• avulsion;
  • child;
  • deciduous;
  • dento-alveolar trauma;
  • exarticulation;
  • primary tooth


  1. Top of page
  2. Abstract
  3. Esthetics/quality of life
  4. Speech impairment
  5. Space loss
  6. Effect on development and eruption of succedaneous tooth
  7. Acquired and prolonged oral habits
  8. Biting/mastication
  9. Conclusion
  10. References

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.

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 1.2–1.5 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].

Table 1. Prevalence of defects to the permanent incisors following avulsion of their primary predecessors
Author(s)YearAvulsed primary teeth (n)Affected permanent successors n (%)
Ravn [5]19682017 (85)
Andreasen and Ravn [6]19712714 (52)
Ravn [7]19758563 (74)
Brin et al. [8]19842312 (52)
von Arx [9]1993269 (38)
Christophersen et al. [10]20053310 (30)
Da Silva Assunção et al. [11]200912648 (38)
de Amorim et al. [12]2011146 (43)

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, 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

  1. Top of page
  2. Abstract
  3. Esthetics/quality of life
  4. Speech impairment
  5. Space loss
  6. Effect on development and eruption of succedaneous tooth
  7. Acquired and prolonged oral habits
  8. Biting/mastication
  9. Conclusion
  10. References

The outcomes of traumatic dental injuries (TDI) to permanent teeth can affect one's self-image and thus one's 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 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 child's 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 [22-24]. 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 doesn't 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

  1. Top of page
  2. Abstract
  3. Esthetics/quality of life
  4. Speech impairment
  5. Space loss
  6. Effect on development and eruption of succedaneous tooth
  7. Acquired and prolonged oral habits
  8. Biting/mastication
  9. Conclusion
  10. References

It has been well established that there exists a strong relationship between the dentition and speech production, especially for the anterior teeth [31-40]. In 1985, 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

  1. Top of page
  2. Abstract
  3. Esthetics/quality of life
  4. Speech impairment
  5. Space loss
  6. Effect on development and eruption of succedaneous tooth
  7. Acquired and prolonged oral habits
  8. Biting/mastication
  9. Conclusion
  10. References

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 and path of eruption of their successors (see section 'Effect on development and eruption of succedaneous tooth').


Figure 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.

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When a permanent tooth is lost due to trauma, maintaining the dimensions of the permanent tooth's 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 [45-48] and more recently in evidence-based reviews [49-51]. 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, 52-56].

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.

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.

Effect on development and eruption of succedaneous tooth

  1. Top of page
  2. Abstract
  3. Esthetics/quality of life
  4. Speech impairment
  5. Space loss
  6. Effect on development and eruption of succedaneous tooth
  7. Acquired and prolonged oral habits
  8. Biting/mastication
  9. Conclusion
  10. References

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) [5-12, 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 crown–root 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 0–2 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.


Figure 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.

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

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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 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 6–26 months) later than those replacing primary incisors exfoliating in the normal expected age (Fig. 4). This is most likely due additional resistance encountered by the erupting tooth from the more fibrotic tissue that results at the extraction or avulsion site.


Figure 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.

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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

  1. Top of page
  2. Abstract
  3. Esthetics/quality of life
  4. Speech impairment
  5. Space loss
  6. Effect on development and eruption of succedaneous tooth
  7. Acquired and prolonged oral habits
  8. Biting/mastication
  9. Conclusion
  10. References

The premature loss of primary anterior teeth could possibly have an acute or chronic effect on the initiation, cessation, or prolongation of common non-nutritive 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 [67-71]. 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 child's 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.

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.


  1. Top of page
  2. Abstract
  3. Esthetics/quality of life
  4. Speech impairment
  5. Space loss
  6. Effect on development and eruption of succedaneous tooth
  7. Acquired and prolonged oral habits
  8. Biting/mastication
  9. Conclusion
  10. References

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.


  1. Top of page
  2. Abstract
  3. Esthetics/quality of life
  4. Speech impairment
  5. Space loss
  6. Effect on development and eruption of succedaneous tooth
  7. Acquired and prolonged oral habits
  8. Biting/mastication
  9. Conclusion
  10. References

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 low-level 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.


  1. Top of page
  2. Abstract
  3. Esthetics/quality of life
  4. Speech impairment
  5. Space loss
  6. Effect on development and eruption of succedaneous tooth
  7. Acquired and prolonged oral habits
  8. Biting/mastication
  9. Conclusion
  10. References
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