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British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx

Systematic review
Injury to the inferior alveolar and lingual nerves in
successful and failed coronectomies: systematic review
M. Dalle Carbonare a,∗ , A. Zavattini b , M. Duncan a , M. Williams a , A. Moody a
aDepartment of Oral and Maxillofacial Surgery, Eastbourne District General Hospital, King’s Dr., Eastbourne, BN21 2UD, East Sussex, United Kingdom
bDepartment of Oral and Maxillofacial Surgery, Queen Elizabeth Hospital, Mindelsohn Way Edgbaston, Birmingham, B15 2TH, West Midlands, United
Kingdom

Accepted 15 September 2017

Abstract

The aim of this systematic review was to evaluate the incidence of damage to the inferior alveolar (IAN) and dental nerves in successful
coronectomies, and to compare the results with coronectomies that failed. To the best of our knowledge no such analyses have been reported.
Between January 1990 and October 2016 we surveyed published papers to find those that examined clinical outcomes after coronectomy.
Fourteen met the criteria for final inclusion. Of 2087 coronectomies, 152 failed (7%). Successful procedures were associated with a low overall
incidence of injury to the IAN (0.5%) and lingual nerve (0.05%). The incidence of injury to the IAN in failed coronectomies was 2.6%. The
incidence of permanent paraesthesia was 0.05% in successful coronectomies and 1.3% in those that failed. No permanent injury to the lingual
nerve was reported. Mobility (36%, 55/152) and migration or exposure (33%, 50/152) of roots were the most common underlying causes of
failure. Coronectomy seems to be safe, but it depends on the patient and the technique used. To ensure adequate assessment of postoperative
complications, we strongly recommend systematic evaluation of the reduction in sensitivity of the lower lip, chin, or tongue, and a standard
follow up.
© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Coronectomy; partial odontectomy

Introduction In 1990, Rood and Shehab3 identified seven radiological

Damage to the inferior alveolar nerve (IAN) during the
extraction of mandibular third molars is a well-known com-
plication, particularly when the teeth are deeply impacted.
The estimated risk of temporary injury ranges from 0.26%
to 8.4%, and the incidence of permanent loss of sensation is
up to 3.6%.1–3 Sensory deficit of the lingual nerve, however,
varies from 0.1% to 22%.1
∗
Corresponding author. Fax: +44 1323 435749.
E-mail addresses: marcodallecarbonare@icloud.com (M. Dalle Car-
bonare), angelzav@hotmail.com (A. Zavattini), milesduncan@nhs.net (M.
Duncan), m.williams16@nhs.net (M. Williams), andrew.moody4@nhs.net
(A. Moody).
markers that were significantly associated with injury to the
IAN: deviation or narrowing of the canal; periapical radiolu-
cency; narrowing, darkening, and curving of the roots; and
loss of lamina dura over the wall of the mandibular canal all
recorded a 30% incidence of injury. In the presence of these
findings, cone-beam computed tomography (CT) is superior
for operative planning and the prevention of injury to the
nerve.4–6
Coronectomy (or partial odontectomy), which involves
removing the crown and leaving the roots in place, was first
introduced by Knutsson et al in 1989 as a means of avoid-
ing damage to the IAN.7 Pogrel et al5 and Gleeson et al8

http://dx.doi.org/10.1016/j.bjoms.2017.09.006
0266-4356/© 2017 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Dalle Carbonare M, et al. Injury to the inferior alveolar and lingual nerves in successful and failed
coronectomies: systematic review. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.09.006
 2

YBJOM-5267;
coronectomies: systematic review. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.09.006
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Table 1
List of studies that report the incidence of injury to the inferior alveolar (IAN) and lingual nerves (LN) in successful and failed coronectomies. Studies with a minimum follow up of six months and at least 50
coronectomies are included. Data are number (%).

M. Dalle Carbonare et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
First author, Study type Preoperative No. of Follow up Coronectomies Transient injury Permanent injury
year and assessment coronectomies (months)
reference (n = 2087)
Successful Failed (n = 152) IAN LN IAN LN

Successful Failed Successful Failed Successful Failed Successful Failed

Pogrel 20045 PCS OPG 50 6-42 47 3 (6) 0 0 1 (2) 0 0 0 0 0

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Agbaje 20156 PCS OPG 96 12 87 9 (9) 0 0 0 0 0 0 0 0
CBCT
Renton 20059 RCT OPG 94 6-24 58 36 (38) 0 1 (3) 0 0 0 2 (6) 0 0
Hatano 200910 CC OPG 102 12 98 4 (4) 1 (1) 0 0 0 0 0 0 0
CBCT
Leung 200911 RCT OPG 171 24 154 17 (10) 1 (0.6) 1 (6) 0 0 0 0 0 0
Cilasun CC OPG 88 6-29 86 2 (2) 0 0 0 0 0 0 0 0
201112
CBCT
O’Riordan RCS OPG 52 24 49 3 (6) 3 (6) 0 0 0 1 (2) 0 0 0
200413
Goto 201214 PCS OPG 124 12 115 9 (7) 0 0 0 0 0 0 0 0
CBCT
Leung 201215 PCS OPG 135 36 131 4 (3) 1 (0.8) 0 0 0 0 0 0 0
Kohara 201516 PCS OPG 111 36 101 10 (9) 1 (1) 0 0 0 0 0 0 0
CBCT
Frenkel RCS OPG 185 6-12 175 10 (5) 1 (0.6) 0 0 0 0 0 0 0
201517
CBCT
Monaco PCS OPG 116 6-36 108 8 (7) 0 0 0 0 0 0 0 0
201518
CBCT
Leung 201619 PCS OPG 612 6-60 592 20 (3) 1 (0.2) 0 0 0 0 0 0 0
Kouwenberg PCS OPG 151 6 134 17 (11) 0 0 0 0 0 0 0 0
201620

RCS: retrospective cohort study; PCS: prospective cohort study; CC: case-control study; RCT: randomised controlled trial; OPG: orthopantogram; CBCT: cone-beam computed tomography
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M. Dalle Carbonare et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Table 2
Overall details of injury to the inferior alveolar (IAN) and lingual nerves. There were no permanent injuries to the lingual nerve. Data are number (%).
Coronectomy
Successful (n = 1935)
Overall injury to IAN 10 (0.5)
Transient injury 9 (0.5)
Permanent injury 1 (0.05)
Injury to LN 1 (0.05)
Injury to IAN:
With OPG only – –
With OPG and cone-beam CT – –
OPG: orthopantogram; CBCT: cone-beam computed tomography.
described two approaches that aimed to section the crown
either completely or partially.
In comparison with conventional extraction, Renton et al9 ,
Hatano et al10 , Leung and Cheung,11 and Cilasun et al12 con-
cluded that coronectomy is safe and reliable for the removal
of deeply impacted teeth and it has a low incidence of nerve
damage. However, as the incidence of failed coronectomies is
reported to range from 2.3% to 38.3%,5,6,9–20 the risk of com-
plications with possible long-term morbidity must be taken
into consideration. We know of no studies that focus on the
incidence of injury to the IAN and lingual nerve after failed
coronectomy.
Our main objective therefore was to estimate the inci-
dence of injury to these nerves in failed coronectomies, and
to compare them with those in successful procedures.
Material and methods
We made a systematic review by searching the terms
“coronectomy” and “partial odontectomy” using the elec-
tronic databases: Medline, Embase, Cochrane library, AMED
(Allied and Complementary Medicine), BNI (British Nurs-
ing Index), CINAHL (Cumulative Index to Nursing and
Allied Health Literature), HBE (Health Business Elite),
HMIC (Health Management Information Consortium), and
®
PsycINFO (American Psychological Association). English
papers that included a minimum of 50 coronectomies (pub-
lished between January 1990 and October 2016) and which
reported at least six months follow up, were included. Those
not in English, animal studies, those that reported root canal
treatment of wisdom teeth before or during coronectomy, and
in vitro studies, were excluded, as were comments, expert
opinions, letters to the editor, posters, case reports, and case
series.
Our first search found 183 papers, which became 98 when
duplicates were eliminated. All 98 titles and abstracts were
read, and we analysed the full text of 20 papers. After read-
ing the full text, six more were excluded. Four were part of
a poster project, the fifth21 matched all the inclusion crite-
ria, but was discarded because the same findings (plus new
ones) had been presented again a year later,11 and the sixth,22
despite presenting 840 coronectomies, focused its research
Please cite this article in press as: Dalle Carbonare M, et al. Injury to the inferior alveolar and lingual nerves in successful and failed
coronectomies: systematic review. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.09.006
3
Total (n = 2087)
Failed (n = 152)
4 (3) 14 (0.7)
2 (1.3) 11 (0.5)
2 (1) 3 (0.1)
0 1 (0.04)
11/1265 (0.9)
3/822 (0.4)
on the histological vitality of the retrieved roots and did not
contemplate any follow up.
Fourteen papers fulfilled our criteria: two retrospective
cohort studies, two case-control studies, two randomised con-
trolled trials, and eight prospective cohort studies.
We also assessed the quality of the studies and the risk of
bias, which adopted the method of modified quality evalua-
tion by Antczak et al.23
Results
Tables 1 and 2 show details of the 2087 coronectomies, of
which 152 failed (7%).
Four studies compared the incidence of injury to the IAN
and lingual nerve between the extraction of third molars and
coronectomy.9–12 Renton et al9 found 19 injuries to the IAN
in 102 extractions of wisdom teeth (19%), no injuries in 58
successful coronectomies, and three in 36 failed coronec-
tomies. Hatano et al10 reported signs of injury to the nerve in
six of 118 (5%) patients who had wisdom teeth extracted. In
the coronectomy group, one of 98 patients developed signs of
injury but there were no injuries after failed coronectomies.
Leung et al11 reported injury to the IAN in nine of 178 patients
(5%) in the third molar extraction group, but only one after
155 successful coronectomies (0.6%). Transient paraesthe-
sia was reported in one of 17 patients whose coronectomies
failed. Cilasun et al12 reported injury to the IAN in two of 87
patients in the extraction group. No patients in the successful
or failed coronectomy groups (n = 88) developed complica-
tions. None of these studies reported injury to the lingual
nerve. O’Riordan13 reported the highest incidence of injury
to the IAN after successful coronectomies (4/49, 8%) (one
patient showed signs of permanent paraesthesia). Renton et
al9 reported the highest incidence of failed coronectomies
(36/94, 38%). Three patients had postoperative signs of injury
to the IAN of which two were permanent. The only case of
(transient) injury to the lingual nerve was reported by Pogrel
et al,5 with an incidence of 2% (1/47).
Table 2 shows the overall incidence of injury to the
IAN after coronectomy of those teeth assessed with an
orthopantogram (OPG) and both OPG and cone-beam CT.
Tables 3 and 4 show the reasons why coronectomies failed.
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Table 3
Reasons that led to failure of coronectomy and the technique used (complete or partial sectioning of the crown).
First author, year, and reference Mean (SD) age No. of failed Technique Underlying reason for removal of root (No.)
(years) coronectomies
Pogrel 20045 - 3 Complete Migration/exposure of root (1)
Mobile roots (2)
Agbaje 20156 - 9 Partial Migration/exposure of roots (5)
Infection (4)
Renton 20059 27.9 (5.8) 36 Partial Mobile roots (36)
Hatano 200910 32.4(10.4) 4 Partial Infection (4)
Leung 200911 26.2 (7.3) 17 Complete Mobile roots (16)
Migration/exposure of roots(1)
Cilasun 201112 - 2 Partial Unknown (2)
O’Riordan 200413 - 3 Partial Infection (1)
Chronic advanced periodontal disease* (1)
Pulpitis (1)
Goto 201214 - 9 Complete Wound dehiscence (7)
Pulpitis (1)
Migration/exposure of root (1)
Leung 201215 27.6 (7.9) 4 Complete Migration/exposure of roots (4)
Kohara 201516 10 - Wound dehiscence (7)
Migration/exposure of roots (2)
Infection (1)
Frenkel 201517 27.6 (11.0) 10 - Enamel retention (6)
Mobile root (1)
Migration/exposure of root (1)
Unknown (2)
Monaco 201518 - 8 Complete Migration/exposure of roots (4)
Enamel retention (3)
Gingival hyperplasia distal to second molar* (1)
Leung 201619 - 20 Complete Migration/exposure of root (14)
Infection (2)
Pulpitis (2)
Enamel retention (1)
Orthognathic surgery* (1)
Kouwenberg 201620 - 17 Complete Migration/exposure of root (17)

-: Data either not available or not clearly deducible.

* Underlying causes that were considered as “other”.

Table 4 Discussion
Failed coronectomies.
No. (%) Since its introduction, coronectomy has been shown9–12 to
Failed coronectomy 152/2087 (7) be safe. Our review confirms this, with an incidence of injury
Mobile root (complete sectioning) 18/55 to the IAN of only 0.5%.
Mobile root (partial sectioning) 36/55 After the removal of mandibular third molars in 250
Total overall underlying causes:
Others* 3/152 (2)
patients by the raising of a lingual flap with a specifically
Pulpitis 4/152 (3) designed double-ended Walter lingual retractor, Pogrel and
Unknown 4/152 (3) Goldman24 reported that lingual paraesthesia was transient in
Enamel retention 10/152 (7) four patients (1.6%) and permanent in none. As the authors
Wound dehiscence 14/152 (9) suggested, the cases of transient injury were presumably
Infection 12/152 (8)
Migration/exposure of root 50/152 (33)
caused by excessive traction.24
Mobile root 55/152 (36) The overall incidence of failed coronectomy (7%),
which includes those of more than 9% in five of the 14
* Chronic advanced periodontal disease, gingival hyperplasia distal to second
studies,6,9,11,16,20 suggests that serious postoperative compli-
molar, or orthognathic surgery.
cations are a threat. The incidence of transient or permanent
injury to the IAN after failed coronectomy was five times
higher (2.6%) than that after successful procedures (0.5%),
but was lower than that after the extraction of mandibular
Assessment of quality and risk of bias showed that three third molars.1–4
studies were high quality,9–11 10 were medium,5,6,12,14–20 and Renton et al9 and Goto et al14 found that coronectomies
one was low13 (Table 5). were most likely to fail in young women with conically-

Please cite this article in press as: Dalle Carbonare M, et al. Injury to the inferior alveolar and lingual nerves in successful and failed
coronectomies: systematic review. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.09.006
 YBJOM-5267;
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M. Dalle Carbonare et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Table 5
Study quality and risk of bias (adopting the method of modified quality evaluation by Antczak et al23 ).
Author Study Sample Radiographic Description Description of Operators Contraindications Clinical Lip/tongue Score Quality
type description evalua- of surgical (≥2 = 2; for technique outcomes* assess- (low: ≤ 10; assessment
(RCT = 3; (full = 2; tion follow approach + antibiotic 1 or (full descrip- (full:5 ele- ment medium:
CC = 2; partial = 1) (preop- up treatment if none tion = 3; ments = 3; (present = 1; 11 - 15;

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PCS/RCS = 1) erative (full = 2; used (full = 2; speci- partial = 2; not partial:3-4 absent = 0) high: ≥ 16)
OPG + cone- par- partial = 1) fied = 1) adopted/described = 1) ele-
beam tial = 1) ments = 2;
CT = 2; poor: ≤2
OPG ele-
only = 1) ments = 1)
Pogrel5 1 1 1 1 2 2 2 2 0 12 Medium
Agbaje6 1 1 2 1 1 1 2 2 1 12 Medium
Renton9 3 2 1 2 2 2 3 2 0 17 High
Hatano10 2 1 2 2 1 2 3 3 1 17 High
Leung11 3 2 1 1 1 2 3 3 1 17 High
Cilasun12 2 1 2 2 2 1 3 1 0 14 Medium
O’Riordan13 1 1 1 2 1 1 1 2 0 10 Low
Goto14 1 2 2 2 1 2 2 2 0 14 Medium
Leung15 1 2 1 2 2 2 1 3 1 15 Medium
Kohara16 1 2 2 2 2 1 1 2 0 13 Medium
Frenkel17 1 2 2 2 2 1 1 2 0 13 Medium
Monaco18 1 2 2 2 1 1 2 3 0 14 Medium
Leung19 1 1 1 2 2 1 3 2 0 13 Medium
Kouwenberg20 1 2 1 2 2 2 1 3 1 15 Medium

*injury of inferior alveolar nerve in successful/failed coronectomy, injury of lingual nerve in successful/failed coronectomy, description of underlying cause for failed coronectomy.
RCT: randomised controlled trial; CC: case-control study; RCS: retrospective cohort study; PCS: prospective cohort study; OPG: orthopantogram; CBCT: cone-beam computed tomography.

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rooted third molars as a result of mobility of the roots. This
may be because the buccal and lingual cortical bone in the
mandible is thinner in women than in men so the apices
of these teeth are closer to the IAN.14,16 Data on age and
sex were lacking in most of the 14 studies, but the five that
specified both showed a higher incidence of complications in
women.9,14–17
None of the coronectomies analysed included root canal
treatment. According to Sencimen et al,25 endodontic treat-
ment does not affect the success of the procedure, but is
contraindicated (7/8 roots transected during root canal treat-
ment had to be removed because of infection, and there were
three cases of injury to the IAN).
Patel et al22 studied the roots of mandibular third molars
histologically after failed coronectomies (26/840 (3%) failed,
and there was one case of transient injury to the IAN). All
the pulp was vital and there was no evidence of periradicular
inflammation, which contradicts the argument that roots left
after coronectomy are a potential source of infection.
In their prospective study, Rood and Shehab3 found that
14% of 125 teeth, which seemed to have an increased risk of
nerve damage on OPG, developed an injury. Our review con-
firms that cone-beam CT enables surgical planning to be more
accurate4–6 as, among 1265 coronectomies assessed only by
OPG, there were 11 injuries to the IAN (0.9%). However,
after assessment by OPG and cone-beam CT there were 3/822
injuries (0.4%). Other authors have also confirmed the better
diagnostic accuracy.26,27 Neves et al26 reported that its preop-
erative use had confirmed that the relative position of the roots
of the wisdom teeth and the inferior dental nerve canal put
them at risk in all 14 cases in which the IAN was exposed dur-
ing operation. The association between exposure of the nerve
and the proximity of the roots to the inferior dental nerve
canal was significant (p = 0.015). In their review, Céspedes-
Sánchez et al27 recommended the use of cone-beam CT when
there were signs of the proximity of the third molars to the
inferior dental nerve canal. The routine use of cone-beam CT
is not, however, justified.28
Currently, there are two main techniques of coronectomy.
The decoronation stage can be divided into complete and par-
tial sectioning. Complete sectioning (described by Pogrel et
al5 ) involves total transection of the crown with a fissure bur
at 45◦ to reduce the risk of the roots becoming mobile. A lin-
gual retractor is essential to avoid injury to the lingual nerve
if the lingual plate is perforated.5,24 The technique requires
the raising of a lingual flap, which improves access to the
surgical site and can simplify removal of the tooth.4 Gleeson
and Patel8 described partial sectioning of the crown to three-
quarters with a fissure bur, and subsequent snapping off with
a Coupland or a straight Warwick-James elevator. This tech-
nique aims to avoid the need to raise a lingual flap and any
possible injury to the lingual nerve, but unfortunately can lead
to mobility of roots. Knutsson et al7 and O’Riordan13 sug-
gested that the pressure within the tooth, which is transmitted
to the IAN when the tooth is split, can lead to paraesthesia.
In both techniques, the retained roots are left 3 mm below
Please cite this article in press as: Dalle Carbonare M, et al. Injury to the inferior alveolar and lingual nerves in successful and failed
coronectomies: systematic review. Br J Oral Maxillofac Surg (2017), http://dx.doi.org/10.1016/j.bjoms.2017.09.006
the alveolar crest to allow bone to form above the transected
tooth.
Tables 3 and 4 show the incidence of mobile roots after
the use of both techniques, and they confirm that partial sec-
tioning of the crown leads to a higher risk. In these cases,
the roots act as foreign bodies that trigger infection, and the
tooth must be removed completely.
Some authors9,12,15 advocate a follow up of 24 months
to evaluate the incidence of early and late complications.
Although roots have been reported to migrate 10 years after
the initial coronectomy, most do so during the first two.15,16
Leung et al15 stated that roots normally migrate within the
first 24 months with a peak of 2.6 mm during the first year and
2.9 mm during the second year, but it then decreases because
bone forms above them. Kohara et al16 reported a further
mean movement of 3.51 mm during the third year. Renton et
al,9 Agbaje et al,6 and Monaco et al18 reported incidences of
root migration of 30%, 40%, and 80%, respectively. We think
that a follow-up period of 24 months is advisable to assess
the exact incidence of complications, as migration does not
seem to be predictable.5 However, roots that migrate late are
likely to erupt away from the nerve, which virtually removes
the risk of nerve injury during their retrieval.4,9,19
For this reason, we decided to recalculate the incidence of
injury to the IAN in failed coronectomies (excluding those
caused by migration or exposure of the root) to gain a more
realistic picture of the risk. We found an overall incidence of
4% (4/102).
Currently, we know of no standard protocol for follow
up after coronectomy. Each of the 14 papers established their
own, and only a few authors6,10,11,15,20 stated that they used a
subjective or objective scaled evaluation of reduced sensation
in the lower lip, chin, and tongue. These figures are important
with regards to quality of life and must be taken into account.
A detailed and standard protocol is therefore necessary to
ensure uniformity.
In conclusion, although coronectomy is a safe and reliable
option for the removal of deeply impacted mandibular third
molars, its success depends on both the patient and the tech-
nique used. The reported failure rate (7%) suggests that the
development of complications is a threat to quality of life,
and it is therefore essential to explain the risks to patients to
ensure that consent is properly informed. The incidence of
permanent injury to the IAN in failed coronectomies is lower
than that for the extraction of mandibular third molars (1.3%
and 3.6%, respectively).
A standard follow up of 24 months would allow a more
accurate estimate of the incidence of complications, but the
need for a specific follow-up protocol must lead us to ask
whether the exposure to radiation that would be needed for
the collection of postoperative data is acceptable.
Conflict of interest
We have no conflicts of interest.
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M. Dalle Carbonare et al. / British Journal of Oral and Maxillofacial Surgery xxx (2017) xxx–xxx
Ethics statement/confirmation of patients’ permission
There is no need for ethics approval or patients’ consent.
Acknowledgements
I would like to thank Dr. Maya Shahsavari for her commit-
ment in providing the final labor limae, despite her being
in the middle of her exams. When the time to travel comes,
remember that “non potrai mai comprendere il mare, ma nav-
igandolo arriverai a capire il tuo cuore.” (Michele Gentile)
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