journal of dentistry 39 (2011) 108–116

available at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/jden

Review

How strong is the evidence for the need to restore posterior

bounded edentulous spaces in adults? Grading the quality
of evidence and the strength of recommendations

Clovis Mariano Faggion Jr.a,*, Nikolaos Nikitas Giannakopoulos a, Stefan Listl b,c
a
Department of Prosthodontics, Dental School Ruprecht-Karls-University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
b
Department of Conservative Dentistry, Dental School Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
c
Mannheim Research Institute for the Economics of Aging, University of Mannheim, Mannheim, Germany

article info abstract

Article history: Background: It is unclear whether or not untreated bounded edentulous spaces (BES) can
Received 3 June 2010 cause patients problems because of migration of unopposed and adjacent teeth.
Received in revised form Objectives: To quantitatively assess BES-related occlusal changes and the level of evidence
4 November 2010 available.
Accepted 9 November 2010 Material and methods: A systematic search of the literature was conducted in triplicate in the
PubMed and Cochrane Register of Controlled Trials (CENTRAL) databases up to and includ-
ing February 2010 to assess studies related to the topic. The LILACS database also was
Keywords: searched by one of the authors (CMF). Quantitative mesio–distal changes and overeruption
Tooth loss were the outcome measures. Manual searching of the reference lists of studies retrieved
Overeruption from the electronic databases was also conducted. Google Scholar in English, French,
Supraeruption German, Greek, Italian, Portuguese, and Spanish was also searched to retrieve potential
Tooth extrusion studies. Grey literature was searched in OpenSIGLE (System for Information on Grey
Tooth shifting Literature in Europe) for more potential papers. The quality of the retrieved literature
Tooth movement and the strength of recommendations were assessed by use of the GRADE system. A
Bounded edentulous space decision-tree-like scheme was produced to depict treatment options.
Results: The available evidence demonstrated that for most cases occlusal changes in BES
after tooth loss might be limited (on average up to 2 mm). The quality of evidence was
regarded as very low, however.
Conclusions: Tooth replacement should not necessarily be regarded as the mainstay of
therapy for posterior BES, although more robust studies are necessary to clarify the long-
term effects of non-treatment. The GRADE approach may be useful for enhancing the
transparency of the decision-making process in dentistry, especially when evidence of only
limited quality is available.
# 2010 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +49 6221 56 6032; fax: +49 6221 56 5371.
E-mail address: clovisfaggion@yahoo.com (C.M. Faggion Jr.).
0300-5712/$ – see front matter # 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2010.11.002
 journal of dentistry 39 (2011) 108–116
1. Introduction
The single posterior bounded edentulous space (BES) is a
clinical situation about which there is frequent argument
that a missing posterior tooth may lead to arch collapse as a
result of movement of adjacent and unopposed teeth. To
solve this problem, a variety of prosthetic treatments (e.g.,
fixed bridges or implant-supported crowns) have been
proposed to replace the missing tooth and restore the
patient’s aesthetics and function. It is, however, unclear
how much occlusal change might be expected after tooth
extraction, or whether or not such changes have much effect
on long-term occlusal stability. Some authors argue that a
single BES does not cause prominent changes in the occlusal
pattern of most adults.1 In contrast, more pronounced
changes of untreated BES are also reported in the literature
and some authors suggest that the replacement of the
missing tooth should be the standard therapy.2,3 For clinical
decision makers there is, hence, great need to clarify this
controversial topic.
The objective of this systematic review is, therefore, to
assess available evidence on the presumed migration of teeth
related to posterior BES. Mesio–distal movement of teeth
adjacent to a posterior BES, and amount of extrusion (over-
eruption) of the unopposed teeth were regarded as measures
of outcome. The quality of available evidence and the strength
of recommendations were determined by use of the GRADE
system and a decision-tree-like scheme was produced to help
clinicians make decisions on the basis of the evidence
available.
2. Materials and methods
We conducted this review by following selected components
of the PRISMA (Preferred Reporting Items for Systematic
reviews and Meta-analyses) and AMSTAR (Assessment of
Multiple Systematic Reviews) statements.4,5 We used the PICO
(participant, intervention, comparison, and outcome) ap-
proach6 to provide an explicit statement of questions to be
addressed in the review:
P (participants): adult patients.
I (intervention): restorative treatment.
C (comparison): non-treatment.
O (outcome): overeruption and mesio–distal BES changes
(in mm).
According to our PICO approach we developed the follow-
ing research question: ‘‘Is there any migration of teeth in
response to non-restored BES?’’
2.1. Literature search
An extensive literature search was conducted in triplicate in
the PubMed and CENTRAL databases up to and including
February 2010. The LILACS database was searched by one of
the authors (CMF). Searches were conducted with the key-
words: tooth loss AND movement, tooth loss AND shifting, tooth loss
AND tipping, tooth loss AND drift*, posterior bounded AND
edentulous, missing AND posterior AND tooth, edentulous AND
space AND shifting, tooth loss AND extrusion, tooth AND over-
109
eruption, tooth AND supraeruption, unopposed AND tooth, tooth
AND migration AND space. All these keyword terms were
combined with the Boolean logic strategy (‘‘OR’’). Manual
searching of the reference lists of included papers was also
conducted to retrieve potential studies. Unpublished and
published randomized controlled trials (RCTs) were sought in
ClinicalTrials.gov and in the internet search engine ‘Google
Scholar’ in Portuguese; French; Greek; English; Spanish;
German; and Italian. The keywords posterior bounded AND
edentulous were used to retrieve articles published in the
language of the original search engine (for example; articles in
Italian in Google Italy; articles in German in Google Germany;
etc.). Finally, grey literature was searched in OpenSIGLE
(System for Information on Grey Literature in Europe; http://
opensigle.inist.fr/). If data were insufficient or dubious;
authors were contacted for clarification.
2.2. Outcome measures
Quantitative loss of mesio–distal space (in mm) between teeth
adjacent to the BES was used as the measure of outcome. The
amount (mm) of overeruption of unopposed teeth was also
assessed.
2.3. Inclusion/exclusion criteria
RCTs, cohorts, case series, and cross-sectional studies were
included. Reviews and case reports were excluded from this
study. Only studies conducted on human adults were
retrieved and assessed. Duplicate publications were also
excluded; only that with the most relevant data was included.
Studies with measures of outcome other than mesio–distal
changes within the bounded space and overeruption of
unopposed teeth were excluded.
Studies including mixed BES and non-BES cases were also
included. For these studies, we tried to contact the authors in
order to obtain precise information on the proportion of BES
and non-BES cases included in each study.
2.4. Statistical assessment
Because of expected high heterogeneity amongst the meth-
odology and measures of outcome of the trials included, we
did not use inferential statistics. We only report the results
descriptively, giving absolute numbers for the epidemiological
distribution of studies.
2.5. Quality assessment of available evidence
The available evidence was assessed by use of the Grading
of Recommendations Assessment, Development and Evalu-
ation (GRADE) system.7,8 The GRADE system clearly dichot-
omizes quality of evidence and the strength of
recommendation of a specific clinical procedure.7 The quality
of evidence is first categorized by study design, where RCTs
are regarded as furnishing high-quality evidence. However,
our confidence in the whole body of evidence on the topic
might decrease when other factors are included.7 Table 1
depicts the GRADE approach for assessing the quality of
evidence.
110 journal of dentistry 39 (2011) 108–116

Table 1 – Determining the quality of evidence and the strength of recommendation by use of the GRADE approach.
Quality of evidence Rationale Strength of Rationale
recommendation

High, moderate, GRADE first defines the quality of evidence Weak or strong Four main factors will determine the
low, or very low on the basis of the study design. For example, strength of recommendation of a clinical
an RCT study will automatically generate procedure:
high-quality evidence. Some key-points can
reduce our confidence in the evidence:
(1) Quality of evidence
- Study limitations
- Inconsistency of results (2) Level of uncertainty on the balance
- Indirectness of evidence between treatment effects and side-effects
- Imprecision (3) Level of uncertainty in the values and
- Reporting bias preferences of the patients receiving the
therapy
In contrast, studies with lower design
(4) Level of uncertainty on the
(e.g., cohort) with improved features,
cost-effectiveness of therapy
for example large or very large treatment
effects, can
The key factor differentiating strong from
be upgraded to a higher level
weak recommendations is uncertainty
about the trade-offs when weighing
variables. The more uncertainty, the more
the likelihood that a weak recommendation
is warranted

2.6. Determining the strength of recommendations
The quality of the retrieved evidence was used to determine
the strength of recommendation of clinical decisions in
different scenarios. The quality of evidence was integrated
with three other factors to determine the strength of
recommendation (weak or strong). The rationale for deter-
mining the strength of recommendation by use of the GRADE
approach is given in Table 1.
2.7. Decision making
An evidence-based decision-tree-like scheme was
developed9–12 on the basis of the available literature. Two
potential scenarios with weak (scenario 1) and strong (scenario
2) recommendations served as the basis for development of two
distinct methods of treatment. The scheme was constructed on
the basis of the available evidence only, rather than on the
cost-effectiveness of the different therapies.13,14
3. Results
included was a randomized controlled trial (RCT). Two studies
had cross-sectional design (one with a control group),15,16 four
were case series,17–20 and one was a cross-sectional survey.21
The characteristics of studies included in the review are listed in
Table 3.
3.3. Results from the literature
3.3.1. Mesio–distal changes
Three studies reported mesio–distal changes in milli-
metres.17,20,21 In most studies changes in BES space were
[()TD$FIG]
Potential titles initially screened in PubMed
(n = 803)
Manuscripts excluded on the basis of title
and abstract (n = 782)
- Unrelated to the topic
- Case reports or reviews
- Not related to the outcome measures
- Full text not available
- Did not fulfill the inclusion criteria
No additional titles screened in the CENTRAL and
LILACS databases, and the grey literature
(OpenSIGLE ); Two papers were retrieved after
assessment of reference lists of studies selected
from PubMed

3.1. PICO approach

There was no study comparing BES closure after use of

restorative treatment and non-treatment approaches. Control
groups in the included studies were normally described as Full-text article screening of potentially relevant
studies for the review
fully dentate patients. (n = 23)

3.2. Available literature Sixteen papers excluded after full-text

assessment

Eight hundred and three potential papers were initially

retrieved. Seven studies were finally selected for the review.
Manuscripts included in the review
Fig. 1 depicts the literature-search process, with reasons for (n = 7)
exclusion of articles. The reasons for exclusion of articles after
full-text assessment are listed in Table 2. None of the studies Fig. 1 – Flow of articles through review.
 journal of dentistry 39 (2011) 108–116 111

Table 2 – Reasons for exclusion of studies after full-text first route was based on a clinical scenario in which the
assessment. patient’s characteristics might affect determination of the
Study Reason strength of recommendation by suggesting a strong recom-
mendation. The second was based on a scenario in which the
McCollum32 Narrative review
Carlsson33 Study not conducted on adults
strength of the recommendation might be regarded as weak by
Cookson34 Study not conducted on adults the patient. In both scenarios the quality of evidence, rather
Hom and Turley35 Tooth movement by use of than the unique reference, was regarded as one of the factors
orthodontic therapy when determining the strength of recommendation.
Toutountzakis et al.36 Narrative review
Compagnon37 Not possible to retrieve the full
text
4. Discussion
Swessi and Stephens38 Study not conducted on adults
Smith39 Non-BES cases
Shugars et al.40 Assessed outcome measures not The results of this systematic review demonstrated that
reported occlusal changes in the form of overeruption and narrowing of
Aquilino et al.41 Assessed outcome measures not posterior BES were limited. For most cases the average change
reported was up to 2 mm and it might be argued that the clinical
Gragg et al.1 Patients derived from the cohort
relevance of this is questionable. Moreover, severe occlusal
of Shugars et al.17
changes affected only a small number of unopposed teeth, and
Craddock et al.42 Patients derived from the same
cohorta other factors might therefore also be important in determina-
Craddock et al.43 Outcome measures not reported tion of BES changes. Age of subjects might be associated with
quantitatively (mm) the severity of changes. A higher incidence of severe over-
Craddock et al.44 Patients derived from the same eruption or mesio–distal BES changes occurred in studies in
cohorta which subjects had a lower range of ages15,21 or a few years
Craddock45 Patients derived from the same
had elapsed since extraction,21 although in one study15
cohorta
Craddock46 Patients derived from the same
overeruption (active eruption) occurred after as long as 10
cohorta years without occlusal contact. Unopposed teeth with peri-
odontal disease seemed also to be prone to more severe
a
Information retrieved after contact with the first author of the overeruption than periodontal healthy teeth.15,20 This infor-
studies. mation might be relevant, because clinicians tend to provide
prosthetic treatment for teeth with better prognosis17 in
limited to 2 mm for most of the patients assessed. One study21 contrast with pathological teeth (for example, teeth with
reported moderate to severe mesial movement (more than periodontal diseases), which are left without treatment. Some
2 mm) of the tooth distal to the space. Two studies17,19 might argue that the severity of BES changes can also be
reported only data related to single-tooth BES. One study associated with tooth condition.
reported BES with one and two missing teeth.21 The other The quality of the evidence on migration of teeth related to
studies15,16,18,20 seem to report data on BES and cases without BES in adults was graded as very low by use of GRADE
distal teeth (free end). Although we had contacted the authors approach. In contrast with other systems,22,23 GRADE has the
of these studies, we could not fully resolve this unclarity until feature of systematically assessing the whole body of evidence
the time of paper submission. not only on the basis of study design, in which, for example,
RCT generate high-quality evidence.8 In this system, factors
3.3.2. Tooth extrusion (overeruption) such as inconsistency of evidence (studies on the same topic
All studies reported changes in the eruption of unopposed but with heterogeneous results) might, reduce our confidence
teeth. In most studies overeruption was limited to 2 mm. One in the whole body of evidence on the topic.24 This was the case
study16 reports moderate to severe (2 mm) overeruption of for one study,21 that did not show significant overeruption
24% of the assessed cases. Quantitative BES measurement after five years of extraction, in contrast with a study that
changes across studies are listed in Table 3. showed active eruption after many years.15 Moreover, it was
not clear in most studies whether or not the data were
3.4. Quality of evidence representative. Some might argue that the evidence might
vary with different ethnicity, for example (indirectness of
The quality of the evidence was initially regarded as low- evidence). Other factors that should be taken into account
grade, because of the characteristics of the study designs in when grading the quality of evidence with the GRADE system
the retrieved literature7 (no study was an RCT). Because the are listed in Table 1.
studies were found to have several limitations (for example, The level of evidence normally correlates with the strength
inconsistency of results), the overall quality of the available of recommendation, and, therefore, low-quality evidence will
evidence was reduced to very-low-grade. generate weak recommendations. In some cases, however,
this linear correlation is not valid, and low or very low
3.5. Deciding on alternative therapy evidence might also generate a strong recommendation.
Strength of recommendation depends both on the quality of
The decision-tree-like scheme considered two different routes evidence and on other factors, for example balance between
on the basis of the strength of recommendation (Fig. 2). The treatment effects and side-effects, patients’ values and
 112
Table 3 – Characteristics of the studies included, inclination in mm, extrusion in mm, and percentage of patients that had changes in mm.
Study Design Participants/methodology Mesio–distal change in mm Overeruption in mm
21,a
Love & Adams Cross-sectional Questionnaire randomly distributed to 85.1% of the subjects with no
survey dental officers at army installations in distal drift or with a slight An average of 94% of the sample had
various areas of the United States. amount (<2 mm); on average slight (<2 mm) or no overeruption
Inclusion criteria were: (1) a natural tooth 65.3 of the sample had >2 mm
must be present on both sides of an mesial movement
edentulous space created by tooth loss. (2)
The edentulous space must have had no
replacement at any time. (3) The tooth or
teeth which originally occupied the space
must have been missing for five years or
longer. Dentists were asked to record: (a)
the age of the patient when the tooth or
teeth creating the space was/were lost; and

journal of dentistry 39 (2011) 108–116

(b) the amount of drift of adjacent teeth
into the space that had occurred. Drift was
divided into four categories: (1) none; (2)
slight (0–2 mm); (3) moderate (2 mm to half
of the space); and (4) severe (over half of the
space). A total of 975 questionnaires were
distributed to nineteen army installations.
553 questionnaires were returned, 17 were
incomplete and were discarded, leaving 536
for analysis.
Compagnon Cross-sectional Three groups of patients were assessed: (1)
and Woda15 25 patients with health and complete NO In teeth without periodontal
dentition, (2) 40 patients with edentulous involvement, 74% of the sample had
space in the mandibular arch enabling overeruption up to 2.13 mm (SD 0.21).
overeruption of only the maxillary first 44% had overeruption up to 0.24 mm (SD
molar (+ normal periodontium), and (3) 10 0.15). Periodontal teeth overerupted
patients with a missing mandibular first 3 mm more on average than non-
molar and with visible signs of periodontal teeth
periodontitis. Measurements of changes in
the height of clinical crown and the level of
the gingival margin were obtained
Kiliaridis et al.16 Cross-sectional 53 patients with molars without
antagonists for a period of at least 10 years. NO 18% of molars with no overeruption,
The following outcome measures were 52% with less than 2 mm
used: overeruption (0 = no sign of 24% moderate to severe (2 mm)
overeruption; 1 = slight overeruption, i.e., overeruption
just detectable elongation up to 2 mm; or
2 = moderate to severe overeruption,
indicating elongation of 2 mm or more,
tipping and rotation)
Shugars et al.17,a
Craddock and Youngson18
Prösl and Kröncke19,a
Christou and Killiaridis20
NO, outcome measure not reported in the study.
a
Studies that deal with posterior BES only.
Case series 111 patients had digitized radiographic 99% of cases less than 1 mm
images of the untreated BES examined on a Mean loss of space across all
video monitor with the help of image cases was approximately
software. The measurements used were: 1 mm, (64% 1 mm) (87%
dDBAT (the shortest distance between the 2 mm) 6% of cases lost more
crowns of the teeth adjacent to the BES), than 3 mm of space between
dPOT (a measure that required the drawing adjacent teeth
of two lines – one from the cusps of the
teeth adjacent to the tooth that directly
opposed the BES and a second drawn
perpendicularly from the first line to the
cusp tip of the tooth opposing the BES, the
latter line being measured as the POT)
Case series 120 patients with one or more unopposed
posterior teeth were invited. There were NO 83.9% of sample had overeruption, 68%
BES and non-BES cases. Occlusal with overeruption of 2 mm or less.
journal of dentistry 39 (2011) 108–116
interferences and overeruption were the
measures of outcome. Overeruption was
measured using CAD-cam software by use
of a study model and a millimetre scale
rule included in each image. Spee curve
was used as reference for the
measurements
Case series 49 patients between 17 and 46 years old
with 55 BES (lower first molar extracted) NO There was no visible BES change in 24 of
were followed-up for 16 weeks to observe 55 BES (43.63% of the sample). In 17 BES
the speed of tilting of the teeth (30.90%), changes were up to 1 mm
neighbouring the BES
Case series 12 subjects with 22 unopposed molars were
followed-up for at least 10 years. Two casts Mean disto–mesial movement Mean eruption of 0.80 mm (SD 0.65) for
were fabricated after alginate impressions of 0.6 mm (SD 0.55) periodontal healthy molars and
(the first immediately after tooth extraction 1.97 mm (SD 0.58) for periodontal
and the second after at least 10 years). 3D affected molars
digital models were produced from the
casts and overeruption, and disto–mesial
and bucco–lingual tooth displacement
were recorded
113
114 journal of dentistry 39 (2011) 108–116
[()TD$FIG]
BES
- Periodontal affected teeth
adjacent to BES GRADE strong*
- Aesthetic concerns recommendation
- Few years elapsed since
extraction
Very low
-quality evidence:
- Indirectness
- Poor study design
- Inconsistency
BES
- Healthy teeth adjacent to GRADE weak*
BES
- No aesthetic concerns recommendation
- Many years elapsed since
extraction
- Cost concerns
* means the strength of recommendation in favour of restorative approach
Fig. 2 – Decision-tree-like scheme demonstrating the possibilities of treatment for a posterior BES.
preferences, and the cost of treatment.25 For example, a young
patient with cancer is very likely to place a higher value on the
treatment effects of chemotherapy than on the side-effects. In
contrast, older patients with a poorer prognosis might not
place a higher value on the treatment effects than on the side-
effects. The quality of evidence is the same, but its effect on
the clinical recommendation might be weak or strong when
other factors, for example age and a patient’s expectation, are
taken into account. A similar example was described in this
study, in which two different treatment routes are illustrated
taking into account the level of evidence (together with some
risk factors for BES change), patients’ preferences, level of
evidence, and use of resources (Fig. 2). Although some
criticism of the difficulty of achieving agreement may arise
when deciding on a strong or weak recommendation, the main
objective of the GRADE system is to explicitly weigh all
variables in a shared decision-making process, to make the
situation more transparent for all the parties involved
(decision makers, clinicians, and patients), instead of finding
reproducible clinical decisions.
It is reported in the literature that lack of posterior teeth
does not necessarily imply a need for their replacement with
prosthetic treatments.26–29 In fact, a threshold of 20 teeth or
more is normally used to decide that patients will probably
have sufficient chewing ability.30 Nevertheless, it is suggested
that the greater the number of teeth lost, the greater will be the
impairment of Oral Health-Related Quality of Life (OHRQoL).30
The patterns of missing occlusal units may be important in
determining variations in OHRQoL. One study30 revealed that
patients who lost their first molars bilaterally suffered from
significantly greater impairment in OHRQoL than patients
with at least a first unilateral first molar occlusion. Neverthe-
less, impairment of OHRQoL does not necessarily justify a
need for restoration, because the information on how much
this impairment will affect a patient’s life is individual and
should be incorporated in the decision-making process.
Hence, although further research on potential functional
problems associated with posterior BES is suggested, on the
basis of current evidence it seems improbable that loss of one
posterior tooth will cause significant complications. Never-
Orthodontic therapy
Dental implant
Active therapy
Fixed partial denture
Removable partial denture
Follow-up (no No treatment
loss of space and
no overeruption)
Orthodontic therapy
Follow-up (loss of Active therapy Dental implant
space and/or
overeruption) Fixed partial denture
Removable partial denture
theless, there is a belief that most clinicians suggest some
active therapy as soon as the tooth is lost in order to avoid
occlusal problems such as overeruption.31
A decision-tree-like-scheme is used graphically to demon-
strate two distinct means of treatment. The objective of this
scheme is not to assess the cost-effectiveness of these
strategies, but to guide clinicians and decision makers solely
on the basis of the available evidence. It seems, however,
logical that if both strategies give similar results, a non-
treatment approach will be more cost-effective.
Only two outcome measures were used (mesio–distal
changes and overeruption). Although this might limit the
view of all possible occlusal changes related to posterior BES,
because of the methods of assessment, occlusal changes in the
extent of, for example, tipping and rotation might be very
difficult to compare across studies. This review therefore
concentrated on quantitative changes (mm) in absolute
numbers to make the comparisons more realistic.
To summarise, this systematic review has revealed that, on
the basis of available evidence, a non-treatment approach for
limited posterior BES might also be an appropriate therapy.
These results, however, should be read with caution because of
the very low quality of evidence. It is, thus, suggested that a
survey be conducted on a more representative, larger cohort of
patients to determine the effect of non-treatment and treat-
ment approaches, for example by assessing patient-related
outcomes such as Oral Health-Related Quality of Life (OHRQoL).
Furthermore, it is important to emphasize that the
uncertainty of treatment outcomes is high when evidence
of only limited quality is available. This is the case in many
clinical situations in dentistry. However, routine treatment
decisions must be made even in the absence of high quality
evidence; moreover, patients should be well informed about
the level of evidence regarding eventual therapies in order to
enable a shared and transparent decision-making process
which involves both patient and dentist. All in all, the
particular contribution of the present study is, thus, to
demonstrate an innovative approach that can help clinicians
to make decisions under such circumstances, i.e. when the
available evidence is weak or nonexistent.
 journal of dentistry 39 (2011) 108–116
Conflict of interest
The first author is member of the GRADE Working Group.
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