SCIENTIFIC ARTICLE

Coronectomy to Prevent Damage

to the Inferior Alveolar Nerve
Michael Anthony Pogrel, DDS, MD

Michael Anthony Pogrel, DDS, MS
Dr. Pogrel received his dental degree from
Liverpool University in England in 1967
and his medical degree from Aberdeen in
Scotland in 1974. He completed his train-
ing in general surgery and oral and maxil-
lofacial surgery in Great Britain, Holland,
and the United States in 1979. He joined
the full-time faculty of the Department of
Oral and Maxillofacial Surgery at the Uni-
versity of California, San Francisco in
1983 and was made Professor and Chair-
man of the Department in 1994—a posi-
tion that he still holds.
C
onventional wisdom advises that when a tooth needs to be extracted,
the whole tooth should be removed, usually with as little surround-
ing bone as possible. However, the evidence to support this is not
compelling, and every dentist has experienced cases where the apices of teeth
are not removed for a variety of reasons and, in most cases, the patient seems
to suffer no ill effects. If one extrapolates from this, it is evident that there
might be instances where it is actually preferable to leave the apical part of
the root rather than remove it, and this can be carried out deliberately. The
usual time that one would consider this is when the inferior alveolar nerve
is intimately related to the roots of the lower molar teeth, and this occurs
most often in relation to the third molar. This concept of deliberately remov-
ing only the crown and part of the root of the tooth is known variously as cor-
onectomy, partial root removal, deliberate vital root retention, or partial
odontectomy.

WHEN TO CONSIDER along the plane of the mandible at

CORONECTOMY
Coronectomy would normally be
considered when there appears to
be an intimate relationship between
the roots of a lower molar (normally
the third molar) and the inferior al-
veolar nerve, although other in-
stances could be envisaged. This
relationship is normally determined
radiographically. Conventionally, for
the last 40 years, the panoramic ra-
diograph has been the standard
technique for determining the rela-
tionship of the inferior alveolar
nerve to the roots of lower molars.
Radiographic standards that have
been developed to predict this rela-
tionship include narrowing of the
nerve canal, deviation of the canal,
loss of the cortical outline of the ca-
nal, and variable radiographic den-
sities.1–3 However, the advent of
cone beam computerized tomogra-
phy (CT) scanning—whereby high
definition images can be obtained
relatively low cost, with relatively
low radiation dosages, and with rel-
ative convenience—means that in
many places, this technique has
now become the standard for evalu-
ating the relationship of the roots of
lower molars to the inferior alveolar
nerve in order to determine the ap-
propriate treatment4–8 (Figure 1).
Nevertheless, even with this tech-
nique, there are occasions when it
is not possible to orient the slices ex-
actly as one would wish, and as a re-
sult, potential damage can still occur
to the inferior alveolar nerve. An ex-
ample of this is shown in Figure 2,
where the sagittal view on the cone
beam CT scan indicates an intimate
relationship between the roots of
the third molar and the inferior alve-
olar nerve, but the coronal views fail
to show exactly what the situation
is; on removal of the tooth, it was
found that the nerve was actually
enclosed between the roots. It was
 CORONECTOMY TO PREVENT DAMAGE TO THE INFERIOR ALVEOLAR NERVE

Figure 1. Panoramic radiograph (A) and cone beam computed tomographic (CT) scan (B) of a lower left third molar. The panoramic
view suggests an intimate relationship of the roots with the inferior alveolar nerve as indicated by narrowing and deviation of the
canal and some loss of the cortical outline. However, the appropriate sections on the cone beam CT scan show the relationship in
greater detail and indicate in three dimensions that the nerve is lying against the tooth. It also shows the thinness of the lingual plate
over the third molar, showing how easily it could be fractured when the tooth is removed. (Reprinted with permission from Pogrel
MA, Partial odontectomy, Oral Maxillofac Surg Clin N Am 2007;19:85–91.)

only because one root fractured on mended that if knowledge of the re- alter the treatment, cone beam CT
tooth removal that the nerve was lationship of the inferior alveolar scanning should be performed. If
not damaged. Currently, it is recom- nerve to the roots of the tooth would such scanning suggests an intimate

Figure 2. Coronal (A) and sagittal (B) cone beam computed tomographic (CT) scan slices showing an intimate relationship of the
roots of a lower left third molar and the inferior alveolar canal. The coronal slice is not definitive and the patient elected to have the
tooth removed. During removal, the mesial root apex fractured and was removed separately. When the roots were reassembled, it
was evident that they enclosed the nerve (C) and it was only the root fracture that prevented damage to the nerve. The patient suf-
fered only a transient paresthesia. This shows that sometimes even cone beam CT scans may not always be diagnostic.

62 Alpha Omegan  Volume 102  Number 2

 CORONECTOMY TO PREVENT DAMAGE TO THE INFERIOR ALVEOLAR NERVE

Figure 4. Lingual retractor (arrow) is placed to protect the lingual soft tissues before
sectioning of the tooth (lower left third molar).

be no decay or infection involving ment of the exposed pulp is re-

Figure 3. The conventional third molar
incision extending down the external
oblique ridge to the distobuccal line an-
gle of the lower second molar, with
a buccal releasing incision going no fur-
ther forward than the midpoint of the
first molar to avoid a frequent arteriole
located in this area. (Reprinted with per-
mission from Pogrel MA, Partial odon-
tectomy, Oral Maxillofac Surg Clin N
Am 2007;19:85–91.)
the roots of the tooth; (3) the tooth
should be vital or adequately end-
odontically treated; (4) the crown
and a sufficient part of the coronal
portion of the roots must be
removed until they are 2 to 3 mm
below the level of the alveolar
crest—animal studies have noted
that bone consistently grows over
the remaining root portions if this
rule is followed9–11; (5) no treat-
quired9–12; and (6) the apical
portion of the roots that are to be re-
tained should not be mobilized dur-
ing the coronectomy procedure.
All patients are placed on prophy-
lactic antibiotics preoperatively, be-
cause it is felt that antibiotics
should be in the pulp chamber of
the tooth at the time it is trans-
ected.13 However, some studies
have indicated that antibiotics were

relationship between the inferior al-

veolar nerve and the roots of the
tooth, one has to consider the fol-
lowing alternatives: (1) not extract
the tooth and carry out an alterna-
tive procedure, such as root canal
therapy, operculectomy, or restor-
ative-type treatment; (2) remove
the tooth surgically and attempt to
avoid injury to the inferior alveolar
nerve; or (3) perform a coronec-
tomy.

CORONECTOMY TECHNIQUE
Although variations in technique
have been described, the following
common principles apply: (1) the Figure 5. The Walters (top) and IRDOG (below) lingual retractors. Note that they are
tooth undergoing coronectomy the appropriate size and shape, with no sharp edges to injure the lingual nerve. Also
must not be mobile; (2) there should shown are spoon-shaped periosteal elevators (bottom).

Alpha Omegan  Volume 102  Number 2 63

 CORONECTOMY TO PREVENT DAMAGE TO THE INFERIOR ALVEOLAR NERVE

molar, the problem area is often

the mesial aspect of the crown,
where further tooth removal may
be necessary. The radiograph also
serves as a baseline for later radio-
graphs to assess bone formation
over the remaining roots of the tooth
and also any subsequent movement
of the roots.
Primary closure of the wound
should be obtained, and for this
a periosteal releasing incision on
the inner aspect of the buccal flap
is often necessary. Once this has
been performed, the buccal flap
can normally be advanced satisfac-
torily to meet the lingual flap and
a watertight seal is obtained using
vertical mattress sutures.
Figure 6. Diagrammatic representation of coronectomy technique. A lingual retractor
has been placed to protect the lingual soft tissues, including the lingual nerve, and CONTRAINDICATIONS TO
a 701 fissure bur is being used at approximately a 45 angle to section the crown com- CORONECTOMY
pletely before removal. The gray area represents the portion of the tooth roots that is
There are relatively few contrain-
then removed to place them at least 3 mm below the alveolar crest. (Reprinted with
permission from Pogrel et al,13 copyright 2004, the American Association of Oral and dications to carrying out coronec-
Maxillofacial Surgeons.) tomy under the appropriate
circumstances, but these do include
the following: (1) any acute infec-
unnecessary.14 To expose the tooth, width to protect the lingual nerve. tion in the oral cavity or around
a conventional buccal incision is The Walters retractor (KLS Martin, the tooth to undergo coronectomy;
made along the external oblique Jacksonville, FL)15 and the IRDOG (2) chronic infection involving the
ridge of the mandible to the disto- retractor (Hartzell G, Concord, CA) root of the tooth to undergo
buccal line angle of the second mo- fulfill these requirements (Figure 5).
lar (assuming that it is the third Once the retractor is positioned,
molar to be removed) and a relieving a 701 fissure bur is used at an angle
incision is then made into the buccal of 45 to section the crown (Fig-
sulcus remaining posterior to the ure 6). The crown must be com-
central line of the first molar, pletely transected rather than
thereby avoiding a troublesome ar- fractured from the root because
teriole that is often present in this this minimizes root mobilization.
area (Figure 3). Buccal and lingual After the crown has been removed,
flaps are then raised and a lingual re- the fissure bur is used to remove
tractor is placed (Figure 4). The lat- a portion of the remaining roots
ter is performed because the crown from the buccal side so that they
must be totally sectioned and mo- are at least 3 mm below the alveolar Figure 7. A horizontally impacted third
bile before removal and, if a retractor crest on both the buccal and lingual molar lying along the superior border
is not used, there is a risk of perfo- aspects (Figure 6). The exposed of the inferior alveolar canal. This tooth
rating the lingual plate and possibly pulp does not need to be treated in may not be suitable for coronectomy be-
cause the nerve could be injured in the
damaging the lingual nerve. The lin- any way. A radiograph is taken to en-
process of sectioning the crown. (Re-
gual retractor should be specifically sure that the tooth and root removal printed with permission from Pogrel
designed with an appropriate shape, are adequate. In the case of a me- MA, Partial odontectomy, Oral Maxillo-
no sharp edges, and an adequate sioangularly impacted lower third fac Surg Clin N Am 2007;19:85–91.)

64 Alpha Omegan  Volume 102  Number 2

 CORONECTOMY TO PREVENT DAMAGE TO THE INFERIOR ALVEOLAR NERVE
Figure 8. Radiographs showing coronal
migration of the retained roots of a lower
right third molar over a 2-year period. A,
Preoperative appearance showing gross
decay of the tooth. B, Six months post-
coronectomy showing good healing. C,
Two years postcoronectomy showing
occlusal migration of the retained roots
necessitating removal, but without risk
to the inferior alveolar nerve.
coronectomy (this includes exten-
sive dental caries and periodontal
disease); (3) any mobility in the
tooth to undergo coronectomy; and
(4) teeth that are horizontally im-
pacted along the course of the infe-
rior alveolar nerve may be
unsuitable for coronectomy (Fig-
ure 7). This is because sectioning
the crown could endanger the
nerve. The technique is more appro-
Alpha Omegan  Volume 102  Number 2
Figure 9. Radiographs showing bone formed over the retained roots of a lower right
third molar over a 1-year period. A, Immediately after coronectomy. B, One year later.
priate for vertical, mesioangular, or
distoangular impacted teeth.
COMPLICATIONS OF
CORONECTOMY
Immediate Complications
Although immediate postopera-
tive infection can occur, it is very
unusual, particularly if antibiotics
and primary closure are used. It is
probably no greater than the risk
of infection that occurs with routine
tooth removal.
If mobilization of the roots occurs
at the time of surgery, the procedure
is likely to fail, and therefore the
roots should be removed. Root mo-
bilization has been described as oc-
curring between 3% and 9% of the
time.13,16,17 This generally occurs
because the crown is not completely
sectioned and is fractured to remove
it. A 38% failure rate was noted in
one study when the roots are
loose.14
Lingual nerve injury can occur in
two ways. If a lingual retractor is
not used, it could conceivably be
damaged during sectioning of the
crown, although this has not been
reported. If a lingual retractor is
used, placement of the retractor
can occasionally cause transient
lingual nerve involvement, and
this has been noted.18,19 No cases
of permanent lingual nerve involve-
ment from this technique have been
reported.
Damage to the inferior alveolar
nerve can occur even though this
technique is designed specifically
to minimize such risk. This is gen-
erally caused by inappropriate cut-
ting with the bur or during
debridement.16
Long-term Complications
By far the most common long-
term complication appears to be
that the root remnants move over
the succeeding months and years af-
ter coronectomy. This has been
noted in every article published on
the subject and appears to occur in
between 14% and 81% of cases, de-
pending on the length of follow-
65
 CORONECTOMY TO PREVENT DAMAGE TO THE INFERIOR ALVEOLAR NERVE

removal an odontogenic cyst. Radio-

Figure 10. Radiographs demonstrating the technique being used in the presence of
pathology. A, Preoperative image showing an impacted lower right third molar in in-
timate relationship with the inferior alveolar nerve and associated with a dentigerous
cyst. B, Postcoronectomy. C, Six months postcoronectomy showing excellent new
bone formation and no movement of the retained roots.
up.13,14,16,17,20 However, in all
cases, the roots moved coronally
away from the nerve so that if subse-
quent removal were necessary, it
would be straightforward (Figure 8).
However, one can also envisage that
if the apical root fragments really are
enclosing the inferior alveolar nerve,
they would probably not be able to
move.
Cases have been noted where ei-
ther late chronic infection arose or
the root fragments migrated coro-
nally and broke through the mucosa,
causing localized inflammation or
graphically, it is evident that bone
will form over the retained roots. Al-
though this has not been studied in
any depth in humans, it has been
verified in animal models. In the hu-
man, where retained root apices
have migrated coronally and re-
quired subsequent removal, it has
often been noted that bone has
formed over all of the roots with
the exception of the one that has mi-
grated coronally through the mu-
cosa.
CONCLUSION
When appropriate imaging sug-
gests an intimate relationship be-
tween the roots of a lower molar
(most often a third molar) and the in-
ferior alveolar nerve, and the tooth
needs to be removed, consideration
should be given to coronectomy
with retention of the portion of the
root(s) that is associated with the in-
ferior alveolar nerve. Because the
literature is limited on this topic,
there is still no standard of care
with regard to this technique. As
more information becomes available,
modifications may be indicated.
References
1. Howe GL, Poynton HG. Prevention of
damage to the inferior alveolar nerve dur-
ing the extraction of mandibular third
molars. Br Dent J 1960;109:355–63.
infection requiring removal of the
2. Blaeser BF, August MA, Donoff RB,
roots.13 Kaban LB, Dodson TB. Panoramic ra-
diographic risk factors for inferior alve-
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3. Rood JP, Shehab BA. The radiological
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work, but all have variations in the nabe NY, Hoshiba D, Kobayashi K,
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