Notes on IN BRIEF

• Outlines the indications for coronectomy.

coronectomy • Outlines the potential consequences of

PRACTICE
coronectomy.
• Increases awareness of the coronectomy
technique among general dental
T. Renton1 practitioners.

VERIFIABLE CPD PAPER

Coronectomy involves removal of a crown from roots of a healthy tooth in healthy patients indicated to prevent inferior
alveolar nerve injury in a high risk case. Since the original paper in 2005 (Br J Oral Maxillofac Surg 2005; 43: 7–12) describ‑
ing a prospective randomised study on coronectomy, there has been a lot of interest in this procedure and it has become
routine practice in many oral surgery departments within the UK and USA. A significant variance in thresholds for pre‑
scribing coronectomy and also for the technique of its delivery has been highlighted by a recent review. This has resulted
in frequent queries about the technique and which patients may be suitable. Thus this paper aims to highlight some finer
points of the coronectomy technique and how to avoid potential pitfalls.

INTRODUCTION
A recent review of coronectomy proce‑
dures1 has brought to light the significant
variance in thresholds for not only pre‑
scribing coronectomy, but the technique
of delivering the procedure. Third molar
surgery related to inferior alveolar nerve
injury is reported to occur in up to 3.6%
cases permanently and 8% cases temporar‑
Fig. 2a DPT preoperative coronectomy left
ily.2,3 Factors associated with inferior alveo‑
Fig. 1a DPT High risk left M3M with juxta M3M
lar nerve injury (IANI) are age, difficulty of
apical area and darkend roots
surgery and proximity to the IAN canal. If
the tooth is closely associated with the IAN
canal radiographically, 20% of patients
having these teeth removed are at risk of
developing temporary IAN nerve injury
and 1‑4% are at risk of permanent injury.2–6
Radiographic signs indicative of possible
IAN risk include:
• Diversion of the canal
• Darkening of the root Fig. 2b DPT left M3M post operative
• Narrowing of the root/canal Fig. 1b DPT high risk left M3M with coronectomy
darkening of roots
• Interruption of the canal lamina dura
• Interruption of the juxta-apical area.
of the third molar will result in elevated inferior alveolar canal (as estimated on
If these plain film radiographic risk fac‑ risk of IANI (2% permanent and 20% tem‑ radiographs or CBCT). The method aims
tors are identified (Figs 1a and 1b), removal porary).3–6 If the tooth is ‘high risk’, carious to remove only the crown (all enamel) of
and/or the patient is medically compro‑ an impacted mandibular third molar while
1
Professor, Oral Surgery, Kings Health Partners Dental mised, the tooth must be extracted and leaving the root and pulp undisturbed,
Institute, Bessemer Road, London, SE5 9RS
Correspondence to: Tara Renton the patient must be informed about the thereby avoiding direct or indirect dam‑
Email: [email protected]; Tel: 020 3299 2313
elevated risk of nerve injury. age to the IAN (Figs 2a and 2b).
Refereed Paper Coronectomy reduces the likelihood The six latest articles on coronectomy
Accepted 3 March 2011
DOI: 10.1038/sj.bdj.2012.265
of nerve injury by ensuring retention of consist of two randomised controlled tri‑
© British Dental Journal 2012; 212: 323-326 the vital roots when they are close to the als, two prospective cohort studies, one case

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© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

control study and one retrospective study.6–13 may be argued that the surgeon should be
Three of the six articles investigate the fate fully cognisant of the relationship between
of third molars deemed at high risk on a DPT the tooth roots and IAN canal to ensure
radiograph that have been coronected.7‑9 minimal morbidity of the nerve should the
The remaining three articles compare the roots be mobilised and require removal. In
techniques of coronectomy versus com‑ addition, if CBCT confirms that the man‑
plete removal of the high risk third molar dibular third molar roots are distinct from
tooth.6,10,11 Interestingly, Dolanmaz et al.11 the ID canal (Figs 3a and 3b) or inextricably Fig. 3a CBCT right M3M distant with ID
canal inferior and corticated. Remove M3M
did not have a high risk control group for involved with the IAN canal (Figs 3c and 3d)
comparison as they deemed this unethical. the surgeon may elect to ensure mobilisation
All six articles suggested that the technique of the roots is prevented by extended sec‑
of coronectomy had merit and many prac‑ tioning of the crown from the roots, but this
titioners regularly use the coronectomy technique may be associated with increased
approach in order to minimise IANIs. risk to the lingual nerve.9
CBCT has provided an additional indi‑
TECHNIQUE cation for elective coronectomy, which is Fig. 3b CBCT nerve proximal and lingual
Preoperative assessment when there is loss of the lingual cortex with decortication of ID canal. Remove M3M
(identified in 30% of cases) and IDC buc‑
The patient cally with a mandibular third molar root
Coronectomy is an alternative procedure to apex ‘sandwiched’ in between (Fig. 4). This
complete extraction when a tooth is deemed minimises injury to the IDC (IAN) during
‘high risk’ (crossing both lamina dura of the attempted elevation of the root, with a
ID canal on a plain film) but vital and in a high risk of loss of the tooth fragment into
patient who is not medically compromised the submandibular space.
(not immune compromised [diabetic, long Also if the patient or tooth is compro‑
Fig. 3c CBCT left M3M roots straddling ID
term steroids, chemotherapy, HIV]; or poten‑ mised the CBCT scan will enable appropri‑ canal
tial poor healing [previous irradiation]). ate planning for removal of the high risk
Patients should be fully cognisant of the mandibular third molar with an appropri‑
potential risks of a ‘dry socket’ (incidence ate consent.
5%) and the additional possibility of a sec‑ CBCT does involve the additional radia‑
ond surgical procedure either early or late tion dose of 60‑120 μSv which must not
postoperatively. be forgotten but is appropriate in planning
to minimise IAN injury in relation to man‑
Radiography dibular third molar surgery.
Fig. 3d CBCT of bifid ID nerve winding
The mandibular third molar is identified as The routine use of CBCT with its atten‑
between roots of left M3M. Coronectomy
high risk based on routine plain film radi‑ dant high radiation dose is justified in that,
ography (Figs 1a and 1b). Once identified based on CBCT findings, only 5-15% of
as a high risk, a cone beam CT is essential the high risk M3M cases will proceed to
in confirming the relationship of the tooth coronectomy, depending on the surgeon
to the inferior alveolar canal (Figs 3a-d). involved. Thus significantly fewer patients
A recent study has explicitly highlighted will have coronectomied retained roots, for
the link between the plain radiographic fea‑ protection of their inferior alveolar nerve,
tures and cone beam CT findings.15 Umar without the additional risk of future infec‑
et al. reviewed 50 cases that had been iden‑ tion and resultant necessary additional
tified as high risk on plain films and then surgery for root removal.
correlated the CBCT findings with their
appearance. Loss of lamina dura of the canal Consent
was linked to contact with the canal in all Taking into account the above, the patient
cases, darkening was related to canal cortical therefore must be consented with the
loss in 78% of cases, contact with the nerve words ‘it is intended for a coronectomy to
in 60% and grooving of the root in one case. be undertaken, however, if the roots are Fig. 4 CBCT close up left M3M root
sandwiched between ID nerve (purple)
This study may reinforce the possibility that mobilised during surgery they will require and loss of lingual plate
plain film assessment and planned coronec‑ removal with the heightened risk of nerve
tomy may negate the need for additional injury’.6 The patient must also be aware the tooth root has erupted away from the
CBCT scanning and its related irradiation. that there is a risk of early and late infec‑ IAN canal but in some cases when the root
However, as the tooth roots may be mobi‑ tion that will necessitate the removal of is perforated by the nerve, dragging the
lised during the coronectomy procedure it the roots, which in most cases occurs once nerve superiorly as it erupts.14

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© 2012 Macmillan Publishers Limited. All rights reserved.
 PRACTICE

gutter of bone adjacent and buccal to

the tooth (not distal) and to expose
the amelo-cemental junction (ACJ).
This would be similar access as that
gained for application points for third
molar elevation but in this scenario
we are trying to gain access to cut
through the ACJ into the pulp
4. A fissure bur is then used and drilled
directly into the pulp at the buccal
Fig. 5a Coronectomy preop left DPT high Fig. 5e Coronectomy with section into pulp groove intersection with the ACJ.
risk M3M chamber for decoronation of crown
This cut is then lateralised to create
a narrow horizontal groove in the
tooth just below the ACJ. The depth
of this cut needs to be into the pulp
then lateralised but no more than
the length of the fissure bur so has
to avoid perforation of the lingual
cortical plate, the distal and mesial
confines of the tooth (in other studies
the whole crown is sectioned from the
roots, eg Pogrel et al)9
Fig. 5b Coronectomy preop partially erupted 5. A small elevator instrument such as
M3M
a Coupland No. 1 or a straight
Fig. 5f Coronectomy illustrating cut surface Warwick James is used to fracture
of retained roots with pulpal exposure off the crown from the roots. Care
must be taken not to apply too much
torque to the tooth at this point,
so the risk of root mobilisation
is minimised. The crown of a
mesioangularly or horizontally
impacted third molar may need
further sectioning to avoid damage to
the lower second molar tooth
Fig. 5c Coronectomy elevated small buccal 6. If at any time the roots are mobilised
triangular flap with bone exposure
they should be removed
Fig. 5g Coronectomy after wound toilet 7. A rose-head bur is then used, if
and irrigation the buccal triangular flap is necessary, to remove any enamel
replaced with 40 vicryl rapide suture spurs and to take the level of the
remaining root a few millimetres
below the alveolar crestal bone level.
The pulp chamber tissue should be
left untouched and untreated during
smoothing of the root surface in order
to maintain vitality of the root. Ideally
Fig. 5h Coronectomy crown fragment, there should be alveolar bone above
Fig. 5d Coronectomy with buccal bone always inspect root surface to ensure all the root edges but this is not always
removal using fissure bur enamel is removed possible where bone levels are absent
(for example the missing lingual plate)
8. The area is then closed primarily with
The operative technique block (lidocaine 2%) may be used in resorbable sutures, usually a single
(a coronectomy case as addition if necessary suture (4/0 vicryl)
illustrated in Fig. 5) 2. A buccal triangular mucoperiosteal 9. The author prefers pre- and
1. Long buccal infiltration and anterior full thickness flap is raised to expose postoperative chlorhexidine
buccal infiltration (4 ml articaine 4%) the third molar tooth (no lingual mouth wash or gel. Antibiotics are
is given as with routine lower third access) not prescribed unless there is a
molar surgery. An inferior dental 3. A fissure bur is used to create a buccal concurrent pericoronal infection.

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© 2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

Postoperatively surgery is required to separate the root mandibular third molars. Br J Oral Maxillofac Surg
2005; 43: 7–12.
from the nerve.14 7. Friedland B, Donoff B, Dodson T B. The use of
Early Remember it is possible for any man‑ 3‑dimensional reconstructions to evaluate the
anatomic relationship of the mandibular canal and
Should the patient return with ‘dry socket’ dibular posterior tooth to be proximal to impacted mandibular third molars. J Oral Maxillofac
symptoms, treat as one would a dry socket the IAN. Be aware that any mandibular Surg 2008; 66: 1678–1685.
8. O’Riordan B C. Coronectomy (intentional partial
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tion and placement of a resorbable dress‑ displays the radiographic signs is associ‑ Oral Med Oral Path Oral Radiol Endod 2004;
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consideration should be given to remov‑ assessed, consented and treated similarly 2004; 62: 1447–1452.
10. Hatano Y, Kurita K, Kuroiwa Y, Yuasa H, Ariji E.
ing the roots. In the author’s experience, to high risk third molar teeth. Clinical evaluations of coronectomy (intentional
two cases have had early postoperative partial odontectomy) for mandibular third
Coronectomy clincal photography provided by Dr G molars using dental computed tomography:
infection with IAN neuritis (intermittent Umar, Associate Specialist in Oral Surgery, KHP. a case-control study. J Oral Maxillofac Surg 2009;
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It is estimated that eruption of the ‘coro‑ 4. Rud J. Third molar surgery perforation of the infe‑ 13. Pogrel M A. An update on coronectomy. J Oral
rior dental nerve through the root. Tandlaegebladet Maxillofac Surg 2009; 67: 1782-1783.
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cases at 2‑5 years. Often the roots will 5. Rud J. Third molar surgery: relationship of root to related to mandibular third molar surgery: an
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have erupted away from the IAN canal nerve. Tandlaegebladet 1983; 87: 619–631. Pathol Oral Radiol Endod 2002; 93: 358–361.
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randomised controlled clinical trial to compare the of the radiological predictive factors of inferior
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