance for prematurely lost primary anterior teeth,
which was based on limited evidence and personal
experience. He advocated maintaining space in children
under age 4 since prior to age 4 crowns of the permanent incisors are usually too high up in the maxilla to
exert a space-maintaining influence when primary incisors are prematurely lost.
MacGregor (57) reviewed the dental literature up to
that time and noted that the publications he reviewed
contained the authors personal approach, but there
has been little supporting scientific research. Based on
his review of the literature, he recommended the following:
1 Maintain space of maxillary and mandibular incisors
only if lost prior to eruption of the primary canines
because the canines may push the deciduous laterals
mesially causing space loss in the quadrant,
2 Maintain the space if a primary canine is prematurely lost to prevent midline shift, and
3 It is not necessary to maintain space for prematurely
lost mandibular primary incisors after the eruption
of the canines because the lower arch is inside the
upper arch space loss ensues.space reopens when
the permanent teeth erupt.
Moss and Maccaro (27) reported that in data scans
of dental records over a period of 20 years of treatment in their clinic at New York University College of
Dentistry, there were no cases of space loss when anterior primary incisors were lost prematurely as evidence
by the space between the mesial surfaces of the primary
canines either remaining the same or increasing. No
hard data were reported in the article such as the number of cases, when and what teeth were lost.
Borum and Andreasen (56) reported that space loss
in the anterior region was noted in only 2% of the 167
prematurely lost primary anterior teeth.
Although space loss seems to be more likely if the
incisor/s is lost prior to the eruption of the primary
canines, this is often not feasible. Based on these studies, a number of general principles can be made in
determining the need for space maintenance when primary anterior teeth are prematurely lost.
Space loss is greater:
1 in the maxilla than in the mandible,
2 in crowded compared with spaced dentitions,
3 the earlier the tooth is lost,
4 the more posterior the tooth is in the dental arch,
and
5 the greater number of teeth lost.
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Premature loss of primary anterior teeth due to trauma

Practical issues generally play a greater role in making the final determination of the need for space maintenance of the primary anterior teeth, which includes
patient cooperation, and the ability to place a reasonably esthetic, stable, and hygienic appliance. In most
cases, given the lack of scientific data on this issue and
overriding practical issues, space maintenance for the
anterior primary incisors is generally not necessary.

103

(a)

Effect on development and eruption of succedaneous

tooth
Damage to the permanent successors

The prevalence of damage to the developing permanent

successors following avulsion of their primary predecessors has been reported to range between 30% and 85%
and only second in prevalence to intrusions (Table 1)
(512, 58). The definition of early loss of primary teeth
includes both tooth loss at the time of injury (i.e., avulsion) and extraction due to late complications following other types of injury. Holan and Ram (17) reported
on immediate extraction of 19 of 310 intruded primary
incisors that were suspected of being pushed against
the developing bud of the permanent successor. These
cases of early loss of primary incisors can inflict damage to their permanent successors. Other types of traumatic dental injuries such as crownroot fracture,
extrusion, and oral luxation may also require extraction and thus early loss of the primary incisors; however, these types of injury usually do not pose an
immediate risk to the permanent teeth. The younger
the child at time of injury the greater the frequency
and severity of the damage observed in the permanent
successor (10, 12). Jacomo et al. (59) reported that
avulsion of primary teeth resulted in enamel discoloration and hypoplasia, eruption disturbances, crown or
root dilacerations, and sequestration of the bud of the
permanent successor (Fig. 2). White or yellow discoloration of the enamel with or without enamel hypoplasia
is the most common type of defect observed in the permanent teeth following avulsion of the primary predecessors (6, 8, 59) (Fig. 3). Ravn (7) found defects in
94.5% of permanent teeth when avulsion of their primary predecessors occurred at age 02 years; 80.5%
between 2 and 4 years and 18.2% after the age of
5 years. They also reported that the damage to the permanent tooth is more severe when the avulsion
occurred before the age of 3 years of age. Zilberman
et al. (60) found that while 13% of 67 cases of luxation
of primary incisors presented root dilaceration or malformation of the permanent successors, none of the
eight permanent teeth, whose primary predecessors
were avulsed, had any sign of root developmental
defect.
Misalignment and delayed eruption of the permanent
successors

Early loss of primary incisors was found to be associated with malposition of their permanent successors.
This was attributed to lack of guidance to the erupting
2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

(b)

Fig. 2. (a, b) Dilaceration of a permanent mandibular left

central incisor as a result of trauma to and premature loss of
its predecessor primary incisor: clinical (a) and radiographic
(b) views.

permanent tooth or to deflection of the developing bud

from its eruptive path at the time of trauma (61).
If primary teeth are lost at an early age, eruption of
their permanent successors is frequently delayed (62).
Korf (63) reported that succedaneous permanent incisors of prematurely lost primary incisors erupt in an
average of 15.7 months (range 626 months) later than
those replacing primary incisors exfoliating in the
normal expected age (Fig. 4). This is most likely due

104

Holan & Needleman

(a)

Brin et al. (64) reported that although premature

loss of primary incisors was not associated with space
loss in the permanent maxillary incisor region, misalignment of the permanent incisors was observed more
frequently when their primary predecessors were prematurely lost (34%) as compared to cases of non-early
loss (25%).
Acquired and prolonged oral habits

(b)

Fig. 3. Radiograph demonstrating a missing primary mandibular right lateral incisor due to avulsion at age 1 (a) and
subsequent enamel hypoplasia of its permanent successor (b).

Fig. 4. Delayed eruption of the permanent maxillary central

incisors in a 7 year old following premature traumatic loss of
all four primary maxillary incisors and right primary canine
2 years earlier.

additional resistance encountered by the erupting tooth

from the more fibrotic tissue that results at the extraction or avulsion site.

The premature loss of primary anterior teeth could

possibly have an acute or chronic effect on the initiation, cessation, or prolongation of common nonnutritive childhood oral habits such as pacifier use,
digit sucking, or tongue thrusting. During the acute
phase of healing after traumatic primary anterior tooth
loss, the child engaging in a pacifier or digit habit may
find it difficult to continue the sucking activity due to
discomfort and/or the altered oral environment. This is
an opportune time for the treating dentist to help
the family begin attempts to encourage permanent
cessation of this non-nutritive sucking habit.
There is little evidence to indicate that an edentulous
space from prematurely lost primary incisors will have
any long-term effects on non-nutritive oral habits. The
premature loss of one or more primary incisors has
been mentioned as a possible etiologic factor in tongue
thrusting (65, 66), but little evidence exists to support
it. The casual relationships between anterior open bite,
tongue position at rest and during function, nasopharyngeal airway space, tongue thrusting, and digit sucking have been much debated (6771). However, the
causative relationship between digit sucking and anterior open bite in the primary dentition has been well
established (72, 73). Primary anterior teeth that are lost
prematurely by definition result in an anterior open
bite. However, even if this edentulous area should promote the development of a tongue thrust or digit sucking, Tulley (74) suggested spontaneous resolution of
the open bite with eruption of the permanent anterior
teeth.
McWilliams and Kent (75) quote Wells (76) in the
discussion section of their paper as stating that tongue-thrusting usually results from the childs failure to
develop an adult swallowing pattern. McWilliams and
Kent continue on by stating that Premature loss of
anterior teeth will augment this pattern, and Prematurely lost deciduous incisors can alter normally swallowing patterns in that the tongue is forced into the
space to effect an adequate seal. They suggest that this
tongue thrusting will prevent proper eruption of the
permanent incisors and create an open bite, which
will further perpetuate the tongue thrusting. However,
there has been no evidence to date supporting this
relationship.
Moss and Maccaro (27) reported that in data scans
of dental records of children, who were treated over a
period of 20 years at New York University College of
Dentistry, there was no genesis of tongue thrusts due
to the early loss of one or more primary incisors. It is
important to note that the study failed to report any
data such as the number of cases, and when and what
teeth were lost.
2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Premature loss of primary anterior teeth due to trauma

In summary, other than being an opportunity to
encourage cessation of pacifier or digit sucking shortly
after the loss of primary anterior teeth, there is no
data-supported evidence supporting any short or long
effects of prematurely losing of primary incisors on
non-nutritive oral habits.
Biting/mastication

The dental literature that relates to the role that primary teeth play in esthetics, speech, and mastication
usually does not distinguish between incisors and
molars. Specifically, the importance of the primary
incisors in preparing food for digestion is not given
specific attention (77). A literature search found no
articles published in the English language reported on
the effect of early loss of primary incisors on feeding,
incising, or mastication. In a recent text, Christensen
and Fields (78) state that feeding is not a problem
even if all four maxillary primary incisors are removed
and the child continues to grow properly when given a
proper diet. Koroluk and Riekman (79) reported that
54.9% of the parents found that their child did not
have difficulty in eating after the extraction of carious
primary incisors. However, one cannot extrapolate
from these findings to cases of trauma because trauma
causes a sudden loss of the teeth while nursing caries
is usually associated with infection, pain, and biting
difficulties even before the extraction. In fact, extraction may even alleviate the pain and discomfort
improving feeding.
Conclusion

The dental literature published in the English language

contains few studies investigating possible short- and
long-term sequelae to the premature loss of primary
incisors. In addition, these studies are generally of lowlevel evidence-based quality. Nonetheless, clinicians can
be guided by this body of literature in evaluating the
possibility that prematurely lost anterior teeth due to
TDI may affect a number of dental issues beyond the
trauma itself and advise parents and manage the child
accordingly.
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