Volume 78 • Number 12

Retention of Hopeless Teeth: The Effect

on the Adjacent Proximal Bone Following
Periodontal Surgery
Eli E. Machtei*† and Ilan Hirsch*

Background: Clinical wisdom often suggests that retention

of periodontally hopeless teeth may accelerate the destruction
of the adjacent periodontium. The purpose of this study was to
examine the effect of retaining hopeless teeth on the adjacent
alveolar bone following periodontal surgery.
Methods: A retrospective study was conducted based on in-
traoral radiographs. Teeth were considered hopeless if they

T
he prevalence of periodontal dis-
had lost ‡70% bone height at either of the proximal surfaces. ease in humans is high, with 10%
The minimal follow-up period after surgery was 24 months. to 15% of patients exhibiting the
All subjects completed periodontal therapy, including scaling severe form of the disease.1,2 Studies3-5
and root planing (SRP), and periodontal surgery at these sites. have demonstrated periodontal disease
Ninety-three subjects with 110 hopeless teeth were included in to be one of the main causes of tooth
this study. Cases were sorted into two groups: retained, which loss worldwide. Lower rates of tooth
included 57 hopeless teeth (50 subjects) that were main- mortality in periodontally treated pa-
tained; and extracted, which included 53 hopeless teeth (43 tients can be achieved: Hirschfeld and
subjects) that were removed at surgery. All radiographs were Wasserman6 examined the periodontal
digitized, and measurements of radiographic bone distance status of subjects who had been treated
(RBD) were made using computerized software. for periodontal disease and subsequently
Results: Mean follow-up was 4.40 – 0.23 years. For the maintained for 22 years or more in a
retained hopeless teeth, there was a mean bone gain of 0.82 specialist practice. They found that 7.1%
mm from baseline (7.18 – 0.35 mm) to the final examination of all teeth were extracted for periodon-
(6.45 – 0.41 mm; P = 0.0061). Likewise, the postoperative tal reasons. Comparable long-term stud-
percentage of RBD of the retained hopeless teeth showed a ies of tooth loss from patients treated
statistically significant improvement from baseline (57.46% – in specialist practices by McFall7 and
1.5%) to the final examination (52.32% – 2.03%; P = 0.0032). Goldman et al.8 reported higher overall
Teeth adjacent to a hopeless tooth had a slight radiographic tooth loss (10% and 13.4%, respectively)
bone gain postoperatively, which was greater in the extracted during a maintenance period >15 years.
group. However, it was significant only for the distal neighboring These studies6-8 showed that molar teeth
teeth (1.50% versus 11.36%, respectively; P = 0.0119). are the most likely to be lost, whereas
Conclusion: Long-term preservation of hopeless teeth fol- the mandibular cuspid is the least likely
lowing periodontal surgery is an attainable goal with no detri- to be lost. The rate of tooth loss and
mental effect on the adjacent proximal teeth. J Periodontol attachment loss (AL) in untreated pop-
2007;78:2246-2252. ulations or in treated subjects not fol-
lowing a regular maintenance care therapy
KEY WORDS
is much higher: Löe et al.9 reported a
Bone loss; periodontitis; retention; surgery. mean annual AL ;0.1 mm in a well-
maintained Norwegian population com-
pared to 0.2 to 0.3 mm in an untreated
* Unit of Periodontology, Department of Oral and Dental Medicine, Rambam Health Care
Campus, Haifa, Israel. group of tea plantation workers from Sri
† Faculty of Medicine, Technion, Haifa, Israel. Lanka. Becker et al.10 reported a loss of
0.61 teeth per subject per year over a
3.7-year period in an untreated popula-
tion, whereas Nabers et al.11 reported a

doi: 10.1902/jop.2007.070125

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J Periodontol • December 2007 Machtei, Hirsch

much lower rate of 0.29 teeth per subject per year over obtained from the subjects’ files. Files of patients
an average 13-year period. treated between 1990 and 2003 were screened for
The anticipated prognosis of any tooth is likely to this study. Subjects were enrolled consecutively until
affect treatment planning; thus, the practice of ex- there were ‡40 participants in each group. Subjects
tracting hopeless teeth is based on the assumption were included in the study if they met all of the follow-
that its retention might result in continuous AL for ing inclusion criteria: a periapical radiograph showing
the hopeless tooth and its proximal neighbors. Thus, the presence of at least one hopeless tooth and its
the methodology of ‘‘strategic extractions’’ (the ex- proximal neighbors; follow-up radiographs taken
traction of hopeless teeth to prevent continuing bone ‡24 months postoperatively; non-smokers with no
loss at adjacent teeth) has evolved.12-14 However, contributory systemic diseases; and a pretreatment
newer information15 about the episodic nature of peri- diagnosis of localized or generalized severe chronic
odontal disease may question the validity of this ap- periodontitis. Teeth were considered hopeless if they
proach. had radiographic bone loss ‡70% at either of their
Several studies have investigated the effect of re- proximal sites.
taining hopeless teeth on the adjacent periodontium. Initially, all participants received hygiene-phase
Machtei et al.16 investigated the alveolar bone therapy. Following this phase of treatment, subjects
changes adjacent to hopeless teeth, with and without were reevaluated, and only those subjects with insuffi-
extraction, in a sample of 145 teeth from 129 subjects cient response (PD >6 mm) were subjected to a surgi-
in whom periodontal treatment was absent. Teeth cal flap debridement procedure performed by a single
were considered hopeless if they had lost ‡50% bone operator (EEM). Upon completion of active treatment,
height at either proximal site or had radiographic subjects were reexamined (reevaluation 2) and placed
evidence of ‘‘through and through’’ bone loss in the into a proper maintenance protocol. Subjects attended
furcation area. Results 4 years later revealed signifi- maintenance therapy every 3 to 6 months, which in-
cantly greater annual bone loss adjacent to retained cluded oral hygiene reinforcement and scaling. A total
hopeless teeth than adjacent to hopeless teeth that of 110 teeth from 93 subjects were included in this
were extracted (3.12% versus 0.23%, respectively). study. Cases were sorted into two groups: retained,
Other studies17,18 demonstrated that surgical removal which included 57 hopeless teeth (from 50 subjects)
of the mandibular third molar in subjects who received that were maintained at the time of the surgery and
no periodontal treatment may lead to a periodontal thereafter (Fig. 1); and extracted, which consisted
breakdown on the distal surface of the second molar. of 53 hopeless teeth (from 43 subjects) that were
By contrast, in a retrospective study, DeVore et al.19 removed at the time of the surgery (Fig. 2).
evaluated the periodontal status of 17 teeth adjacent The decision about whether to extract or maintain
to one hopeless tooth. Teeth were characterized as the hopeless teeth was left entirely to the subject, with-
hopeless if they presented with two or more of the fol- out any influence or contribution from the operator
lowing criteria: loss of 75% of the supporting bone; performing the procedure.
probing depth (PD) >8 mm; Class 3 furcation involve- All radiographs were digitized using an advanced
ment or mobility; poor crown/root ratios; root proxim- radiographic scanner.‡ Measurements of linear dis-
ity; and a history of periodontal abscess. All teeth tances were performed on the digital images by a sin-
received surgical periodontal treatment that included gle examiner (IH), using custom-made software.§ Root
osseous resection and were followed for a mean of length was measured from the root apex to the cemento-
3.5 years. The investigators concluded that retention enamel junction; bone height was measured from
of periodontally hopeless teeth had no detrimental ef- the root apex to the alveolar crest; radiographic bone
fect on the proximal periodontium of adjacent teeth distance (RBD) was calculated as the difference be-
prior to and following treatment. In a follow-up re- tween the above measurements. Bone loss was defined
port,20 these investigators presented further valida- as the difference between RBD preoperatively and RBD
tion of the results 8 years postoperatively. postoperatively (positive values represented bone gain),
The purpose of the present study was to compare the and the percentage of RBD was calculated as (RBD/root
long-term effect of extracting or maintaining hopeless length) · 100. Results were recorded and grouped, and
teeth on the alveolar bone height of the adjacent teeth. means and standard errors were calculated.

MATERIALS AND METHODS Statistical Analysis

This retrospective study was conducted at the Depart- Changes in RBD from baseline to the end of the follow-
up period were calculated for each group indepen-
ment of Periodontology and Oral-Dental Medicine,
dently using the Student t test for paired observations.
Rambam Health Care Campus in accordance with
the Helsinki Declaration of 1975, as revised in ‡ Canonscan 3000f, Canon, Tokyo, Japan.
2000. The study was based on periapical radiographs § Virtual Measuring Tape, Virtual Measurements, Tel Aviv, Israel.

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Effect of Treated Hopeless Teeth on the Adjacent Periodontium Volume 78 • Number 12

0.35 (SE) mm for the mesial

neighbor of the retained and
extracted teeth, respectively
(P = 0.4015), and 5.46 – 0.35
(SE) mm versus 5.41 – 0.51
(SE) mm for the distal neigh-
bor of the retained and ex-
tracted teeth, respectively (P =
0.9321).
The postoperative radio-
graphic parameters are shown
Figure 1.
A) Preoperative radiograph of hopeless tooth #14. B) The radiographic bone height on adjacent tooth in Table 2. The postoperative
#13 is almost unchanged from baseline at 7 years postoperatively. RBD of the teeth adjacent to
the hopeless teeth did not differ
between groups: 5.40 – 0.44
(SE) mm versus 4.63 – 0.33
(SE) mm for the mesial neigh-
bor of retained and extracted
teeth, respectively (P = 0.1717),
and 5.17 – 0.39 (SE) mm ver-
sus 4.44 – 0.45 (SE) mm for
the distal neighbor of retained
and extracted teeth, respec-
tively (P = 0.781).
Changes in the radiographic
Figure 2. parameters from baseline to
A) Periapical radiograph of tooth #14 preoperatively. The tooth was removed at the time of surgery. the final examination for the re-
B) Neighboring teeth #13 and #15 exhibit minimal or no radiographic bone loss at 5 years tained group are given in Table
postoperatively. 3. Postoperatively, there was a
mean radiographic bone gain
(RBG) on the mesial (1.1 –
Changes in RBD between the groups (retained versus 0.35 [SE] mm) and distal (0.83 – 0.33 [SE] mm) as-
extracted) were compared using the two-tailed Stu- pects of retained hopeless teeth (P = 0.0032 and
dent t test for unpaired observations. A 5% signifi- 0.0164, respectively). For the adjacent proximal
cance level was chosen. teeth (mesial and distal), there was a slight RBG
(;0.3 mm) compared to baseline; however, these dif-
RESULTS ferences were not statistically significant.
Ninety-three subjects (59 females and 34 males) with Table 4 compares the changes in RBD of neighbor-
110 hopeless teeth were included in this study. Sub- ing teeth between the two groups. In general, there
jects were followed for 2 to 13 years (mean, 4.40 – was greater RBG for adjacent teeth in the extracted
0.23 [SD] years). Ages ranged from 16 to 68 years group compared to the retained group (0.71 – 0.33
(mean, 45.54 – 1.13 [SD] years). Of the retained [SE] mm and 0.28 – 0.34 [SE] mm for the mesial teeth
teeth, 31 were multirooted, and 26 were single- and 1.14 – 0.40 [SE] mm and 0.29 – 0.31 [SE] mm for
rooted; of the extracted teeth, 43 were multirooted, the distal teeth); however, these differences did not
and 10 were single-rooted. Approximately two-thirds reach statistical significance (P >0.05). The percent-
of these teeth were maxillary (both groups). age of RBG at the distal neighboring teeth was
Table 1 compares the preoperative radiographic 11.36% – 3.30% SE in the extracted group compared
parameters between groups. The preoperative mean to 1.50% – 2.1% SE in the retained group; these differ-
RBD was very similar for the extracted (7.25 – 0.39 ences were statistically significant (P = 0.0119).
[SE] mm) and retained (7.18 – 0.35 [SE] mm) groups
(P = 0.8841). Similarly, the mean percentage of RBD DISCUSSION
for the extracted (60.08% – 1.88% [SE]) and retained In the present study, the retained hopeless teeth had
(57.46% – 1.50% [SE]) groups did not differ signifi- slight bone gain following periodontal surgery. Devore
cantly (P = 0.1642). Likewise, the preoperative RBD et al.,19 who evaluated mesial surfaces adjacent to 17
of teeth adjacent to hopeless ones did not differ be- hopeless teeth and compared them to non-adjacent
tween groups: 5.68 – 0.35 (SE) mm versus 5.25 – surfaces, reported similar findings, i.e., no differences

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J Periodontol • December 2007 Machtei, Hirsch

Table 1. tenance program. In a long-term

maintenance study of subjects
Preoperative Radiographic Parameters
treated for advanced periodonti-
tis, Lindhe and Nyman21 reported
Retained Extracted
that subjects’ mean PD, AL, and
Variable (mean – SE) (mean – SE) P Value
RBD did not progress significantly
RBD hopeless teeth (mm) 7.18 – 0.35 7.25 – 0.39 0.8841 over a 14-year period. Likewise,
Svardstrom and Wennstrom,22
RBD hopeless teeth (%) 60.08 – 1.88 57.46 – 1.50 0.1642
in a similar 10-year longitudinal
RBD adjacent mesial teeth (mm) 5.68 – 0.35 5.25 – 0.35 0.4015 study, reported minimal annual
radiographic bone loss (0.01 to
RBD adjacent mesial teeth (%) 42.44 – 2.33 41.49 – 2.35 0.7741
0.06 mm) in molars treated for fur-
RBD adjacent distal teeth (mm) 5.46 – 0.35 5.41 – 0.51 0.9321 cation involvement.
Smoking is another major risk
RBD adjacent distal teeth (%) 41.64 – 2.07 46.08 – 3.46 0.2483
factor for periodontal disease pro-
gression.23,24 Grossi et al.25,26
found that heavy smokers had
Table 2. greater odd ratios for attachment
and alveolar bone loss compared
Postoperative Radiographic Parameters to non-smokers. It was shown that
smoking affected the response of
Retained Extracted non-surgical and surgical peri-
Variable (mean – SE) (mean – SE) P Value odontal treatment.27-29 The exclu-
RBD hopeless teeth (mm) 6.46 – 0.41 – – sion of smokers from the present
study might have resulted in greater
RBD hopeless teeth (%) 52.32 – 2.03 – – bone gain postoperatively. This is
RBD adjacent mesial teeth (mm) 5.40 – 0.44 4.63 – 0.33 0.1717 consistent with the study by Ah et
al.,30 who reported that smokers
RBD adjacent mesial teeth (%) 40.56 – 3.20 39.41 – 2.55 0.2672 exhibited significantly less reduc-
RBD adjacent distal teeth (mm) 5.17 – 0.39 4.44 – 0.45 0.781 tion in PD and less gain of probing
attachment level compared to
RBD adjacent distal teeth (%) 40.15 – 2.30 36.04 – 3.62 0.3253 non-smokers following surgical
– = not applicable. and non-surgical therapy over a
maintenance period of 6 years.
The results of the present study
in PD and bone loss between groups, whereas there showed that the retention of hopeless teeth did not ex-
was a significant reduction in the mean PD for the ad- ert any detrimental effect on the adjacent proximal
jacent surfaces from pretherapy to post-surgery (from teeth. Nonetheless, teeth adjacent to hopeless teeth
4 mm to 3 mm). A follow-up report20 8.4 years post- that were extracted had slightly greater RBG com-
operatively published by the same authors confirmed pared to those adjacent to retained teeth; however,
their previous findings. A major disadvantage of the these differences were statistically significant only
above two studies was the small sample (only 17 sub- for the distal neighbors of the hopeless teeth that were
jects, of whom 15 underwent surgical treatment19); extracted compared to retained ones (1.5% – 2.1%
even more importantly, only 10 subjects from the versus 11.36% – 3.3%, respectively). This can be
original sample were included in the follow-up study. attributed to the larger sample size of teeth with avail-
To the contrary, in our previous study,16 we reported able distal aspects for measurement (n = 96) com-
that the retention of hopeless teeth had a negative ef- pared to mesial aspects (n = 74). Likewise, the
fect on their proximal neighbors. However, the lack of effect of surgical removal of mandibular third molars
any periodontal treatment in this earlier study likely on the RBD of the adjacent second molars was re-
accounted for the continuous bone loss that was ob- ported recently.31 A significant RBG was observed
served. at the treated (extracted) sites, whereas slight bone
The present study showed that periodontal surgery loss was reported for the non-extracted controls.
inhibited further bone loss and resulted in slight RBG Non-standardized periapical radiographs were used
for the hopeless teeth (0.82 – 0.34 mm). Several fac- in the present study. Although standardized radio-
tors may explain these results; the most important graphs have greater accuracy,32 Merchant et al.33
factor was the subject’s plaque control and strict main- showed that non-standardized radiographs can still

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Effect of Treated Hopeless Teeth on the Adjacent Periodontium Volume 78 • Number 12

Table 3.
Changes in Radiographic Parameters of Retained Hopeless Teeth From Baseline to
Final Examination

Preoperative Postoperative
Variable (mean – SE) (mean – SE) Change – SE* P Value

RBD hopeless teeth (mm) 7.18 – 0.35 6.45 – 0.41 0.82 – 0.34 0.0061

RBD hopeless teeth (%) 57.46 – 1.49 52.32 – 2.03 5.94 – 2.12 0.0032
RBD adjacent mesial teeth (mm) 5.68 – 0.36 5.40 – 0.44 0.28 – 0.23 0.422
RBD adjacent mesial teeth (%) 42.45 – 2.33 40.56 – 3.21 1.88 – 1.92 0.5384

RBD adjacent distal teeth (mm) 5.46 – 0.35 5.17 – 0.40 0.29 – 0.25 0.3673
RBD adjacent distal teeth (%) 41.65 – 2.07 40.15 – 2.30 1.50 – 1.85 0.4811
* Positive numbers represent bone gain.

Table 4.
Changes in Radiographic Bone Height of the Neighboring Teeth: Comparison
Between Groups*

Retained Extracted
Variable (mean – SE) (mean – SE) P Value
Changes in RBD of the mesial neighboring teeth (mm) 0.28 – 0.34 0.71 – 0.33 0.36
Changes in RBD of the mesial neighboring teeth (%) 1.88 – 3.04 2.57 – 2.36 0.8605
Changes in RBD of the distal neighboring teeth (mm) 0.29 – 0.31 1.14 – 0.40 0.1175

Changes in RBD of the distal neighboring teeth (%) 1.50 – 2.10 11.36 – 3.3 0.0119
* Positive numbers represent bone gain.

be a useful tool to assess radiographic bone changes studies have shown much greater survival rates with
in longitudinal studies. surgical periodontal treatment. In a longitudinal study35
Furthermore, the use of the percentage of bone of furcation-involved molars, Carnevale et al. reported
gain/loss as a surrogate outcome variable (in addition a 10-year survival rate of 93% to 99% following surgi-
to bone loss/gain in millimeters) and the similarity of cal treatment. The factors affecting the long-term sur-
the changes using both variables helped to validate vival of questionable and hopeless teeth was studied
our findings. recently by several groups using a logistic regression
Data on the survival rates of the retained hopeless analysis.36,37 Baseline periodontal breakdown was not
teeth were not available in this analysis, which re- identified by the model, whereas age, smoking, oral hy-
quires some caution. Nonetheless, several longitudi- giene, and time since conclusion of active treatment
nal, long-term studies have examined the survival of were included and accounted for most of the variation.
severely compromised teeth following periodontal Of the 74 multirooted hopeless teeth, 43 were
treatment. Earlier studies6,7 reported that a relatively extracted, and 31 were retained, whereas only 10 of
large percentage of these teeth were lost following the 36 hopeless single-rooted teeth were extracted.
therapy. However, many of the subjects in these The subjects’ preference of tooth retention in the an-
studies received only SRP as their active treatment. terior dentition is likely due to the initial esthetic im-
Recently, Harrel and Nunn34 compared different treat- pact that such extraction might have in these sites.
ment modalities for advanced periodontitis using a Nonetheless, one should keep this in mind when con-
site-/tooth-based analysis. They concluded that teeth sidering these data.
receiving no treatment or SRP only showed further dis- Finally, over the last decades, dental implants have
ease progression, whereas surgically treated sites become a common treatment alternative for peri-
showed significant improvement in PD. More recent odontally compromised teeth. With a survival rate

2250
J Periodontol • December 2007 Machtei, Hirsch

>90% over 5 and 10 years,38,39 many clinicians tend 12. Saadoun AP. Periodontal and restorative consider-
to prefer the extraction of hopeless teeth and replace- ations in strategic extractions. Compend Contin Educ
ment with dental implants.40 The results of the present Dent 1981;2:48-55.
13. Ibbott CG. The role of extraction in periodontal ther-
study and more recent reports on the survival rate of apy. J Can Dent Assoc 1986;52:144-145.
these teeth, therefore, would invite a revision of this 14. Yulzari JC. Strategic extraction in periodontal pros-
trend in favor of saving and maintaining questionable thesis. Int J Periodontics Restorative Dent 1982;2(6):
and hopeless teeth. 50-65.
15. Socransky SS, Haffajee AD, Goodson JM, Lindhe J.
New concepts of destructive periodontal disease.
CONCLUSIONS J Clin Periodontol 1984;11:21-32.
16. Machtei EE, Zubrey Y, Ben Yehuda A, Soskolne WA.
Within the limitations of the study, it seems that long- Proximal bone loss adjacent to periodontally ‘‘hope-
term preservation of hopeless teeth following periodon- less’’ teeth with and without extraction. J Periodontol
tal surgery is an attainable goal with no detrimental effect 1989;60:512-515.
on the neighboring teeth. However, results should be 17. Ash MM, Costich ER, Hayward JR. A study of peri-
odontal hazards of third molars. J Periodontol 1962;
interpreted with caution, and each case must be dealt
33:209-219.
with separately. Prospective longitudinal studies in- 18. Peng KY, Tseng YC, Shen EC, Chiu SC, Fu E, Huang
volving larger sample sizes and combining radiologic YW. Mandibular second molar periodontal status after
and clinical parameters are necessary to substantiate third molar extraction. J Periodontol 2001;72:1647-
the evidence of the present study. 1651.
19. DeVore CH, Beck FM, Horton JE. Retained ‘‘hopeless’’
teeth. Effects on the proximal periodontium of adja-
ACKNOWLEDGMENT cent teeth. J Periodontol 1988;59:647-651.
20. Wojcik MS, DeVore CH, Beck FM, Horton JE. Retained
Drs. Machtei and Hirsch report no conflicts of interest ‘‘hopeless’’ teeth: Lack of effect periodontally treated
related to this study. teeth have on the proximal periodontium of adjacent
teeth 8 years later. J Periodontol 1992;63:663-666.
21. Lindhe J, Nyman S. The effect of plaque control and
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Effect of Treated Hopeless Teeth on the Adjacent Periodontium Volume 78 • Number 12

bone height of the adjacent second molar. Int J Oral 37. Leung WK, Ng DK, Jin L, Corbet EF. Tooth loss in
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