Premature Loss

Premature loss of primary anterior teethdue to trauma – potential short- andlong-term sequelaeREVIEW ARTICLE

Gideon Holan1, Howard L.Needleman2,3

1The Hebrew University–Hadassah School of

Dental Medicine, Jerusalem, Israel;2Department of Developmental Biology, Harvard

School of Dental Medicine; 3Department of

Dentistry, Boston Children’s Hospital, Boston,

MA, USA

Key words: avulsion; child; deciduous;dento-alveolar trauma; exarticulation; primarytooth

Correspondence to: Dr. Gideon Holan, TheHebrew University–Hadassah School ofDental Medicine, P.O. Box 12272, 91120Jerusalem, IsraelTel.: 972-2-6776124Fax: 972-2-6431747e-mail: [email protected]

Accepted 10 September, 2013

Abstract – Traumatic dental injuries (TDIs) can result in the prematureloss of primary anterior teeth due to an immediate avulsion, extractionlater after the injury because of poor prognosis or late complications, orearly exfoliation. There are a number of potential considerations orsequelae as a result of this premature loss that have been cited in thedental literature, which include esthetics, quality of life, eating, speechdevelopment, arch integrity (space loss), development and eruption of thepermanent successors, and development of oral habits. This articleprovides a comprehensive review of the dental literature on the possibleconsequences of premature loss of maxillary primary incisors followingTDI.

Premature loss of primary anterior teeth due to traumacan be the outcome of an avulsion, extraction after theinjury because of poor prognosis (1), late complicationsof the injury (2), or early exfoliation because of acceler-ated resorption of the root (3). The prevalence of avul-sion out of all types of traumatic injuries to primaryteeth ranges between 5.8% (4) and 19.4% (5) (Table 1).The prevalence of avulsion out of luxation injuries isonly 19.2% (13). Avulsion occurs more often in 2-4year-old children (14) and it affects boys 1.2–1.5 timesmore often than girls (15). The maxillary primary centralincisor is involved more than any other tooth (7, 15, 16),followed by maxillary lateral incisors and mandibularcentral incisors (7).

Extraction of traumatized primary incisors may benecessary due to poor prognosis, the inability of thechild to accept complex dental treatment, the parentsnot being in favor of treatment to maintain primaryteeth, the tooth imposing risk to the permanent succes-sors, poor healing of surrounding soft tissues, and thedevelopment of late complications. Such extractionshave been reported following intrusion (17), root frac-ture (18), and a variety of types of luxation injuries (2).The sequelae resulting from premature loss of primaryincisors can affect esthetics, quality of life, eating,

speech development, arch integrity, development anderuption of the permanent successors, and developmentof oral habits.

The purpose of this comprehensive review is to pres-ent the dental literature published in English on thepossible consequences of premature loss of maxillaryprimary incisors following traumatic dental injuries(TDIs).

Esthetics/quality of life

The outcomes of traumatic dental injuries (TDI) topermanent teeth can affect one’s self-image and thusone’s quality of life (19). However, a PubMed searchof the dental literature published in English did notreveal any publication on the effect of early loss of pri-mary teeth on either esthetics or quality of life.Impaired esthetics of the anterior maxillary primarydentition in preschool children may be the result offracture, displacement, and/or early loss of one or moreof these incisors.

Most esthetic conditions develop slowly, for exam-ple, with dental caries, and allow for gradual adapta-tion to the change in the esthetic defects. Conversely,TDI such as avulsion of a maxillary primary incisor

100 © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Dental Traumatology 2014; 30: 100–106; doi: 10.1111/edt.12081

results in a sudden change in the appearance of thechild. It is therefore not surprising that parents oftendemand replantation of avulsed teeth (20, 21) to allayany concerns they have about how this will affect theirchild’s appearance and thus the parents’ view of thechild. It has been our experience that this esthetic con-cern is generally limited to parents.

However, there is some data demonstrating that pre-school children attribute behavioral characteristics toother children based on their attractive or unattractiveappearance (22–24). It was reported that children withnormal dental appearance were judged to be betterlooking, more desirable as friends, more intelligent,and less likely to behave aggressively (25). The oralregion proved to be of primary importance in deter-mining overall facial attractiveness (25). Kapur et al.(26) suggesting that children even as young as 3 yearsof age are conscious of their appearance and areprompting parents to report to dentists for esthetic rea-sons due to missing or discolored teeth. Moss (27), onthe contrary, stated that ‘children do not become awareof the loss of a primary incisor prior to age five or six.It doesn’t make a great deal of difference to thembecause their classmates also lose their incisors’. How-ever, neither Kapur nor Moss cited any data or refer-ences to support their statements.

Another aspect of esthetics relates to parents whomay look for a way to cope with the impaired estheticscaused by a sudden loss of a front tooth. Woo et al.(28) evaluated parents’ perception of the esthetics ofmaxillary primary incisors that were grossly cariousand infected or darkly discolored. Parents, primarilymothers, found these conditions to be unattractive.

Several solutions have been suggested in the dentalliterature for replacement of prematurely lost maxillaryprimary tooth/teeth, which include replantation of anavulsed tooth (29), placement of an anterior estheticfixed (30) or removable appliance, and even the use ofthe natural crown of an exfoliated tooth of anotherchild (26).

Speech impairment

It has been well established that there exists a strongrelationship between the dentition and speech produc-tion, especially for the anterior teeth (31–40). In 1985,

Riekman and ElBadrawy (41) reported that 4 of 14 chil-dren who prematurely lost maxillary primary incisorsdue to early childhood caries had some degree of speechimpairment with 2 being severe. All those with speechimpairment had the extractions prior to age 3, whilethose with extractions at a later age were less likely todo so. They concluded that ‘minor residual effects mayoccur if such extractions are performed in childrenyounger than 3 years of age…’. However, it is impor-tant to note that no controls were used in the study.Moreover, it can be assumed that whether primary inci-sors reach the stage that they are no longer restorableand need extraction, their crowns must have lost muchof their original form and thus their role in articulation.Unlike the sudden loss of primary incisors due totrauma, destruction of the crowns because of earlychildhood caries is relatively slow and allows adaptationof articulation to the gradual changing condition, whichmay explain why there were less speech problems whenteeth were extracted after the age of three.

In 1990, Palviainen and Laine (42) examined the roleof the eruption stage and occlusal anomalies as etiolog-ical factors for articulatory speech disorders in 157 firstgraders with articulatory disorders. They concludedthat articulatory speech disorders were not affected byany type of occlusal anomalies during the first phase ofthe mixed dentition. In addition, some spontaneouscorrection of speech sound articulation occurs withmaturing of the articulators with age and with develop-ment of permanent teeth. Specifically, improvementwas most notable for the/s/sound for which the incisorsare critical.

In 1995, Gable et al. (43) performed a controlledstudy with 26 children with premature extraction of themaxillary incisors and 26 children with normal exfolia-tion of their primary maxillary incisors. All subjectswere subsequently tested for speech impairment afterthe eruption of their permanent incisors. Interestingly,at least half of the subjects tested in both groups hadarticulation impairments with no statistical differencebetween the groups. Both groups demonstrated a matu-ration effect with the number of articulation errorsdecreasing with age.

Based on these few studies of various scientific quali-ties, one can advise parents of child who prematurelylose anterior primary incisors due to trauma that anypotential resultant speech impairment such as lisping isnot likely to occur. However, if speech problems dooccur, they will likely be transient and should resolvewith 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 asa result of spontaneous drifting of the adjacent teethinto the edentulous space (Fig. 1). This loss of spacecan cause intra-arch discrepancies during the primary,mixed, and/or permanent dentition, which includedelay or ectopic eruption of the succedaneous teethwith a resultant malocclusion. Even without space loss,the early loss of primary teeth can affect the timing

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

Author(s) Year

Avulsed primary

teeth (n)

Affected

permanent

successors

n (%)

Ravn (5) 1968 20 17 (85)

Andreasen and Ravn (6) 1971 27 14 (52)

Ravn (7) 1975 85 63 (74)

Brin et al. (8) 1984 23 12 (52)

von Arx (9) 1993 26 9 (38)

Christophersen et al. (10) 2005 33 10 (30)

Da Silva Assunc�~ao et al. (11) 2009 126 48 (38)

de Amorim et al. (12) 2011 14 6 (43)

© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Premature loss of primary anterior teeth due to trauma 101

and path of eruption of their successors (see sectionEffect on Development and Eruption of SuccedaneousTeeth).

When a permanent tooth is lost due to trauma,maintaining the dimensions of the permanent tooth’sedentulous space is critical to avoid migration of theadjacent permanent teeth into this area. In an excellentreview, Alani et al. (44) described the contemporarymanagement of replacement of such teeth. However,when primary teeth are lost prematurely, it is not clearas to which primary teeth and at what age maintainingthe integrity of the edentulous space is necessary. Thereexists a large body of evidence on this topic best sum-marized in both descriptive review articles (45–48) andmore recently in evidence-based reviews (49–51). The

vast majority of this evidence is limited to the issue ofmaintaining space for prematurely lost primary molars,which can result in space loss with resultant limitedmalocclusions. However, there is little data regarding ifspace is lost following the premature loss of primaryanterior teeth and those that do are primarily descrip-tive and suffer from very small sample sizes and lackof controls (27, 52–56).

Clinch and Healy (53) followed 29 children for11 years who had lost either primary anterior teeth ormolars and reported no space loss in the few cases ofpremature extraction of incisors or canines.

Kohn (54) made recommendations for space mainte-nance for prematurely lost primary anterior teeth,which was based on limited evidence and personalexperience. He advocated maintaining space in childrenunder age 4 since ‘prior to age 4 crowns of the perma-nent incisors are usually too high up in the maxilla toexert a space-maintaining influence when primary inci-sors are prematurely lost’.

MacGregor (57) reviewed the dental literature up tothat time and noted that the publications he reviewedcontained the authors’ ‘personal approach, but therehas been little supporting scientific research’. Based onhis review of the literature, he recommended the fol-lowing:1 Maintain space of maxillary and mandibular incisors

only if lost prior to eruption of the primary caninesbecause the canines ‘may push the deciduous lateralsmesially’ causing space loss in the quadrant,

2 Maintain the space if a primary canine is prema-turely lost to prevent midline shift, and

3 It is not necessary to maintain space for prematurelylost mandibular primary incisors after the eruptionof the canines ‘because the lower arch is inside theupper arch space loss ensues….space reopens whenthe permanent teeth erupt’.Moss and Maccaro (27) reported that in ‘data scans’

of dental records over a period of 20 years of treat-ment in their clinic at New York University College ofDentistry, there were no cases of space loss when ante-rior primary incisors were lost prematurely as evidenceby the space between the mesial surfaces of the primarycanines either remaining the same or increasing. Nohard data were reported in the article such as the num-ber of cases, when and what teeth were lost.

Borum and Andreasen (56) reported that space lossin the anterior region was noted in only 2% of the 167prematurely lost primary anterior teeth.

Although space loss seems to be more likely if theincisor/s is lost prior to the eruption of the primarycanines, this is often not feasible. Based on these stud-ies, a number of general principles can be made indetermining the need for space maintenance when pri-mary 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,

and5 the greater number of teeth lost.

(a)

(b)

Fig. 1. Radiograph (a) and clinical photograph (b)demonstrating migration of primary teeth into spacepreviously occupied by a primary maxillary left centralincisor. This tooth was lost prematurely due to intrusion atage 3 years 3 months; however, the intercanine distanceappears to be unchanged.


102 Holan & Needleman

Practical issues generally play a greater role in mak-ing the final determination of the need for space main-tenance of the primary anterior teeth, which includespatient cooperation, and the ability to place a reason-ably esthetic, stable, and hygienic appliance. In mostcases, given the lack of scientific data on this issue andoverriding practical issues, space maintenance for theanterior primary incisors is generally not necessary.

Effect on development and eruption of succedaneoustooth

Damage to the permanent successors

The prevalence of damage to the developing permanentsuccessors following avulsion of their primary predeces-sors has been reported to range between 30% and 85%and only second in prevalence to intrusions (Table 1)(5–12, 58). The definition of early loss of primary teethincludes both tooth loss at the time of injury (i.e., avul-sion) and extraction due to late complications follow-ing other types of injury. Holan and Ram (17) reportedon immediate extraction of 19 of 310 intruded primaryincisors that were suspected of being pushed againstthe developing bud of the permanent successor. Thesecases of early loss of primary incisors can inflict dam-age to their permanent successors. Other types of trau-matic dental injuries such as crown–root fracture,extrusion, and oral luxation may also require extrac-tion and thus early loss of the primary incisors; how-ever, these types of injury usually do not pose animmediate risk to the permanent teeth. The youngerthe child at time of injury the greater the frequencyand severity of the damage observed in the permanentsuccessor (10, 12). Jacomo et al. (59) reported thatavulsion of primary teeth resulted in enamel discolor-ation and hypoplasia, eruption disturbances, crown orroot dilacerations, and sequestration of the bud of thepermanent successor (Fig. 2). White or yellow discolor-ation of the enamel with or without enamel hypoplasiais the most common type of defect observed in the per-manent teeth following avulsion of the primary prede-cessors (6, 8, 59) (Fig. 3). Ravn (7) found defects in94.5% of permanent teeth when avulsion of their pri-mary predecessors occurred at age 0–2 years; 80.5%between 2 and 4 years and 18.2% after the age of5 years. They also reported that the damage to the per-manent tooth is more severe when the avulsionoccurred before the age of 3 years of age. Zilbermanet al. (60) found that while 13% of 67 cases of luxationof primary incisors presented root dilaceration or mal-formation of the permanent successors, none of theeight permanent teeth, whose primary predecessorswere avulsed, had any sign of root developmentaldefect.

Misalignment and delayed eruption of the permanent

successors

Early loss of primary incisors was found to be associ-ated with malposition of their permanent successors.This was attributed to lack of guidance to the erupting

permanent tooth or to deflection of the developing budfrom its eruptive path at the time of trauma (61).

If primary teeth are lost at an early age, eruption oftheir permanent successors is frequently delayed (62).Korf (63) reported that succedaneous permanent inci-sors of prematurely lost primary incisors erupt in anaverage of 15.7 months (range 6–26 months) later thanthose replacing primary incisors exfoliating in thenormal expected age (Fig. 4). This is most likely due

(a)

(b)

Fig. 2. (a, b) Dilaceration of a permanent mandibular leftcentral incisor as a result of trauma to and premature loss ofits predecessor primary incisor: clinical (a) and radiographic(b) views.



additional resistance encountered by the erupting toothfrom the more fibrotic tissue that results at the extrac-tion or avulsion site.

Brin et al. (64) reported that although prematureloss of primary incisors was not associated with spaceloss in the permanent maxillary incisor region, mis-alignment of the permanent incisors was observed morefrequently when their primary predecessors were pre-maturely lost (34%) as compared to cases of non-earlyloss (25%).

Acquired and prolonged oral habits

The premature loss of primary anterior teeth couldpossibly have an acute or chronic effect on the initia-tion, cessation, or prolongation of common non-nutritive childhood oral habits such as pacifier use,digit sucking, or tongue thrusting. During the acutephase of healing after traumatic primary anterior toothloss, the child engaging in a pacifier or digit habit mayfind it difficult to continue the sucking activity due todiscomfort and/or the altered oral environment. This isan opportune time for the treating dentist to helpthe family begin attempts to encourage permanentcessation of this non-nutritive sucking habit.

There is little evidence to indicate that an edentulousspace from prematurely lost primary incisors will haveany long-term effects on non-nutritive oral habits. Thepremature loss of one or more primary incisors hasbeen mentioned as a possible etiologic factor in tonguethrusting (65, 66), but little evidence exists to supportit. The casual relationships between anterior open bite,tongue position at rest and during function, nasopha-ryngeal airway space, tongue thrusting, and digit suck-ing have been much debated (67–71). However, thecausative relationship between digit sucking and ante-rior open bite in the primary dentition has been wellestablished (72, 73). Primary anterior teeth that are lostprematurely by definition result in an anterior openbite. However, even if this edentulous area should pro-mote the development of a tongue thrust or digit suck-ing, Tulley (74) suggested spontaneous resolution ofthe open bite with eruption of the permanent anteriorteeth.

McWilliams and Kent (75) quote Wells (76) in thediscussion section of their paper as stating that ‘ton-gue-thrusting usually results from the child’s failure todevelop an adult swallowing pattern’. McWilliams andKent continue on by stating that ‘Premature loss ofanterior teeth will augment this pattern’, and ‘Prema-turely lost deciduous incisors can alter normally swal-lowing patterns in that the tongue is forced into thespace to effect an adequate seal’. They suggest that thistongue thrusting will prevent proper eruption of thepermanent incisors and create an open bite, whichwill further perpetuate the tongue thrusting. However,there has been no evidence to date supporting thisrelationship.

Moss and Maccaro (27) reported that in data scansof dental records of children, who were treated over aperiod of 20 years at New York University College ofDentistry, there was no genesis of tongue thrusts dueto the early loss of one or more primary incisors. It isimportant to note that the study failed to report anydata such as the number of cases, and when and whatteeth were lost.

(a)

(b)

Fig. 3. Radiograph demonstrating a missing primary mandib-ular right lateral incisor due to avulsion at age 1 (a) andsubsequent enamel hypoplasia of its permanent successor (b).

Fig. 4. Delayed eruption of the permanent maxillary centralincisors in a 7 year old following premature traumatic loss ofall four primary maxillary incisors and right primary canine2 years earlier.



In summary, other than being an opportunity toencourage cessation of pacifier or digit sucking shortlyafter the loss of primary anterior teeth, there is nodata-supported evidence supporting any short or longeffects of prematurely losing of primary incisors onnon-nutritive oral habits.

Biting/mastication

The dental literature that relates to the role that pri-mary teeth play in esthetics, speech, and masticationusually does not distinguish between incisors andmolars. Specifically, the importance of the primaryincisors in preparing food for digestion is not givenspecific attention (77). A literature search found noarticles published in the English language reported onthe effect of early loss of primary incisors on feeding,incising, or mastication. In a recent text, Christensenand Fields (78) state that feeding is not a problemeven if all four maxillary primary incisors are removedand the child continues to grow properly when given aproper diet. Koroluk and Riekman (79) reported that54.9% of the parents found that their child did nothave difficulty in eating after the extraction of cariousprimary incisors. However, one cannot extrapolatefrom these findings to cases of trauma because traumacauses a sudden loss of the teeth while nursing cariesis usually associated with infection, pain, and bitingdifficulties even before the extraction. In fact, extrac-tion may even alleviate the pain and discomfortimproving feeding.

Conclusion

The dental literature published in the English languagecontains few studies investigating possible short- andlong-term sequelae to the premature loss of primaryincisors. In addition, these studies are generally of low-level evidence-based quality. Nonetheless, clinicians canbe guided by this body of literature in evaluating thepossibility that prematurely lost anterior teeth due toTDI may affect a number of dental issues beyond thetrauma itself and advise parents and manage the childaccordingly.

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