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BACKGROUND: In the esthetic zone, difficult decisions must be made regarding extraction or retention of compromised teeth. Numerous factors need to be considered to arrive at a proper treatment plan, which may differ from a plan devised for the posterior region of the mouth. TYPES OF REVIEWED STUDIES: Studies were selected that provided background information for clinical decision-making concerning whether a compromised tooth should be retained or removed. RESULTS: In the esthetic zone, before resective surgical procures are used to resolve periodontitis, consideration should be given to the esthetic outcome. If endodontic therapy is required, additional issues need to be reviewed before initiating treatment, including restorability of the tooth, presence of a large periapical area, use of the tooth as an abutment, etc. Furthermore, before initiating periodontal or endodontic treatment, the patient’s susceptibility to additional periodontal disease progression and caries should be evaluated. CLINICAL IMPLICATIONS: In the esthetic zone, deciding whether to treat or remove a compromised tooth requires careful deliberation. The possibility that additional bone loss can compromise a future implant site needs to be considered before providing periodontal therapy. This is particularly true if recession will be induced. Endodontic therapy is effective; however if crown lengthening is required because of subgingival caries or tooth fracture, thought needs to be given to removal of the tooth before altering the gingival topography. Numerous other factors need to be considered when deciding whether to save or extract a tooth in the esthetic zone: restorability, disease susceptibility, papillary and gingival considerations, tooth esthetics, etc. In conclusion, the decision to extract or maintain teeth must include deliberation with regard to benefits vs risks of retaining compromised teeth. The judgment to remove a tooth may be based on one critical issue or it may rely on collective risks related to a few factors.