See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/273464858

Fractured root tips during dental extractions and retained root fragments. A
clinical dilemma?

Article  in  British dental journal official journal of the British Dental Association: BDJ online · March 2015
DOI: 10.1038/sj.bdj.2015.147 · Source: PubMed

CITATIONS READS

18 114,214

4 authors:

Junaid Nayyar Mary D Clarke

University College Cork Trinity College Dublin
3 PUBLICATIONS   19 CITATIONS    11 PUBLICATIONS   406 CITATIONS   

SEE PROFILE SEE PROFILE

Michael O'Sullivan Leo F A Stassen

Trinity College Dublin Trinity College Dublin
47 PUBLICATIONS   976 CITATIONS    180 PUBLICATIONS   2,037 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Ipsilateral second nasolabial flap reconstruction for oral squamous cell carcinoma View project

Performing mucosal tissue biopsies in general dental practice View project

All content following this page was uploaded by Junaid Nayyar on 02 February 2016.

The user has requested enhancement of the downloaded file.

Fractured root tips during dental
extractions and retained root
fragments. A clinical dilemma?
J. Nayyar,1 M. Clarke,2 M. O’Sullivan3 and L. F. A. Stassen*4
Root tip fracture can occur during the extraction of teeth. The clinician must then decide to either leave the root fragment
in situ, or to attempt its removal. A similar decision is made when retained root fragments are found incidentally on oral
radiographs. The prevalence of retained root fragments is reported as 11-37%. This article aims to highlight the risk benefit
matrix of the removal or retention of retained root fragments, in light of the present evidence base.
INTRODUCTION
Retained root fragments are a common
occurrence in both dentate1–3 and edentu-
lous patients.4–9 Practitioners often differ in
their opinion on whether these retained roots
should be removed and their presence can
pose challenges to clinicians when formulat-
ing a treatment plan based on an individual
patient’s needs. Historically, in the 1920s,
there was a common consensus that all root
tips should be removed, as anything less
than complete removal of the crown-root
complex was seen as a disservice to patients
which would lead to pain, infection and cyst
development.10 This article aims to high-
light the risk benefit matrix of the removal
or retention of retained root fragments, to
allow practitioners to make clinical decisions
in light of the evidence base.
Studies carried out on the prevalence of
retained roots1,2,4,7–9,11–13 have shown that the
majority of retained root fragments cause no
harm to patients and are only detected as inci-
dental radiographic findings.8,14 Several histo-
logical studies have examined the healing of
extraction sockets in the presence of fractured
root fragments.8,15–21 The studies showed that,
under certain circumstances, root fragments
could successfully remain in situ with normal
healing taking place together with the for-
mation of a cementum layer on the dentine
1
Dental student, 2Oral Surgeon/Lecturer, 3Senior Lec-
turer/Consultant in Restorative Dentistry, 4Professor in
Oral & Maxillofacial Surgery, Dublin Dental University
Hospital, Trinity College Dublin, Ireland
*Correspondence to: Professor Leo F. A. Stassen
Email: leo.stassen@dental.tcd.ie
Refereed Paper
Accepted 21 January 2015
DOI: 10.1038/sj.bdj.2015.147
© British Dental Journal 2015; 218: 285-290
BRITISH DENTAL JOURNAL VOLUME 218 NO. 5 MAR 13 2015
allowing bone deposition, thus enclosing the
root fragment within bone.
This knowledge led to the further develop-
ment of the submerged-root concept22–26 and
decoronation27–29 to help preserve alveolar
bone for future prosthodontic treatment. It
also led to the research and the practice of
coronectomy,30–34 which is the removal of
a wisdom tooth crown from its roots (in a
healthy tooth) in suitable patients to prevent
inferior alveolar nerve injury (resulting in a
numb lip, when there is significant injury).34
However, retained roots also have the pro-
pensity to cause pain and discomfort35,36 to
patients and can be a source of infection,
especially if fractured during the extraction of
non-vital teeth.8,15,16 Retained roots can com-
plicate the fabrication of complete dentures as
they can potentially cause pain and numbness
if the denture base or flange impinges close
to the root fragment, either immediately37
or after several years due to alveolar ridge
resportion.38 Dentures impinging on retained
roots may cause nerve compression.35
Clinicians should carry out a risk-ben-
efit matrix analysis when considering the
removal of retained roots for each individual
patient (Fig.  1). If it is decided to leave a
retained root fragment in situ, the dentist is
obliged to advise the patient, and to ensure
regular clinical and radiographic follow-up
while taking into account safe radiation
exposure guidelines.39
LITERATURE REVIEW
Prevalence of retained
root fragments
The prevalence of retained root fragments
in edentulous mouths is well described
with retained roots being the most common
© 2015 Macmillan Publishers Limited. All rights reserved
IN BRIEF
• Discusses the present evidence
base regarding the advantages and
PRACTICE
disadvantages of removing root
fragments, which can occur during the
extraction of teeth, compared to leaving
them in situ.
• Outlines how a risk benefit matrix can be
used by clinicians to determine the best
course of action relating to fractured
root tips during dental extractions.
High Medium High Critical
Impact of occurence
Medium Low Medium High
Low Low Low Medium
Low Moderate High
Likelihood of occurence
Fig. 1 Risk benefit matrix
finding on radiographic examination.4,11
The prevalence varies between studies, with
15.4-37.3%4,11 of edentulous patients having
at least one retained root (Table 1).
The prevalence of retained root fragments
in partially dentate mouths has been reported
to have a lower frequency, with incidences of
20%,1 13%2 and 11%3 being reported.
Herd8 in 1973 reported an uneven distri-
bution of retained roots within the mouth
with 161 retained roots present in the max-
illa compared to just 67  in the mandible.
Maxillary molars and premolars are most
likely to fracture during extraction, with
an increased proportion of retained roots
detected on radiographs in these regions.6,8,9
It is thought that these teeth are susceptible
to intra-operative fracture due to divergent
and curved root morphology, difficult opera-
tor access44 and thin and multiple roots.41,45
Maxillary left molars had a higher propor-
tion of root fractures and oro-antral com-
plications (59.3-60.2%) than maxillary right
molars (40.7-39.8%),2,44 with the operator’s
dominant hand being postulated as a causa-
tive factor44 (Table 2).
285
 PRACTICE

Spyropoulos et al.9 provided a visual rep- Table 1 Percentage of edentulous patients with retained roots detected on radiographic
resentation of the distribution of retained examination
roots within the mouth (Fig. 2). Study Year reported Sample population Number of Percentage with
patients retained roots
HEALING OF EXTRACTION (%)
SOCKETS WITH FRACTURED Cook5 1927 Not reported 500 29
ROOT SEGMENTS Cheppe 40
1936 Dental school patients 190 30.5
The events following tooth extractions have Waggener & Austin13 1941 Not reported, patients surveyed 1380 27
been well described in both animals46 and post extraction
humans.47–52 Animal15–20,53 and human8,14,54 Swenson41 1944 Not reported 331 31.23
studies on the histologic reaction to retain- Storer42 1957 Not reported 500 25.2
ing root fragments showed that while the Dachi & Howell1 1961 Dental school patients 611 26.4
histological processes are often quicker in
Ettinger 43
1971 Dental school patients and 538 33
animals than in humans - due to the dif- armed services personnel
ference in socket size47,48 - the actual events
Scandrett et al.6 1973 Veterans care facility 212 37.3
are similar.55 When a portion of the root
fractures and is left in situ there is a depar- Spyropoulos et al. 9
1981 Dental school patients, 368 31
requiring complete dentures
ture from normal healing, with the length,47
pulpal status16 and position8,56 of the root Kharat2 1991 Dental school patients 237 27
along with adequate closure of the socket Sumer4 2007 Dental school patients, 328 15.4
requiring complete dentures
margins16,17,19,20 dictating the outcome.

THE ROLE OF EPITHELIUM

Table 2 Distribution of retained roots in different areas of the mouth
Glickman,18 Smith19 and Pietrokovski20 all
carried out experimental fractures of the Study Year Sample Right Anterior Left Right Left Anterior
roots of molar teeth Albino rats, retaining population maxilla maxilla maxilla mandible mandible mandible
(%) (%) (%) (%) (%) (%)
the apical portion of the root. Most extrac-
tion sites healed well, but slower than empty Herd8 1973 Dental hospi- 29.8 12.7 28 14.9 10.9 3.5
tal, referrals
extraction sockets due to inflammatory pro-
to oral surgery
cesses. It was seen that when bone or root department
fragments were close to the surface, the epi-
Scandrett 1973 Veterans care 50.7 (left 11.3 33.8 (left 4.2
thelium was not continuous and extended et al.6 facility & right) & right)
around the fragments similar to a periodon-
Spyropoulos 1981 Dental school 28.1 12.3 28.1 12.3 12.2 3.5
tal pocket18,19 (Fig. 3). et al.9 patients,
The surface epithelium extruded the requiring com-
inflamed bony and root fragments during plete dentures
the healing of extraction sockets by extrud- Kharat2 1991 Dental school 18.7 9.7 27.6 16.3 21.9 9.5
ing inflamed bony and root fragments.19,20 patients
Fragments that are close to the surface of Masood2 2007 Dental school 26.3 7.9 21 29 13.1 2.6
the socket are easily extruded. Fragments patients,
that are deeper within the socket are not requiring com-
plete dentures
externalised, as the epithelium is unable to
extend under the root fragment completely.
These deeper fragments and the surrounding
inflammatory cells remain in the socket, are
exposed to the oral micro flora, and develop
periapical abscesses18,19 (Fig. 4).

CEMENTUM FORMATION AND SIG-

NIFICANCE OF PRIMARY CLOSURE
Whitaker16 and Johnson,17 in 1974, under-
took separate experiments to study the effects
of retained roots in the Cebus Apallae and
Macaca Nemestrina monkeys. Roots were
fractured 1-3 mm below the level of the alveo-
lar bone and the sockets sutured. Both studies Fig. 2 Distribution of retained root fragments in edentulous arches (each dot represents one
concluded that roots with vital pulp tissue that fragment)9
were excluded from oral fluids, healed suc-
cessfully with a cementum layer forming over complete canal closure through osteodentine there was epithelial proliferation and inflam-
the fractured dentine surface (Fig. 5). bridge formation. matory cell infiltration into the pulp.17 The
Johnson17 reported that, based on his- However Johnson17 found one of the 24 exposure to oral fluids led to infection and
tology, the root fragments remained vital retained roots to have a small mucosal open- subsequent pulpal necrosis. Whitaker,16 in his
after one year, with some roots achieving ing. This was the only root which showed experiment, also submerged root segments

286 BRITISH DENTAL JOURNAL VOLUME 218 NO. 5 MAR 13 2015

© 2015 Macmillan Publishers Limited. All rights reserved


Fig. 3 Partially extruded root with necrotic
pulp bordered by a periodontal pocket. Seen
at 31 days (haematoxylin-eosin stain, ×100
magnification)18
Fig. 4 Proliferation of epithelium towards
the inflamed fractured root surface, as
well as across the socket margins. Seen at
14 days (haematoxylin-eosin stain, ×25
magnification)20
Fig. 5 a = Submucosa; b = osteocementum
on root; c = artefactual; split;
d = osteocementum-dentine deposition;
e = dentine; f = pulp. Seen at eight months
after fracture (haematoxylin-eosin stain, ×11
magnification)17
BRITISH DENTAL JOURNAL VOLUME 218 NO. 5 MAR 13 2015
Fig. 6 Root fragment in contact with the
tips of the implant threads. Note that
treated dentine (D) is covered by newly
formed cementum (arrows) and that the
space between the threads is partially filled
with an amorphous mineralised tissue.
BB = buccal bone (toluidine blue/pyronine
G stain 58
Fig. 7 Occlusal view of the retained root
fragment on the buccal aspect58
Fig. 8 Occlusal view showing the root
fragment in direct contact with the implant58
Fig. 9 Five months after implant placement58
© 2015 Macmillan Publishers Limited. All rights reserved
PRACTICE
filled with gutta percha and noted that after
25  weeks of submergence only 17.6% of
endodontically treated roots had no inflam-
matory infiltrate. This was attributed to vital
roots having a collateral blood supply to
aid healing, and the gutta percha causing a
foreign-body type reaction.
BONE FORMATION AND IMPLANT
PLACEMENT TECHNIQUES
Buser57 and Hurzeler58 studied the effects of
endosseous titanium implant placement and
integration in the presence of retained roots
in monkeys and Beagle dogs respectively.
Buser57 reported that immediate implant
placement over apical portions of fractured
retained roots resulted in cementum apposi-
tion between the fractured root and implant
surface. Hurzeler58 took this idea further
and fractured the roots axially preserving
the buccal portion of the root and placed
an enamel matrix derivative (Emdogain,
Straumann, Basel, Switzerland) in the socket
before placing an implant. He reported simi-
lar results, showing that cementum covered
the surface of both the retained root frag-
ment and the implant (Fig. 6).
Hurzeler also carried out a ‘socket-shield’
procedure in a single human patient as a
proof-of concept. The buccal portion of the
root of a central incisor was sectioned and
the remainder of the tooth was extracted
(Fig. 7). An implant was placed in the socket
in direct contacted with the root fragment
(Fig. 8). Hurzeler reported a successful out-
come (Fig. 9). While the socket-shield tech-
nique may need further research, it is clear
that retained root fragments don’t always
implicate a negative outcome for the patient.
RETAINED ROOT
FRAGMENTS FOUND ON
INCIDENTAL RADIOGRAPHS
Helsham14 in 1960 conducted a survey of
2,000 patients referred for the removal of
retained roots. He reported 1,676 (83.8%)
retained root fragments were not associ-
ated with any symptoms or pathology. The
symptomatic and pathologic fragments are
presented (Table 3).
Helsham concluded that the ‘vast majority
of roots that are retained were vital when
fractured, [if] tissues have healed over them’,
and there was a progression of root canal
closure and fibrosis of the pulp (Fig. 10).
Herd8 in 1973 conducted a similar sur-
vey to observe the histology of retained
root fragments present in bone. The sam-
ple size consisted of patients referred for
the removal of both symptomatic and
asymptomatic fragments.
A total of 228 fragments were removed
and 62 (27%) showed a clinical abnormality
287
 PRACTICE
Table 3 Frequency of different presentations of retained root fragments (*Note: there is
overlap of presentations, eg pain and acute infection)14
Symptom or pathology Number of patients
Granulation tissue 236
Sclerosis around root 113
Pain 82
Cyst 38
Acute infection 21
Total* (symptomatic or pathologic) 324
Table 4 Frequency of different histological observations in 228 retained root fragments in
humans (Note: a retained root may be have more than one histological observation)8
Histological observation Number of fragments
Resorption and repair at fractured surface 206
Vital pulp – no inflammation 163
Vital pulp – mild inflammation 19
Necrotic pulp 43
Periodontal inflammation 40
External root resorption 30
Periapical abscess 14
Caries 11
Resorption at fracture surface 11
Radicular cyst 10
or pathosis (Table  4). The most common
clinical abnormalities were sinus tracts asso-
ciated with 26 fragments, followed by 19
with areas of inflammation. Pain was only
a symptom in 19 out of 171 patients (11%).
On histological examination of the frag-
ments two distinct histological variations
were described. Root fragments that were
asymptomatic were seen to be vital with nor-
mal pulp tissue present. There was apposition
of laminated acellular cementum along den-
tinal walls, produced by cementoblasts arising
from undifferentiated mesenchymal cells in
the pulp. Fractured surfaces of the fragments
appeared to be undergoing constant resorp-
tion and repair with the net result of acellular
cementum replacing fractured dentine.
Root fragments that were symptomatic
or had clinical abnormalities revealed pulps
with inflammation or necrosis. The associ-
ated pathology varied from mild inflamma-
tion to radicular cysts, and caries was also
noted in fragments that were in communica-
tion with the oral cavity.
RISKS OF ATTEMPTING
ROOT TIP REMOVAL
Before pursuing a fractured root tip or a
retained root fragment, a risk-benefit analy-
sis should be considered.38 ‘There are occa-
sions when leaving the root is one of the
most prudent and sound clinical decisions
one can make.’59
Roots may displace into surrounding
anatomical structures such as the maxillary
288
Percentage (%)
11.8
5.65
4.1
1.9
1.05
16.2
Percentage of fragments (%)
90.4
71.5
8.3
18.9
17.5
13.2
6.14
4.8
4.8
10
antrum44,60 and lingual pouch,45 and their
removal can damage adjacent teeth61 or
the inferior alveolar nerve.45 The risk of an
oral-antral fistula increases with age due to
the increased density of alveolar bone62 and
pneumatisation of the maxillary sinus reduc-
ing the distance interval between the root
tips and the maxillary sinus.63
When root tips fracture during challeng-
ing extractions, prolonged operative times
may increase the risk of alveolar osteitis.64,65
Parthasarathi66 in 2011 found a statistically
significant correlation (P = 0.003) between
intra-operative root fracture and alveolar
osteitis, but other studies have failed to dem-
onstrate a link.64,67 Interestingly, the surgical
removal of teeth doesn’t increase the risk,
leading clinicians to believe that the absolute
force applied is more significant than the
duration of extraction.68
BENEFITS OF RETAINING ROOTS
Submergence of vital roots has been shown
to maintain alveolar bone for prosthodon-
tic purposes.23,24,69 Decoronated ankylosed
teeth can be used to preserve alveolar bone
width and height for future implant place-
ment.27–29,70 The ankylosed teeth are decoro-
nated 2 mm below alveolar bone to allow for
wound closure and healing as demonstrated
by earlier studies.15–17 Ideally conventional
root filling materials will not be present to
cause an inflammatory reaction.16 Implants
have been shown to successfully integrate
around vital root fragments with cementum
BRITISH DENTAL JOURNAL VOLUME 218 NO. 5 MAR 13 2015
© 2015 Macmillan Publishers Limited. All rights reserved
Fig. 10 Transverse section of a 20-year-
old root fragment showing a narrowed vital
pulp. A = new calcified tissue; B = outline
of original pulpal wall; C = vital pulp. (×100
magnification)1
apposition directly between the implant and
fractured root surface.57,58
Coronectomy was first advocated by
Knutsson30 in 1989 as the intentional reten-
tion of roots where third molars are close
to the inferior alveolar nerve (IAN). It was
shown by Renton34 in 2012 that for a suc-
cessful coronectomy, root tips should not be
mobilised during the procedure and there
must not be any bacteria present in the pulp
before decoronation.34,71 Migration away
from the IAN occurred in 2-5% of roots after
2-5 years,34 with most migration in the first
three months71 and roots displacing 2-3 mm
after 1-2 years.72,73
CONCLUSION
Several histological studies in animals and
humans8,30 have shown vital root fragments
are well tolerated by the oral environment,
healing enclosed in a layer of cementum
with bone eventually filling the extrac-
tion socket. The factors that were shown to
allow successful healing of fractured root
fragments are:
• Vitality of the pulp within the
fractured root
• Fractured root hasn’t been mobilised to
any great extent during extraction
• Complete wound closure.
In our research of the literature we did
not come across any research that quanti-
fied the size of fragment that is acceptable
to leave behind.
However non-vital fragments or frag-
ments communicating with the oral cavity
become infected with periapical abscesses
surrounding them or are occasionally simply
extruded out of the socket. It is sometimes
difficult to ascertain in certain situations if
a fractured root segment contains vital or
necrotic pulp. It is possible to review the
healing of the socket clinically and radio-
graphically. However, radiographs should
only be taken when necessary as recom-
mended by the European Commission in

RPI 136.39 The practitioner needs to take
into consideration the clinical history and
symptoms of the patient as well as the future
treatment plan before exposing the patient
to radiographs.
Retained root fragments are seen on radio-
graphic examination of edentulous patients,
and the majority of them are present without
any associated symptoms (73-84%).8,14 When
these fragments are studied histologically, it
is seen that only fragments presenting with a
clinical abnormality, such as pain or a sinus
tract, have non-vital pulps or areas of infec-
tion around them, requiring their removal.
In some cases a significant amount of
bone needs to be removed to access the
root fragments, which can be unnecessary.
Leaving root fragments carries the risk of
future infection or osteoradionecrosis for
patients who will receive radiation to the
head and neck.
The decision to remove retained root frag-
ments either found incidentally on radio-
graphs or those roots that have fractured
intra-operatively during tooth extraction
procedures needs to be made on a case-
by-case basis. The advantages and disad-
vantages of surgery vs. non-surgery must
be taken into consideration. The authors
recommend a pragmatic approach of ‘non
nocere’ – ‘do no harm’.
1. Dachi S F, Howell FV. A survey of 3,874 routine full-
mouth radiographs. I. A study of retained roots. Oral
Surg Oral Med Oral Pathol 1961; 14: 916–924.
2. Kharat D U, Saint T. Embedded root fragments in
completely and partially edentulous jaws. Saudi
Dent J 1991; 3: 8–12.
3. Bayanzadeh S, Shokri S. Radiographic evaluations of
patients seeking removable prostheses treatment.
J Dent Med 2004; 16: 78-81.
4. Sumer A P, Sumer M, Guler A U, Bicer I. Panoramic
radiographic examination of edentulous mouths.
Quintessence Int 2007; 38: e399–403.
5. Cook T J. Statistics obtained by clinical and roent-
genographs examination of 500 edentulous and
partially edentulous mouths. The Dental Cosmos
1927; 69: 349–351.
6. Scandrett F R, Tebo H G, Quigley M B, Miller J T.
Radiographic examination of edentulous patient.
II. Differences in number and location of root frag-
ments. Oral Surg Oral Med Oral Pathol 1973; 35:
872-875.
7. Bremner V A, Grant A A. A radiographic survey of
edentulous mouths. Aust Dent J 1971; 16: 17–21.
8. Herd J R. The retained tooth root. Aust Dent J 1973;
18: 125–131.
9. Spyropoulos N D, Patsakas A J, Angelopoulos A P.
Findings from radiographs of the jaws of edentulous
patients. Oral Surg Oral Med Oral Pathol 1981; 52:
455–459.
10. Heidbrink J A. Necessity for removal of all broken-
off root tips. J Dent Res 1921; 3: 389–390.
11. Scandrett F R, Tebo H G, Miller J T, Quigley M B.
Radiographic examination of edentulous patient. I.
Review of literature and preliminary report compar-
ing three methods. Oral Surg Oral Med Oral Pathol
1973; 35: 266-274.
12. Masood F, Robinson W, Beavers K S, Haney K L.
Findings from panoramic radiographs of the
edentulous population and review of the literature.
Quintessence Int 2007; 38: e298–305.
13. Waggener D T, Austin L T. Dental structures remain-
ing in 1948 edentulous jaws: a statistical study. J
BRITISH DENTAL JOURNAL VOLUME 218 NO. 5 MAR 13 2015
Am Dent Assoc 1941; 28: 1855–1857.
14. Helsham R W. Some observations on the subject
of roots of teeth retained in the jaws as a result of
incomplete exodontia. Aust Dent J 1960; 5: 70–77.
15. Plata R L, Kelln E E, Linda L. Intentional retention of
vital submerged roots in dogs. Oral Surg Oral Med
Oral Pathol 1976; 42: 100–108.
16. Whitaker D D, Shankle RJ. A study of the histologic
reaction of submerged root segments. Oral Surg Oral
Med Oral Pathol 1974; 37: 919–935.
17. Johnson D L, Kelly J F, Flinton R J, Cornell M T.
Histologic evaluation of vital root retention. J Oral
Surg 1974; 32: 829–833.
18. Glickman I, Pruzansky S, Ostrach M. The healing
of extraction wounds in the presence of retained
root remnants and bone fragments: an experimen-
tal study. Am J Orthodontics Oral Surg 1947; 33:
263–283.
19. Smith R L. The role of epithelium in the healing of
experimental extraction wounds. J Dent Res 1958;
37: 187–194.
20. Pietrokovski J. Extraction wound healing after tooth
fracture in rats. J Dent Res 1967; 46: 232–240.
21. Jin H, Thomas H F, Chen J. Wound healing and
revascularization: a histologic observation of experi-
mental tooth root fracture. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1996; 81: 26–30.
22. Masterson M P. Retention of vital submerged roots
under complete dentures: report of 10 patients. J
Prosthet Dent 1979; 41: 12–15.
23. Casey D M, Lauciello F R. A review of the
submerged-root concept. J Prosthet Dent 1980; 43:
128–132.
24. Dugan D J, Getz J B, Epker B N. Root banking to
preserve alveolar bone: a review and clinical recom-
mendation. J Am Dent Assoc 1981; 103: 737–743.
25. von Wowern N, Winther S. Submergence of roots for
alveolar ridge preservation. A failure (4-year follow-
up study). Int J Oral Surg 1981; 10: 247–250.
26. Bowles W H, Daniel R E. Reevaluation of submerged
vital roots. J Am Dent Assoc 1983; 107: 429–432.
27. Malmgren B. Decoronation: how, why, and when? J
Calif Dent Assoc 2000; 28: 846–854.
28. Malmgren B, Malmgren O, Andreasen J O V E.
Alveolar bone development after decoronation
of ankylosed teeth. Endodontic Topics 2008; 14:
35–40.
29. Filippi A, Pohl Y, von Arx T. Decoronation of an anky-
losed tooth for preservation of alveolar bone before.
Dent Traumatol 2001; 17: 93–95.
30. Knutsson K, Lysell L, Rohlin M. Postoperative status
after partial removal of the mandibular third molar.
Swed Dent J 1989; 13: 15–22.
31. O’Riordan B C. Coronectomy (intentional partial
odontectomy of lower third molars). Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2004; 98:
274–280.
32. Pogrel M A, Lee J S, Muff D F. Coronectomy: a tech-
nique to protect the inferior alveolar nerve. J Oral
Maxillofac Surg 2004; 62: 1447–1452.
33. Patel V, Moore S, Sproat C. Coronectomy – oral sur-
gery’s answer to modern day conservative dentistry.
Br Dent J 2010; 209: 111–114.
34. Renton T. Notes on coronectomy. Br Dent J 2012;
212: 323–326.
35. Nairn R I. Interference with function of inferior
dental nerve by a root fragment. Oral Surg Oral Med
Oral Pathol 1973; 36: 188-191.
36. Park S H, Sorensen W P, Wang H L. Management
and prevention of retrograde peri-implant infection
from retained root. Int J Periodontics Restorative
Dent 2004; 24: 422–433.
37. Kramer S. An unexpected adverse reaction due to a
retained root. N Y State Dent J 1983; 49: 768-770.
38. Caplin R L. Oral surgery: problems. Br Dent J 1989;
166: 171–177.
39. European Commission. Radiation Protection No.
136: European guidelines on radiation protection in
dental radiology: the safe use of radiographs in den-
tal practice. 2004. Available at: http://www.worldcat.
org/title/radiation-protection-136-european-guide-
lines-on-radiation-protection-in-dental-radiology-
the-safe-use-of-radiographs-in-dental-practice/
oclc/56206512 (accessed January 2015).
40. Cheppe E. Tabulation and analysis of the results of
© 2015 Macmillan Publishers Limited. All rights reserved
PRACTICE
Xray examination of edentulous mouths. Northwest
Univ Dent Res Crad Quart Bull 1936; 36: 12–15.
41. Swenson H M. Roentgenographic examination of
the edentulous mouth. J Am Dent Assoc 1944; 31:
475–478.
42. Storer R. A radiographic survey of edentulous
mouths. Br Dent J 1957; 103: 344–347.
43. Ettinger R L. Roentgenographic evaluation of the
edentulous patient. Aust Dent J 1971; 16: 210–219.
44. Jones E H, Steel J S. Roots in the maxillary sinus.
Aust Dent J 1969; 14: 8-11.
45. Pierse J E, Dym H, Clarkson E. Diagnosis and man-
agement of common postextraction complications.
Dent Clin North Am 2012; 56: 75–93.
46. Claflin R S. Healing of disturbed and undisturbed
extraction wounds. J Am Dent Assoc 1936; 23:
945–959.
47. Simpson H E. The healing of extraction wounds. Br
Dent J 1969; 126: 550–557.
48. Devlin H, Sloan P. Early bone healing events in the
human extraction socket. Int J Oral Maxillofac Surg
2002; 31: 641–645.
49. Amler M H, Johnson P L, Salman I. Histological
and histochemical investigation of human alveolar
socket healing in. J Am Dent Assoc 1960; 61: 32–44.
50. Boyne P J. Osseous repair of the postextraction
alveolus in man. Oral Surg Oral Med Oral Pathol
1966; 21: 805–813.
51. Evian C I, Rosenberg E S, Coslet J G, Corn H. The
osteogenic activity of bone removed from healing
extraction sockets in. J Periodontol 1982; 53: 81–85.
52. Trombelli L, Farina R, Marzola A, Bozzi L, Liljenberg
B, Lindhe J. Modeling and remodeling of human
extraction sockets. J Clin Periodontol 2008; 35:
630–639.
53. Poe G S, Hillenbrand D G, Johnson D L. Vital root
retention in dogs by coronectomy. International
Association of Dental Research. Program and
Abstracts of Papers 1972: 596.
54. Cook R T, Hutchens L H, Burkes E J. Periodontal osse-
ous defects associated with vitally submerged roots.
J Periodontol 1977; 48: 249–260.
55. Steiner G G, Francis W, Burrell R, Kallet M P, Steiner
D M, Macias R. The healing socket and socket
regeneration. Compend Contin Educ Dent 2008; 29:
114-116, 118, 120-124.
56. Mahan C J, Hurt W C. Retained deciduous tooth
fragments and periodontal lesions: radiographic,
clinical, and histologic observations. Oral Surg Oral
Med Oral Pathol 1973; 35: 708-714.
57. Buser D, Warrer K, Karring T, Stich H. Titanium
implants with a true periodontal ligament: an
alternative to osseointegrated implants? Int J Oral
Maxillofac Implants 1990; 5: 113–116.
58. Hurzeler M B, Zuhr O, Schupbach P, Rebele S F,
Emmanouilidis N, Fickl S. The socket-shield tech-
nique: a proof-of-principle report. J Clin Periodontol
2010; 37: 855–862.
59. Leonard M. The root tip: to pursue or not to pursue.
Dent Today 2001; 20: 108.
60. Krishnan B. Removal of a fractured palatal root. Br J
Oral Maxillofac Surg 2008; 46: 421.
61. Leonard M S. Removing third molars: a review for
the general practitioner. J Am Dent Assoc 1992; 123:
77-78, 81-82, 85-86.
62. Bruce R A, Frederickson G C, Small G S. Age of
patients and morbidity associated with mandibular
third molar surgery. J Am Dent Assoc 1980; 101:
240–245.
63. Sharan A, Madjar D. Maxillary sinus pneumatization
following extractions: a radiographic study. Int J Oral
Maxillofac Implants 2008; 23: 48–56.
64. Lata J, Choudhary N K. Effectiveness of sterile versus
nonsterile gloves following dental extraction. Indian
J Dent Sci 2012; 4: 1–4.
65. Kolokythas A, Olech E, Miloro M. Alveolar osteitis: a
comprehensive review of concepts and controver-
sies. Int J Dent 2010; 2010: 249073.
66. Parthasarathi K, Smith A, Chandu A. Factors
affecting incidence of dry socket: a prospective
community-based study. J Oral Maxillofac Surg
2011; 69: 1880–1884.
67. Cheung L K, Chow L K, Tsang M H, Tung L K. An
evaluation of complications following dental extrac-
tions using either sterile or clean gloves. Int J Oral
289
 PRACTICE

Maxillofac Surg 2001; 30: 550–554.
68. Blum I R. Contemporary views on dry socket
(alveolar osteitis): a clinical appraisal of standardiza-
tion, aetiopathogenesis and management: a critical
review. Int J Oral Maxillofac Surg 2002; 31: 309–317.
69. Salama M, Ishikawa T, Salama H, Funato A, Garber
D. Advantages of the root submergence technique
for pontic site development in esthetic implant
therapy. Int J Periodontics Restorative Dent 2007;
27: 521-527.
70. Sapir S, Shapira J. Decoronation for the manage-
ment of an ankylosed young permanent tooth. Dent
Traumatol 2008; 24: 131–135.
71. Monaco G, de Santis G, Gatto M R, Corinaldesi G,
Marchetti C. Coronectomy: a surgical option for
impacted third molars in close proximity to the
inferior alveolar nerve. J Am Dent Assoc 2012;
143: 363–369.
72. Renton T, Hankins M, Sproate C, McGurk M. A
randomised controlled clinical trial to compare
the incidence of injury to the inferior alveolar
nerve as a result of coronectomy and removal of
mandibular third molars. Br J Oral Maxillofac Surg
2005; 43: 7–12.
73. Leung Y Y, Cheung L K. Coronectomy of the lower
third molar is safe within the first 3 years. J Oral
Maxillofac Surg 2012; 70: 1515–1522.

Corrigendum
Practice article (BDJ 2015; 218: 69-74)
A review of dental treatment of head and neck cancer patients, before, during and after radiotherapy: part 2

The citations to Fig. 3-8 within the text of the above article were incorrect.

n The citation to Fig. 3 should have read as follows (on p 70): Nutritional supplements such as Ensure drinks contain refined carbo-
hydrate (sucrose and/or glucose) and often they are consumed in frequent small sips (Fig. 3).

n The citation to Fig. 3 in the text (on p 71) should have read Fig. 4: A simple wedge made by stacking and taping together tongue
spatulas can be used by the patient (Fig. 4)

n The citation to Fig. 4 (on p 71) should have read Fig. 5: The TheraBite® jaw motion rehabilita­tion system is a portable system spe-
cifically designed to treat trismus and mandibu­lar hypomobility (Fig. 5).

n The citation to Fig. 5 (on p 71) should instead have read Fig. 6: OraNurse is unfla­voured toothpaste which has 1,450 ppm sodium
fluoride (Fig. 6).

n The citation to Fig. 7 should have read as follows (on p 72): Tooth mousse comes in a variety of flavours: strawberry, orange, lemon,
vanilla, melon and mint (Fig. 7).

n The citation to Figs 6 and 7 (on p 73) should have read Fig. 8: HBO therapy (HBOT) involves breath­ing oxygen under increased
atmospheric pressure in a specially designed chamber (Figs 8).

The authors apologise for any confusion caused.

290 BRITISH DENTAL JOURNAL VOLUME 218 NO. 5 MAR 13 2015

View publication stats © 2015 Macmillan Publishers Limited. All rights reserved