C o ron e c t o m y

Partial Odontectomy or Intentional

Root Retention
M. Anthony Pogrel, DDS, MD, FRCS

KEYWORDS
 Coronectomy  Intentional root retention  Partial odontectomy  Third molars  Wisdom teeth
 Inferior alveolar nerve

KEY POINTS
 Coronectomy protects the inferior alveolar nerve from damage when lower third molars need
removing.
 Cone-beam computed tomography (CBCT) has become the standard of care in deciding whether
to offer coronectomy to a patient where there is a close relationship between the tooth and the
nerve.
 There are reported variations in technique, but they do not seem to affect the results.
 Root migration seems to be the most frequent complication.

My personal interest in coronectomy started when Dental Association approved a procedure code
I heard Brian O’Riordan (a London-based oral and (D7251) for coronectomy, effective January
maxillofacial surgeon) give his retirement talk to 2011. However, just because the American Dental
the annual meeting of the British Association of Association recognized the technique and gave it
Oral and Maxillofacial Surgeons in Buxton, En- a code number does not make it universally
gland in 1997. The title of his talk was “Uneasy accepted and even more does not ensure that
Lies the Head that Wears a Crown.”1 In this he dental insurance companies will reimburse for
presented a fascinating story of his 30-year love the technique, and even now several of them do
affair with coronectomies and showed much of not reimburse for this technique. Nevertheless,
the rationale and also his long-term results. I re- the technique does seem to be gaining wider
turned to California energized and determined to acceptance, although there are some differences
try this technique. At that time, it was not widely in the indications and actual technique used
practiced in the United States and nobody was within and between countries.
lecturing or publishing on the topic. As we began In this article I discuss these differences in the
to develop the technique and look at our early re- light of personal experience. The degree of accep-
sults (our first publication was in 2004),2 the tance of the technique in some ways can be judged
technique began to gain some popularity locally on the number of articles in peer-reviewed journals
and nationally, and although it still remains on the topic. From 1965 to 2004, there were only
oralmaxsurgery.theclinics.com

controversial in the United States, it did assume seven articles on coronectomy in the English lan-
a degree of respectability when the American guage literature over a 38-year period,1,3–8 and all

Department of Oral and Maxillofacial Surgery, University of California San Francisco, Box 0440, Room C522,
521 Parnassus Avenue, San Francisco, CA 94143-0440, USA
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 27 (2015) 373–382

http://dx.doi.org/10.1016/j.coms.2015.04.003
1042-3699/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
374 Pogrel

of these were after 1988. Since then, the numbers 1. Low risk: This occurs when the panoral radio-
each year are as follows: graphic appearance turns out on the CBCT
scan to be superimposition only. There is sepa-
2004 3 ration of the nerve and the root with a covering
of bone in between (Fig. 1).
2005 3
2. Medium risk: This occurs when the nerve is
2006 2
directly adjacent to the roots of the tooth or is
2007 1 mildly grooving the root of the tooth (Fig. 2).
2008 1 3. High risk: This occurs when there is deep
2009 5 grooving of the tooth by the nerve or even
2010 5 perforation of the tooth root by the nerve with
2011 6 the roots growing around the nerve (Fig. 3).
2012 8 We prefer not to use numbers, or percentages,
2013 11 because patients often want to apply overall
2014 6 numbers to their own personal situation.
It is important to realize the differences in image
acquisition with fan-beam (medical grade) CT and
CBCT scanning. In principle, fan-beam or medical-
CONTROVERSIAL ISSUES CONCERNING grade CT uses slices that are now usually less than
CORONECTOMY 1 mm apart, to build up a composite image. In
contrast, CBCT scanning uses volumetric image
Most authorities agree that the technique is indi-
acquisition and visualization. Because of this, the
cated when there is high probability of damage
resolution of CBCT scanning cannot match that of
to the inferior alveolar nerve if the whole tooth is
fan-beam CT scanning and so it is not always
removed. Previously evaluations were made on
possible to visualize the exact relationship at some
Panorex radiographs using several criteria
including overlapping of the nerve shadow on the
roots of the teeth, narrowing of the nerve shadow,
or deviation of the nerve shadow.9–12
Although medical-grade (also called fan beam
or multislice) computed tomography (CT) scan-
ning has been available since the mid-1970s to
determine the relationship in three dimensions, it
was not widely used because it was relatively
expensive, the radiation dosage was compara-
tively high, the availability was limited, insurance
would not reimburse for it, and the software did
not allow easy visualization of the relationship
between the inferior alveolar nerve and the roots
of the third molar. The increasing availability of
cone-beam CT (CBCT) scanning from 2002 on-
ward eased these problems in that the radiation
dose is much lower than with fan-beam CT, the
cost is much lower (around $300 in the United
States), and the software makes easy visualiza-
tion of the relationship between the inferior alve-
olar nerve and the tooth in three dimensions.
CBCT scanning is now the preferred imaging
technique to determine in three dimensions what
appears to be a close relationship between the
inferior alveolar nerve and the third molar
roots.13–19
Classifications of the relationship of the nerve to Fig. 1. A coronal slice from a cone-beam CT scan
the tooth vary on CBCT, but in general there are showing the inferior alveolar nerve (arrow) as sepa-
three groups, based on the risk of permanent infe- rate from the root of the tooth. This represents a
rior alveolar nerve damage following removal of low risk of permanent nerve involvement following
the whole tooth. removal of the tooth.
 Coronectomy 375

Fig. 3. A coronal slice of a cone-beam CT scan showing

the inferior alveolar nerve (arrow) passing between
the roots of the lower third molar. This represents a
high risk of permanent nerve involvement should
this tooth be removed in one piece.

Fig. 2. An axial slice of a cone-beam CT scan where the

inferior alveolar nerve (arrow) is directly adjacent to the instrument players). The patient’s age is important
root of the tooth and is lightly grooving it. There is no in treatment planning, in that conceptually coro-
indication of cortical bone separating the nerve from nectomy is believed to be more appropriate for
the tooth. This represents a medium risk of permanent older patients, who in general do not tolerate nerve
nerve involvement following removal of the tooth. damage as well as young patients. It was not
precise points. The images shown in Fig. 4 are of a initially designed for teenagers (the commonest
case where the nerve actually passed through a group having third molars removed in the United
hole in the roots, and although a CBCT scan was States) for the following reasons:
taken preoperatively, the resolution did not allow 1. It is often important to remove the tooth
direct visualization of the root perforation. Therefore, completely in teenagers in conjunction with or-
this tooth was subsequently removed complete and thodontic treatment.
the perforation was seen clinically. If this had been 2. Teenagers are less likely to get nerve involve-
accurately visualized preoperatively, it is likely that ment because the nerve is more resilient.
a coronectomy would have been performed. 3. If they do get nerve involvement, it is more likely
to recover and less likely to result in permanent
INDICATIONS FOR CORONECTOMY dysesthesia.
4. Even if it does turn out to be permanent in a
The technique is generally performed on lower teenager, they often get used to it and are
third molars but occasionally on deeply impacted hardly aware of it, whereas older patients are
second molars and even very occasionally first much less adaptable and much more likely to
molars.20 The technique is offered to any patient be inconvenienced by the discomfort of perma-
when there is a moderate or high risk of damage nent nerve involvement.
to the inferior alveolar nerve if the tooth is re-
moved completely as assessed by Panorex-type In our particular program, we do not routinely
radiograph supplemented by CBCT scanning. offer coronectomy to younger patients having third
The technique may be offered in low-risk cases molars removed unless it is believed that they are
on patients older than 25 or where nerve involve- at medium or high risk. For older patients, it is
ment might present special problems (eg, wind offered even when there is a low risk.
376 Pogrel

Fig. 4. (A) Panoramic reconstruction. (B) Axial slices. (C) Actual tooth after removal. These represent an attempt
to visualize the relationship between the inferior alveolar nerve and the lower third molar before tooth removal.
The cone-beam CT, because of its more limited power of resolution, cannot visualize objects in the detail that can
be obtained with fan-beam CT. In this case, the cone-beam CT scan was unable to show that the nerve went right
between the roots of the tooth. The tooth was consequently removed without coronectomy, but fortunately the
mesial root fractured and so it was possible to remove the tooth without causing permanent nerve damage. If
this had been visualized preoperatively, coronectomy would probably have been performed. (From Pogrel MA.
Coronectomy to prevent damage to the inferior alveolar nerve. Alpha Omegan 2009;102:61–7; with permission.)

CONTRAINDICATIONS FOR CORONECTOMY technique have increased. As originally conceived,

the technique involved total sectioning of the
The following situations are contraindications for crown of the tooth, removal of all enamel, and
coronectomy: removal of enough of the coronal portion of the
 When the tooth is lying horizontally along the tooth such that the portion to be retained was at
path of the inferior alveolar nerve. In these cir- least 2 to 3 mm below the alveolar crest of bone.
cumstances, sectioning of the crown could This was believed to be important for new bone
present as high (if not higher) risk of nerve to grow over the retained roots and for them not
involvement than just taking out the whole to become exposed. As described by our unit,
tooth (Fig. 5). the technique involves raising buccal and lingual
 Where it is not believed that all the enamel of flaps, the placement of a lingual retractor to pro-
the tooth can be removed. Retention of tect the lingual nerve and lingual soft tissues so
enamel seems to be associated with a much that the crown of the tooth could be sectioned
higher failure rate (Fig. 6). with a 702-type fissure bur through the whole
 Infection involving the roots of the teeth. crown of the tooth.2 This is the technique that is
 Caries involving the roots of the teeth. still used in our unit (Fig. 7). However, two other
 If the roots are mobilized during the proce- techniques have been described.
dure, they should be removed.
 When the second molars are to be distalized
orthodontically.

SURGICAL TECHNIQUE
As the procedure has gained wider acceptance
the numbers of variations on the basic surgical

Fig. 5. Lower third molars lying horizontally along the Fig. 6. A postcoronectomy radiograph showing re-
inferior alveolar nerve making it impossible to carry tained enamel on the mesial aspect of the lower left
out coronectomy. third molar.
 Coronectomy 377

Fig. 7. (A) The conventional third

molar incision extending down the
external oblique ridge to the disto-
buccal line angle of the lower second
molar with a buccal releasing incision
going no further forward than the
midpoint of the first molar to avoid
a frequent arteriole located in this
area. (B) Diagramatic representation
of coronectomy technique. A lingual
retractor has been placed to protect
the lingual soft tissues, including the
lingual nerve, and a 702 fissure bur
is used at approximately a 45-degree
angle to section the crown
completely before removal. The gray
area represents the portion of the
tooth root that is then removed to
place them 3 to 4 mm below the alve-
olar crest. (From [A] Pogrel MA. Partial odontectomy. Oral Maxillofac Surg Clin North Am 2007;19:85–9, with
permission; and [B] Pogrel MA, Lee JS, Muff DF, et al. Coronectomy: a technique to protect the inferior alveolar
nerve. J Oral Maxillofac Surg 2004;62:1447–52, with permission.)

The first is a similar technique except that a The most frequent instance of this is in the case of
lingual flap is not raised and a lingual retractor is the dentigerous cyst (Fig. 8). Although a fairly large
not placed, but rather the crown of the tooth is defect may be left, this does not seem to require
removed from above with either a fissure bur or a any type of grafting in most cases.22 No authors
high-speed round bur such that the crown is either currently recommend any type of endodontic treat-
split vertically from above into small sections or it ment of the retained roots,23 and articles have
is just ground away until one ends up 2 to 3 mm shown that the retained roots do remain vital.24
below the alveolar crest. Other areas showing differences in techniques
The second is a technique whereby no lingual are discussed next.
flap is raised and no lingual retractor is used,
but the crown is still sectioned horizontally in Antibiotics
the same manner as one would use for routine
Many authors have always believed that the use
third molar removal. In this, the fissure bur is
of antibiotics is important for the success of this
taken approximately two-thirds of the way across
technique. It is believed that antibiotics should
the tooth and then the crown is fractured off in the
be given prophylactically so that they are in the
normal way with a straight elevator. The crown is
pulp chamber of the tooth to be sectioned at
then removed and the roots smoothed if neces-
the time of removal. This means giving them peri-
sary to the correct level.21 In this technique there
operatively if given intravenously, or an hour pre-
is a reasonable possibility of mobilizing the re-
operatively if given orally. However, several
tained roots, which must then be removed. How-
authors have published on carrying out the tech-
ever, the proponents of this particular technique
nique without using any antibiotics, and the suc-
state if the roots are mobilized or loosened, it nor-
cess rates and infection rates seem similar.21,25–27
mally means that the nerve could not be too inti-
mately involved with the roots and therefore they Suturing
can be removed without undue risk. If the roots
are firm, they are retained in the usual way. In our technique we raise a buccal flap, and un-
Studies using this technique always show a dermine and release the periosteum if necessary,
higher incidence of failed coronectomies in that to obtain a tension-free, water tight, primary
the roots are removed at the initial surgery. How- closure of the socket.28 This was believed to be
ever, proponents of this technique do not report important for primary healing and for new bone
any higher incidence of inferior alveolar nerve to grow over the socket. However, some authors
involvement. suture without raising a buccal flap and without
Coronectomy can also be used in conjunction periosteal release, so that the socket is not
with removal of pathology in the third molar region. completely closed.21 Again, success rates seem
to be similar.
378 Pogrel

Fig. 8. Radiographs demonstrating the technique being used in the presence of pathology. (A) Preoperative im-
age showing an impacted lower right third molar in a close relationship with the inferior alveolar nerve and asso-
ciated with a dentigerous cyst. (B) Postcoronectomy.

The Distance Below the Alveolar Crest to primarily in dogs.29–31 Now that there are adequate
Leave the Roots results obtained from clinical studies on patients, it
does seem that the technique works best if the
As originally described, this technique recommen-
retained roots are left 3 to 4 mm below the alveolar
ded removal of the tooth until it was 2 to 3 mm
crest of bone.15,25,32 By leaving them a little lower
below the alveolar crest of bone (Fig. 9). These
down, the bone grows over the roots more consis-
numbers were derived from animal studies,
tently and they may move somewhat less.

RESULTS
Randomized controlled clinical trials are difficult to
perform but have been attempted33,34 as have
case control studies.15 Other studies are mainly
case series2,25,35–37 or review articles.38,39 Most
published papers describe successful results
with a low complication rate.32 Because the tech-
nique is designed to avoid permanent damage to
the inferior alveolar nerve, most published papers
do show that this aim is achieved.28,35,40,41
Typically the infection rate is noted to be no
higher than with complete third molar removal,
and by definition there can be no dry socket
because there really is no socket. Most cases of
infection seem to result from leaving some enamel
behind, from the tooth being removed. There
seems no doubt that retained enamel can harbor
bacteria and that bone does not attach to enamel,
leaving a potential problem area.
Excessive pocketing behind the second molar
has not been reported, and on average, pocket
depths measure 2 to 4 mm. If this is believed to
be an issue grafting has been suggested.42
The major complication seems to be that many
of these roots subsequently migrate. Migration
Fig. 9. Clinical result postcoronectomy. Note the
exposed pulp chamber and the retained root frag- occurs at different times but can be visible on ra-
ments below the rim of the alveolar crest. (From diographs 3 months after the extraction. It appears
Pogrel MA, Lee JS, Muff DF, et al. Coronectomy: a tech- as a periapical radiolucency and comparison of
nique to protect the inferior alveolar nerve. J Oral serial Panorex radiographs makes the movement
Maxillofac Surg 2004;62:1447–52; with permission.) obvious (Fig. 10). Some practitioners have
 Coronectomy 379

Fig. 10. Panorex radiographs showing early migration of retained roots of lower left third molar. (A) Immediately
postcoronectomy. (B) Four months later. Note that beneath the apices of the roots there is a radiolucency that has
been mistaken for periapical infection. Roots have moved despite the appearance of bone growing over the
roots.

mistaken the periapical radiolucency for infection, In our own program, the results are as follows:
but this is not the case. The radiolucency merely
represents the space where the roots were but  Total number of cases carried out between
have now migrated. The roots always appear to 1997 and August 2014: 742.
migrate away from nerve, and although sometimes  Infections: six (0.8%); two roots subsequently
they do migrate all the way to the surface (Fig. 11), required removal.
they seem to be easy to remove without complica-  Number of teeth migrating following coronec-
tion and this may occur in 1% to 5% of cases.21,43 tomy: 230 (31%).
It was believed that if the nerve truly perforated the  Number of roots subsequently requiring
roots, or the roots were deeply grooving them, removal: six or 0.8% (two for infection and
they could not in fact migrate. However, cases four because of migration). One of these pa-
have been described where the roots have tients suffered an inferior alveolar nerve injury
migrated apically taking the inferior alveolar nerve (see later).
up with them.3 Obviously, if roots such as these  The number of teeth migrating and the num-
had to be removed subsequently, considerable ber of retained roots that are subsequently
care would need to be taken. removed is probably related to the time of

Fig. 11. Radiograph showing coronal migration of the retained roots of a lower third molar over a 2-year period.
(A) Preoperative appearance showing gross decay of the tooth. (B) Six months postcoronectomy showing good
healing with apparent bone over the retained roots. (C) Two years postcoronectomy showing occlusal migration
of the retained root necessitating removal now without risk to the inferior alveolar nerve. (From Pogrel MA. Cor-
onectomy to prevent damage to the inferior alveolar nerve. Alpha Omegan 2009;102:61–7; with permission.)
380 Pogrel

follow-up, and the longer the patients are fol- technique is obviously time consuming (and pre-
lowed, the more likely it is that retained roots sumably costly) but may be indicated in certain
move and need removal. We need to await circumstances.
20- and 30-year follow-up studies to assess
the final outcome. Sequential Removal of Small Portions of the
 Number of failed coronectomies (roots were Occlusal Surface of the Impacted Third Molar
mobilized at the time of surgery and were
removed): 12, none causing inferior alveolar The technique of sequential removal of small por-
nerve symptoms. tions of the occlusal surface of the impacted third
molar such that it can erupt further until it moves
In our own series, the infection rate is actually far enough away from the nerve so that it can be
lower for coronectomy than for routine third molar safely removed was advocated by Tolstunov and
removal, and we have speculated on the reason coworkers,47 under the name of pericoronal ostec-
for this. It could simply be that many of our third tomy. Presumably one does need adequate
molars are removed by residents in training, access to the crown of the tooth to remove 1 or
whereas coronectomies are normally performed 2 mm of the occlusal surface and whichever sur-
by attendings, and therefore a lower infection face is causing the impaction at the time, and
rate might be expected. We also had one partic- again if the tooth is actually perforated by the
ularly troublesome case where the patient did get nerve, presumably it will not erupt.
repeated infections after coronectomy, and the
decision was made to surgically remove the re-
tained roots, which were found to be perforated
SUMMARY
by the inferior alveolar nerve. Despite removing Coronectomy (also called intentional root retention
the tooth fragments as atraumatically as possible, or partial odontectomy) should be considered in
this patient did suffer inferior alveolar nerve cases of patients older than 25, where there ap-
involvement, which after 6 months has largely pears to be an intimate relationship (low, medium,
resolved, but not completely. The patient still or high risk) between the roots of a retained lower
has about a 10% nerve involvement, fortunately third molar (or occasionally second or even first
manifest as paresthesia and not dysesthesia. Us- molars) and the inferior alveolar nerve, in circum-
ing our technique of lingual nerve retraction, we stances where it is not contraindicated. It may be
have had a transient lingual paresthesia rate of used on younger patients with a medium to high
slightly above 1% (eight cases), all but one of risk of inferior alveolar nerve damage. The decision
which resolved over 10 days. This last case did to use this technique is currently made with the aid
resolve completely but took 5 months to do so, of CBCT scans. The short- to medium-term suc-
which was concerning. Presumably these injuries cess rate seems to be excellent, but long-term
are stretch injuries of the lingual nerve. We have studies are not yet available and could influence
no other cases of inferior alveolar nerve the conclusions.
involvement.

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