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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2018  |  Volume : 36  |  Issue : 4  |  Page : 391-395

Speech evaluation in children with missing anterior teeth and after prosthetic rehabilitation with fixed functional space maintainer

1 Department of Pediatric and Preventive Dentistry, Government Dental College, Jaipur, Rajasthan, India
2 Department of Orthodontics and Dentofacial Orthopaedics, Oral Health Sciences Centre, PGIMER, Chandigarh, India

Date of Web Publication16-Oct-2018

Correspondence Address:
Dr. Garima Kalia
Department of Pediatric and Preventive Dentistry, Government Dental College, Jaipur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JISPPD.JISPPD_221_18

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Introduction: Speech and language development in children is a dynamic process. Development of vocal sound into meaningful speech was one of the major discoveries which have made the human beings to reach the pinnacle of the animal kingdom. The ability to speak is determined by the flow of air into the mouth which affects pronunciation of various words and phrases. Aim: This study aimed to evaluate speech changes before and after prosthetic rehabilitation with fixed functional space maintainer in children with missing maxillary anterior teeth. Materials and Methods: The study sample comprised of 25 children in the age range of 3–6 years having at least two maxillary anterior teeth indicated for extraction or had already got extracted. Speech therapist evaluated articulation of [v], [ph], [n], [d], [dh], [th], [t], [s.],[s], and [l] speech sounds of patients preoperatively (T0), postoperatively after the appliance insertion (T1), and postoperatively after 7 days (T2) using Weiss Comprehensive Articulation Test. The data obtained were analyzed using Chi-square and Mcnemar's test. Results: There was statistically significant (P < 0.05) correction in [v], [ph], [d], [dh], [th], [t], [s.], and [s] speech sounds immediately after prosthetic rehabilitation (T1). While, the assessment of speech sounds after 7 days of appliance insertion (T2) showed statistically nonsignificant differences. Conclusions: The results suggested that treatment of a patient with missing anterior teeth should not be restricted to esthetic and functional oral rehabilitation, but also comprehend with the speech, as premature loss of the primary maxillary incisor appears to have long-term effect on the speech development.

Keywords: Esthetic appliance, fixed space maintainer, maxillary anterior tooth loss, missing, speech

How to cite this article:
Kalia G, Tandon S, Bhupali NR, Rathore A, Mathur R, Rathore K. Speech evaluation in children with missing anterior teeth and after prosthetic rehabilitation with fixed functional space maintainer. J Indian Soc Pedod Prev Dent 2018;36:391-5

How to cite this URL:
Kalia G, Tandon S, Bhupali NR, Rathore A, Mathur R, Rathore K. Speech evaluation in children with missing anterior teeth and after prosthetic rehabilitation with fixed functional space maintainer. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2022 Dec 2];36:391-5. Available from: http://www.jisppd.com/text.asp?2018/36/4/391/243455

   Introduction Top

Development of speech and language is a dynamic process.[1] Every individual has its own unique voice and proper speech is a reflection of education and may play an important role in shaping human's destiny. The size of the resonator system (oral cavity, larynx, pharynx, vocal folds, and nasal sinus) which vibrates at different frequencies generally determines the production of various sounds. The researchers evaluated the effect of teeth on the articulation of speech sounds because the consonant speech sounds categorized as labiodental ([f] and [v]), dental ([θ] and [d]), and alveolar ([n], [t], [dh], [s], and [z]) are formed with the help of the anterior teeth.[2],[3] Functional maladaptation of various structures of the mouth during speech produces orofacial and dental abnormalities mainly those in which the articulation of the vowels and consonants are distorted.[4] In the normal orofacial development, tongue is positioned on the lingual side of the maxillary incisors which results in production of appropriate sounds. However, speech compensations may develop in the absence of teeth from the anterior region of the dentition. Speech articulations and sounds that are most frequently in error due to dentition are /S/as in soap, /Z/as in zebra, and /th/as in think.[5] It has been reported that if extraction of the primary maxillary anterior teeth was done before 4 years of age, articulation of the [s] and [z] speech sounds could get affected.[6]

One class of foreign objects inserted into oral cavity are dental appliances. Dental appliances are used over a wide span or ages from very young children who wear fixed functional space maintainers for replacement of anterior teeth, to young children who wear appliances to tip individual teeth and to the older population to replace missing teeth. The insertion of these appliances has the potential to affect the oral space, and therefore may alter speech sounds. Previous studies on speech and dental appliances have examined the acoustic changes and negative effects caused by removable retainers, bite blocks, dentures, and orthopedic functional appliances.[5],[7] The partial dentures in children have become one of the commonest appliances to be used for replacement of missing teeth. Parents who express concerns about their child's appearance may request prosthesis to improve self-esteem and enhance socialization with other children, particularly as they prepare for kindergarten.[6] However, there are fewer studies in which the effect of both early primary anterior tooth loss and then restoration with fixed partial dentures in children on speech have been evaluated. Therefore, this study was undertaken to investigate whether early primary anterior tooth loss causes alterations in speech of the children and to assess the effect of fixed partial dentures on speech in those children.

   Materials and Methods Top

A total of 30 children in the age range of 3–6 years were selected randomly from the outpatient department in whom at least two maxillary primary incisors were indicated for extraction or had already got extracted. The present study was approved by the ethical committee of the institution.

The procedure to be undertaken and its possible discomfort and benefits were explained to the guardian of the children involved and their written consent was obtained prior to the investigation. Case history and comprehensive oral examination of each patient was recorded [Figure 1]. The mother tongue of all of the subjects was Hindi.
Figure 1: Preoperative photographs (a) extraoral frontal rest (b) extraoral frontal smiling (c) intraoral frontal

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Final sample comprised of 25 patients (13 males and 12 females) as 3 patients had not reported after initial case examination and 2 patients did not reported after appliance placement. The mean age of the males and females was 52.71 ± 10.18 and 52.83 ± 7.09 months, respectively [Table 1]. Children with a history of systemic illness/disease or recent hospitalization, special health care need (seizure disorders, mental retardation, and immunocompromised patients), previous history of speech therapy, having poor ability to follow-up or having very poor hygiene, with inappropriate feeding habits and significant deep bite, excessive overjet or anterior crossbite and hearing impairment were excluded from the study.
Table 1: Demographic characteristics of the sample

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Speech assessment was done by a trained speech therapist using a standardized articulation test, i.e., Weiss Comprehensive Articulation Test. Before proceeding for speech assessment, all the speech tasks were read by the speech therapist to instruct the children. The articulation of [v], [ph], [n], [d], [dh], [th], [t], [s.], [s], and [l] speech sounds of children were evaluated when hemorrhage control was established (if extraction of anterior teeth is required) and soft tissue was completely in healthy state and appliance design was planned. The bands were adapted on both the maxillary second deciduous molar teeth and an alginate impression was made. A stainless steel 0.036” wire was conformed passively against the anteroinferior aspect of the palatal vault and was soldered to the molar bands. The wire struts (ball clasp wire) for support and retention of the teeth were placed in their proper position. The struts for the central incisors extended 5 mm from the crest of the alveolar ridge; the lateral incisor struts extended 3 mm. The appliance was cemented into place utilizing Type 1 luting Glass Ionomer Cement (GC corporation, Tokyo, Japan). After insertion of fixed functional space maintainer [Figure 2], parents were given instructions regarding the proper use and care of the appliance. The speech assessment was performed at three time intervals; before appliance delivery (T0), just after appliance insertion (T1), and 7 days after appliance insertion (T2) according to the following errors.
Figure 2: Postoperative photographs after prosthetic rehabilitation (a) extraoral (b) intraoral frontal (c) intraoral occlusal

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Phonological errors

  1. Omission: Absence of a required speech sound in a word
  2. Substitution: Replacing a speech sound with the correct speech sound
  3. Addition: Adding an extra speech sound next to the articulated speech sound.

Articulation errors

  1. Distortion: Inaccurate production of a speech sound

    1. Interdental lisping: A type of distortion characterized by the production of sibilant consonants with the tongue tip placed too far forward (against the teeth or between the teeth); most common lisps involve [s] and [z]

  2. Mass effect: A type of distortion because of a mass in the mouth, without any articulation error.

Statistical analysis

Data were statistically analyzed using IBM Statistical Package for the Social Sciences (SPSS) version 22.0 (IBM SPSS Statistics Inc., Chicago, Illinois, USA) Windows software program. The variables were assessed for normality using the Kolmogorov–Smirnov test. Chi-square and Mcnemar's test were used for qualitative data with level of significance set at P = 0.05 (P ≤ 0.05 – significant, P ≤ 0.01 – highly significant, P ≤ 0.001 – very highly significant).

   Results Top

The total sample comprised of almost equal number of males and females children (13 males and 12 females), so there were no differences in the quality of voice in relation to gender distribution. Distortion of speech was observed with the v, ph words in 40% of children [Table 2], while more number of children (94%) has distortion error with d, dh, t, th consonants [Table 3]. Only 6 children had distortion of speech in pronouncing of s, s. words and also substitution error in only 2 children was noted with the production of these words [Table 4]. No speech errors were noted with the l, n words [Table 5]. A statistically significant (P = 0.008) reduction in distortion errors [Table 2], [Table 3], [Table 4] was observed with speech of v, ph, d, dh, t, th, s, s., words immediately after the prosthetic rehabilitation (T1). There was statistically nonsignificant effect (P > 0.05) on speech after 7 days of insertion of fixed functional space maintainer (T2).
Table 2: Comparison of words v, ph preoperatively (T0), after appliance insertion (T1) and 7 days postinsertion (T2) on speech

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Table 3: Comparison of words d, dh, t, th preoperatively (T0), after appliance insertion (T1) and 7 days postinsertion (T2) on speech

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Table 4: Comparison of words s, s. preoperatively (T0), after appliance insertion (T1) and 7 days postinsertion (T2) on speech

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Table 5: Comparison of words l, n preoperatively (T0), after appliance insertion (T1) and 7 days postinsertion (T2) on speech

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   Discussion Top

Significant problems for the growing child may arise if premature loss of primary anterior teeth occurs. These concerns are not only limited to speech alteration, but also affect the physiological as well as psychosocial growth patterns. Distortion of the continuant consonants (v, f, th, z, and s) may arise due to premature loss of teeth since their correct production requires forcing of air stream through an opening in the oral cavity small enough to produce friction noises. Hence, the presence or absence of teeth plays a major role in the proper production of speech.

The anterior tooth loss in children can be regarded as an esthetic as well as functional impairment. The child who loses his or her teeth before 4–6 years old will have problem in correctly pronouncing certain sounds such as s, z, th, zh, f, and v.[4] Snow also evaluated the relationship between the articulation of consonant speech sounds ([f], [v], [ð], [θ], [s], and [z]) and the primary maxillary incisors and observed that speech production is better in children with intact primary maxillary incisors than without incisors.[8] Chakraborty et al. in their study observed that pronunciations of certain consonants such as “t,” “d,” “s,” “sh,” and “ch” and labial sounds such as “f” and “v” are altered during speech if early tooth loss in anterior incisal segment occurred.[9] Robinson et al. reported that incisal edges of maxillary central incisors affect the size and shape of the air flow for “F” and “V” sounds and when a patient is pronouncing “5,” “55,” “F” and “V” sounds, vermillion border of lower lip should contact incisal edges of maxillary central incisors. Similarly, Runte et al. in their study found that the tongue comes into contact with the teeth, alveolar ridge, or hard palate during the articulation of speech sound.[10] Therefore, absence of teeth may cause a changed perception and may alter tongue movement or position which is helpful in the production of speech. In the present study, the results also showed similar findings; that loss of maxillary incisors in children of age group 3–6 years have more pronounced effects on words [f], [v], [d], [dh], [th], [s], [s.] with omission of words [f] and [v], substitution of word [s] by [s.] and [d] by [dh].

In 1989, Takagi and Tsunokawa did a study and established that pronunciation of certain words can be recovered if 4–6 years old children are provided with an appliance to replace missing teeth. Therefore, an alternative to correct these sounds in children can be a prosthetic appliance functioning as fixed functional space maintainer. Das et al. discussed about a fixed dentulous appliance that was constructed to replace the primary upper anterior in a 4-year-old boy.[11] They evaluated that besides enhancing the facial aesthetics it acts as a functional space maintainer, assists in development of proper speech; prevents development of any untoward oral habits and hence aid in sound development of the child. Speech sounds ([f] and [v]), dental ([t] and [d]) and alveolar ([n], [th], [dh], [s] and [sh] were observed by Turgut et al.[2] They found no significant speech errors in the children with missing teeth which had been attributed to compensatory ability of the tongue and lips, and adjustment of the air stream to articulate the speech sounds correctly in the children. They replaced the anterior teeth with removable dentures no statistically significant difference in speech was observed immediately after denture insertion and after 7 days of replacement. While in our study children with missing anterior teeth had speech errors and a statistically significant correction was achieved after the replacement of those teeth with fixed functional space maintainer (prosthetic rehabilitation). This may be due the proper positioning of tongue and its association with the anterior teeth was achieved. Also, no statistical significant difference was noted when the speech was assessed after 7 days of appliance placement which shows the adaptation of children to that appliance. Therefore, treatment of children with anterior teeth loss should not be restricted to esthetic and functional oral rehabilitation, but instead must also comprehend speech; as premature loss of the primary maxillary incisor appears to have long-term effect on the speech development of most children whose speech was tested at 3–6 years of age. Further studies are required to evaluate the effect of absence of maxillary anterior teeth on speech and the effect of removable as well as fixed functional space maintainer in larger sample size with longer follow-up period.

   Conclusions Top

In the present study, statistically significant distortion articulation errors of [v], [d], [dh], [t], [th], [s], [sh] consonants were observed. There was improvement in articulation errors of these sounds after insertion of fixed functional space maintainer. This will not only result in the enhancement of esthetics, but also help in the proper development of speech, prevent development of abnormal oral habits and will definitely increase the confidence of a child toward the outer world during the developmental years.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Shetty P. Speech and language delay in children: A review and the role of a pediatric dentist. J Indian Soc Pedod Prev Dent 2012;30:103-8.  Back to cited text no. 1
  [Full text]  
Turgut MD, Genç GA, Başar F, Tekçiçek MU. The effect of early loss of anterior primary tooth on speech production in preschool children. Turk J Med Sci 2012;42:867-75.  Back to cited text no. 2
Riekman GA, el Badrawy HE. Effect of premature loss of primary maxillary incisors on speech. Pediatr Dent 1985;7:119-22.  Back to cited text no. 3
Giovannetti M, Casucci A, Casucci D, Mazzitelli C, Borracchini A. Phonetic analysis and maxillary anterior tooth position: A pilot study on preliminary outcomes. Int Dent SA 2011;5:32-9.  Back to cited text no. 4
Mattuella LG, da Fontoura Frasca LC, Bernardi L, Moi GP, Medeiros Fossati AC, De Araújo FB. Tooth supported prosthetic rehabilitation in a 5-year-old child with early childhood caries. J Clin Pediatr Dent 2007;31:171-4.  Back to cited text no. 5
Waggoner WF, Kupietzky A. Anterior esthetic fixed appliances for the preschooler: Considerations and a technique for placement. Pediatr Dent 2001;23:147-50.  Back to cited text no. 6
Klapper BJ, Strizak-Sherwin R. Esthetic anterior space maintenance. Pediatr Dent 1983;5:121-3.  Back to cited text no. 7
Snow K. Articulation proficiency in relation to certain dental abnormalities. J Speech Hear Disord 1961;26:209-12.  Back to cited text no. 8
Chakraborty S, Dhawan P, Rastogi P. Repalcement of primary anterior teeth by anterior fixed functional space maintainer. Int J Oral Health Med Res 2015;2:51-2.  Back to cited text no. 9
Runte C, Lawerino M, Dirksen D, Bollmann F, Lamprecht-Dinnesen A, Seifert E, et al. The influence of maxillary central incisor position in complete dentures on /s/sound production. J Prosthet Dent 2001;85:485-95.  Back to cited text no. 10
Das PK, Datta P, Bora A, Zahir S, Kundu GK. A simple modification of aesthetic fixed appliance for replacement of avulsed maxillary primary incisors. Int J Applied Dent Sci 2015;1:23-5.  Back to cited text no. 11


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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