Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2021; 66: 136–149

doi: 10.1111/adj.12825

Coronectomy of mandibular third molars: a systematic

literature review and case studies
A Mann,* JF Scott*
*Private Practice, Adelaide, South Australia, Australia.

ABSTRACT
Background: Extraction of mandibular third molars (M3M) close to the inferior alveolar nerve (IAN) has a higher risk
of neurological disturbance. This review aims to evaluate the evidence supporting the use of the coronectomy technique
compared to complete extraction for such M3Ms. Case studies by a specialist oral and maxillofacial surgeon are
included to illustrate clinical practice.
Methods: Three databases (Cochrane Library, Embase, PubMed) were searched (November 2020). Additional articles
were sought by hand searching the reference list of included articles. All studies published in English comparing out-
comes of coronectomy with complete extraction with at least 50 subjects and 6 months follow-up were included.
Results: Of the six included studies, five reported a lower rate of IAN disturbance after coronectomy compared with
complete extraction. There were no reported cases of lingual nerve disturbance. Other outcomes of coronectomy such as
pain, infection, alveolar osteitis were either similar or lower compared to complete extraction. There were high rates of
root migration but low rates of exposure and reoperation. Follow-up protocols varied considerably.
Conclusions: There is medium quality evidence to support the option of coronectomy for high risk M3M cases. Further
studies to develop follow-up protocols to assist general dental practice is warranted.
Keywords: Coronectomy, inferior alveolar nerve, nerve injury, surgical removal, third molars.
Abbreviations: CBCT = cone beam computed tomography; CT = computed tomography; GA = general anaesthetic; GDP = general dental
practitioner; HRQOL = health related quality of life; IAN = inferior alveolar nerve; M3M = mandibular third molar; NHMRC =
National Health and Medical Research Council; NOS = Newcastle-Ottawa scale; NRCT = non-randomised controlled trial; OMS = oral
and maxillofacial surgeon; OPG = orthopantomogram; RCT = randomised controlled trial; VAS = visual analog scale.
(Accepted for publication 18 January 2021.)

left in-situ.10,11 The technique was first described in

INTRODUCTION
Surgical extraction of third molars is one of the most
common procedures in dentistry.1 One of the more
significant complications of removing mandibular
third molars (M3M) is the disturbance to the inferior
alveolar nerve (IAN), with a reported incidence
between 0.4–8.4%.2-4 For high risk cases, such as
M3Ms displaying radiographic features as described
by Rood and Shehab5 or as analysed using Howe and
Poyton’s criteria,6 the incidence of temporary IAN
disturbance may be as high as 20–35%3,7 with perma-
nent disturbances ranging from 0.9% to 4%.4,5,8,9
Whilst generally the aim is to remove the entire
tooth if possible, where perceived risks outweigh the
perceived benefits, coronectomy can be considered.
The concept of coronectomy, also known as partial
odontectomy or intentional root retention, involves
removing only the crown with the root deliberately
the literature in the 1980s3,10,12 as a technique to
minimise the risk of IAN disturbances in the manage-
ment of high risk M3M cases. Cases are carefully
selected as teeth with caries into the dentine, imma-
ture teeth with wide open apices and horizontal
impactions with molars that lie along the IAN are not
good candidates for coronectomy.13
Even though the technique is well described, some
surgeons and patients still have reservations regarding
its short and long term outcomes.14-17 In a recent
Swiss study, 54.8% of oral and maxillofacial surgeons
(OMS) surveyed reported coronectomy as not reliable
and 51.6% have never performed this procedure.15 In
a survey of members of the British Association of
Oral and Maxillofacial Surgeons, 19% of respondents
did not perform coronectomy.17 The top three reasons
cited by surgeons included a lack of evidence to sup-
port the benefit of coronectomy, perception that it has

136 © 2021 Australian Dental Association


Coronectomy of mandibular third molars: a systematic literature review and case studies
more complications of a non-neurological nature and
increased need for a second operation.17 Concerns
about possible future reoperation was also a common
reason for patients to decline the coronectomy
option.17 A recent study also found a marked varia-
tion in case selection between general dental practi-
tioners (GDP) referring for coronectomies compared
with specialist surgeons.18 Further continued educa-
tion to foster a team led approach between the refer-
ring clinician and specialist surgeons is indicated.
As the technique becomes more common, GDPs
may be more likely to come across patients with
retained coronectomised roots during general dental
examination. Where patients have moved away from
the original surgeon, GDPs unfamiliar with the treat-
ment history may be tasked with monitoring and
managing coronectomised roots. The discovery of
such retained roots should be recognised as the out-
come of carefully planned surgery, and not as roots
inadvertently left behind.
This paper aims to provide an update on coronec-
tomy regarding treatment outcomes, complication
rates and follow-up recommendations to foster a team
approach in managing M3Ms close to the IAN. A sys-
tematic literature review was conducted followed by
illustration using clinical case studies. This paper also
aims to record an unusual presentation whereby the
mandibular canal appears to have migrated subse-
quent to coronectomy of a M3M perforated by a
branch of a bifid IAN.
METHOD
A literature review was conducted using PRISMA
guidelines.19 A literature search was performed in
November 2020 on three databases: Cochrane
Library, Embase and PubMed. Combination of key-
words of “(coronectomy) OR (partial odontectomy)
OR (intentional root retention)” were used in search
algorithms (Table 1). No limit was imposed regarding
the time of publication. Reference sections of accepted
articles were screened for further articles of relevance.
EndNote (Clarivate Analytics, EndNote X9.3.3, 2020)
was used to organise and collate articles.
Table 1. Search strategy for all databases
Database Keywords combinations
Cochrane (coronectomy):ti,ab,kw OR (partial odontectomy):
Library ti,ab,kw OR (intentional root retention):ti,ab,kw
Embase ’coronectomy’/exp OR coronectomy OR ’partial
odontectomy’:jt OR ’intentional root retention’:au
Pubmed ((coronectomy) OR (partial odontectomy) OR
(intentional root retention)) OR (i)
© 2021 Australian Dental Association
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Inclusion criteria:
• human in vivo studies
• comparison of coronectomy with complete extrac-
tion of M3Ms close to the IAN
• longitudinal study with 50 or more subjects
• minimum follow-up period of 6 months
• reported on at least one or more of the following
outcomes: neurological disturbance, post-operative
pain, patient experience, postoperative infection,
dry socket, alveolar osteitis, root migration, root
exposure, reoperation rate
• publications in English
Exclusion criteria:
• studies with no control group
• any cases utilising hard or soft tissue grafting
• papers where the number of subjects were unclear
• coronectomies performed as part of management of
cysts or other resorptive lesions
• abstracts or summaries of poster presentations, oral
abstracts, opinion pieces or letters to the editor
After duplicates were removed, abstracts were
screened and full copies of papers that met the inclu-
sion and exclusion criteria were obtained and
reviewed according to PRISMA guidelines (Fig. 1).19
The level of evidence for each of the included studies
were ranked according to the National Health and
Medical Research Council (NHMRC) hierarchy of
evidence (Table 2).20 The quality and risk of bias of
included studies were assessed using published assess-
ment tools.
Data regarding neurological disturbance, post-oper-
ative pain, patient experience, postoperative infection
and alveolar osteitis for both coronectomy and com-
plete extraction of M3Ms were synthesised. Further
data on root migration, root exposure, reoperation
rate and follow-up protocol after coronectomy was
collated using piloted forms.
RESULTS
Study characteristics
A total of 349 papers were found from the initial
search. There were 227 records after de-duplication.
Where the same cohort of patients were reported in
multiple papers, only one paper was included. 6
papers were included after application of inclusion
and exclusion criteria. Reasons for exclusion are sum-
marised within Fig. 1. The characteristics of included
studies are summarised in Table 3. All included stud-
ies selected only patients deemed at high risk of IAN
disturbance based on radiographic features from
panoramic radiography, computed tomography (CT)
or cone beam computed tomography (CBCT). The
results of individual studies on the incidence of IAN
disturbances, lingual nerve disturbances, pain/patient
137
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A Mann and J Scott

Cochrane Embase Pubmed

Library n = 171 n = 177 through other sources
n=1 n=0

227 records after

Screening de-duplication

227 records screened 133 records excluded

based on abstract

88 records excluded after

Eligibility

94 full-text articles reading full-text articles

assessed against inclusion
and exclusion criteria

Reasons for exclusion

• Expert opinion (n=20)

• Less than 6mths follow-up (n=1)
• Less than 50 subjects (n=32)
• No control group (n=27)
6 articles included
Included

• Not on M3Ms (n=6)

• Reported on same dataset as
included article (n=2)

Fig. 1 PRISMA flow diagram of systematic literature review strategy.

Table 2. National Health and Medical Research clinical studies. The literature search yielded only 2
Council evidence hierarchy20 RCTs by Leung and Cheung2 and Renton et al.21 In
the study by Leung and Cheung,2 patients were ran-
Level Intervention
domised by a house officer using a randomisation
I A systematic review of level II studies table generated by a computer. Renton et al.21 ran-
II A randomised controlled trial
III-1 A pseudo-randomised controlled trial (ie: alternate
domised patients using a of random numbers blinded
allocation or some other method) from the surgeon.
III-2 A comparative study with concurrent controls: Following the publication of the 2 RCTs, patients
• Non-randomised, experimental trial
• Cohort study
in subsequent studies were no longer randomised as it
• Case-control study was deemed unethical.13,22,23 Considering the scarcity
• Interrupted time series with a control group of RCTs, non-randomised clinical trials (NRCTs)
III-3 A comparative study without concurrent controls:
• Historical control study
which met the inclusion and exclusion criteria were
• Two or more single arm study included to provide a more comprehensive evidence
• Interrupted time series without a parallel control group base for this review. To reduce risk of bias, only stud-
IV Case series with either post-test or pre-test/post-test
outcomes
ies with a control group were included.
RCTs and NRCTs have fundamental differences
by virtue of their study designs and require different
quality assessment criteria.24 As there is no consen-
experience, early post-operative infections, alveolar sus for the ideal risk of bias tool to assess both
osteitis, failed coronectomy, root migration, root RCT and NRCTs together, 2 different risk of bias
exposure, reoperation rate and their follow-up proto- tools were used.24 RCTs were assessed using the
cols are summarised in Table 4. Cochrane Collaboration’s tool for assessing risk of
bias as this was designed for assessment of
RCTs.24,25 NRCTs were evaluated using Newcastle-
Quality assessment of included studies Ottawa Scale (NOS),26 one of the most commonly
According to the NHMRC evidence hierarchy,20 used for NRCTs.24 The results are summarised in
RCTs represent the highest level of evidence for Tables 5 and 6.

138 © 2021 Australian Dental Association

 Table 3. General Characteristics of the included studies and evaluation of levels of evidence according to NHMRC recommendation20
Author Study Radiographic Location Funding Number of subjects Age limit of Qualification of Followup length (range) Level of
design assessment (coronectomy/ subjects operator(s) evidence

© 2021 Australian Dental Association

extraction)

Cilasun Case- CT Kocaeli Not specified 120 after 4 excluded No Age Limit 1 specialist surgeon III-2
et al. control (88 teeth/87 teeth) Specified • Coronectomy
(2011)22 study 16.97 months (6–
29 months)
• Extraction
17.62 months (6–
30 months)
Hatano Case- CT Nagoya Not specified 220 At least 16 years 1 specialist surgeon III-2
et al. control (102 subjects/118 old, no upper • Coronectomy
(2009)23 study subjects) limit 13.5 months (14.85)
• Extraction 13 months
(1.31 months)
Kang et al. Case- CBCT Shanghai Not specified 92 18–35 years old Not specified III-2
(2019)13 control (55 teeth/55 teeth) • Coronectomy
study 36 months
Leung RCT Panoramic Hong Not specified 231 after 40 dropped No Age Limit Unspecified number II
et al. Radiograph Kong out Specified of surgical • Coronectomy
(2009)2 (171 teeth/178 teeth) residents 10.6 months (SD
7.7 months)
• Failed Coronectomy
11.4 months (SD
7.9 months)
• Complete extraction
7.7 months (SD
6.6 months)
Manor Prospective Panoramic Tel Aviv Not specified 69 No Age Limit 2 specialist surgeons III-2
et al. Cohort Radiograph (34 teeth/35 teeth) Specified • Unclear, only stated
(2016)27 Study “at least 1 year”
Renton RCT Panoramic London British Association of Oral 128 No Age Limit 3 surgeons, did not II
et al. Radiograph and Maxillofacial (94 teeth/102 teeth) Specified specify specialist • 25 months (SD
(2005)21 Surgeons status 13 months)

RCT = randomised controlled trial; CT = computed tomography, CBCT = cone beam computed tomography.
Coronectomy of mandibular third molars: a systematic literature review and case studies

139
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 140
Table 4. Data extracted from included studies and their findings
Author IAN Lingual nerve Pain/Patient Early Alveolar Failed Root Root Reoperation Coronectomy follow up
disturbance disturbance experience postoperative osteitis coronectomy migration exposure rate protocol
N (%) N (%) N (%) infection N (%) N (%) N (%) N (%) N (%)
P value vs. N (%)
extraction

Cilasun Coronectomy: Not specified Coronectomy: Coronectomy: Coronectomy: 2/88 Not Not 1/88 Did not report protocol
A Mann and J Scott

et al. 0/88 (0%) 1/88pt (1.14%) 1/88 (1.14%) 0 (0%) (2.27%) specified specified (1.14%) Mean followup
(2011)22 Extraction: Extraction: 0/87 Extraction: Extraction: time = 17.29 months
2/87pt (0%) 0/87 (0%) 1/87pt
(2.30%) (1.15%)
Hatano Coronectomy: Coronectomy: Coronectomy: Coronectomy: Coronectomy: 5 (5.06%) 87/102 5/102 5/102 Post-op Exam then reviewed
et al. 1/102 0/102 (0%) 19/102 (18.63%) 1/102 2/102 (85.29%) (4.90%) (4.90%) at 1, 3, 6, 9, 12 months,
(2009)23 (0.98%) Extraction: 0/ Extraction: 8/118 (0.98%) (1.96%) then annually
Extraction: 118 (0%) (6.78%) Extraction: Extraction: CT taken 3 and 12 months
6/118 4/118 10/118 postop
(5.08%) (3.39%) (8.47%) Mean followup
P = 0.126 time = 13 months
Kang Coronectomy: Not specified Reported on pain Coronectomy: Coronectomy: 9/55 50/55 6/55 Not Post-op Exam reviewed at
et al. 0/55 (0%) duration 0/88 (0%) 1/55 (1.82%) (16.4%) (90.9%) (10.91%) specified 3, 6, 9, 12, 36 months
(2019)13 Extraction: Coronectomy: Extraction: Extraction: 2/ CBCT taken at 12 and
6/55 2.61 days (1.95) Unclear/Not 55 (5.45%) 36 months postop
(10.91%) Extraction: 3.40 explicitly Followup time = 36 months
P = 0.036 (1.55) specified
Leung Coronectomy: Coronectomy: Coronectomy: Coronectomy: Coronectomy: 16/177 At least 2/155 1/155 Post-op Exam reviewed at
et al. 1/155 0/155 (0%) 65/155 (41.9%) 9/155 (5.8%) 0/155 (0%) (9.03%) 96/155 (1.29%) (0.65%) 1 week, 3, 6, 9, 12,
(2009)2 (0.65%) Extraction: 0/ Extraction: 102/178 Extraction: Extraction: (62.2%) 24 months each with
Extraction: 178 (0%) (57.3%) 12/178 5/178 (2.8%) OPGs
9/178 (6.7%) Mean followup
(5.10%) time = 10.6 months
P = 0.023
Also 1 case in
failed
coronectomy
group
Manor Coronectomy: Not specified Used HRQOL Not specified Not specified Not Not Not 2/24 “Followed up for at least
et al. 0 (0%) questionnaire specified specified specified (8.33%) 1 year” but further details
(2016)27 Extraction: 0 “No significant not specified
(0%) difference”
coronectomy and
extraction groups
Renton Coronectomy: Coronectomy: Coronectomy: 8/58 Coronectomy: Coronectomy: 36/94 At least 0 (0%) 0 (0%) First review by phone
et al. 0/58 (0%) 0/58 (0%) (13.8%) 3/58 (5.2%) 7/58 (12.1%) (38.3%) 5/58 3 days post op
(2005)21 Extraction: Extraction: 0/ Extraction: 22/102 Extraction: Extraction: (8.62%) Further reviews at 1 week,
19/102 102 (0%) (21.6%) 1/102 10/102 6, 12, 24 months with
(18.6%) Failed Failed coronectomy: (0.98%) (9.6%) unspecified type of review
P = 0.004 coronectomy: 4/36 (11.1%) Failed Failed radiograph
Also 5 case 0/36 (0%) coronectomy: coronectomy: Mean followup
(8.3%) in 0/36 (0%) 4/36 (11.1%) time = 25 months
failed
coronectomy
group

© 2021 Australian Dental Association

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Coronectomy of mandibular third molars: a systematic literature review and case studies

Table 5. Quality assessment of RCTs according to the Cochrane Collaboration’s tool for assessing risk of bias25
Author Random Allocation Blinding of Blinding of Incomplete Selective Other
sequence concealment participants and outcome outcome data reporting sources of
generation personnel assessment bias

Leung et al. + + ? ?
(2009)2
Renton et al. + + ? ? ?
(2005)21

Table 6. Quality assessment of non-randomised clinical studies using NOS according to Newcastle-Ottawa Qual-
ity Assessment Scale26
Author Selection (Max = 4) Comparability (Max = 2) Outcome (Max = 3) Total score (Max = 9) Risk of bias

Cilasun et al. (2011)22 2 1 2 5 Medium

Hatano et al. (2009)23 3 1 2 6 Medium
Kang et al. (2019)13 3 1 2 6 Medium
Manor et al. (2016)27 1 0 1 2 High

Comparison of outcomes between coronectomy and Early postoperative infection

complete extraction
IAN disturbance
All included studies reported on this primary outcome
of concern. Five studies indicated coronectomy had a
lower risk of IAN disturbance compared to complete
extraction. One study reported no difference.27 The
reported ranges were 0–0.98% for the coronectomy
group compared with 0–18.6% for complete extrac-
tion group. Only 4 studies2,13,21,23 performed statisti-
cal analyses with 3 studies2,13,21 reporting a
statistically significant lower rate of IAN disturbance
after coronectomy compared with complete extraction
(P < 0.05). Neither Cilasun et al.22 nor Manor et al.27
performed any statistical analysis. The data are pre-
sented in Table 4.
Lingual nerve disturbance
Only 3 studies reported on lingual nerve disturbance,
with nil reports for both coronectomy or complete
extraction groups.2,21,23
Pain/patient experience
All studies reported on pain outcomes but with differ-
ent methodologies. Kang et al.,13 Leung and Cheung2
and Renton et al.21 reported that their coronectomy
groups reported less pain compared to complete
extraction. Meanwhile similar levels of pain were
reported in both groups by Cilasun et al.22 and
Manor et al.27 Interestingly, the coronectomy group
had higher levels of pain in the study by Hatano
et al.23 The results are summarised in Table 4.
© 2021 Australian Dental Association
All studies with the exception of Manor et al.27
reported on postoperative infection rates. Renton
et al.21 found higher rates of infection for their coro-
nectomy group compared to complete extraction
group. All other studies reported similar or less rates
of infection for their coronectomy groups. The specific
results are reported in Table 4.
Dry socket/Alveolar osteitis
Four papers found a lower incidence of dry socket fol-
lowing coronectomy compared to complete extrac-
tion.2,13,22,23 Manor et al.27 did not report on dry
sockets. Meanwhile, Renton et al.21 was the sole
study to report the opposite with a higher rate of dry
socket after coronectomy (12.1%) compared to com-
plete extraction (9.6%). The full data are reported in
Table 4.
Root migration, root exposure, reoperation rate
Three papers reported very high rates of root migra-
tion of between 62.2–90.9%.2,13,23 These were also
the only studies with reported exposure of coronec-
tomised roots ranging 1.29–10.91%.2,13,23 Renton
et al.21 observed only 8.62% of coronectomised roots
had migrated in their study with no root exposures.
Neither Cilasun et al.22 nor Manor et al.27 reported
on root migration nor root exposure.
Concurrent with low numbers of root exposures,
there were very few reported cases of reoperation rang-
ing from 0% to 8.33%.2,21-23,27 Kang et al.13 did not
specify their reoperation rate. A number of reoperations
were due to factors other than root exposure. Cilasun
141

A Mann and J Scott
et al.22 reoperated on one patient’s request for an
unspecified reason. Leung and Cheung2 reoperated on a
root which became repeatedly exposed due to endodon-
tic pathosis on an adjacent tooth affecting bony healing.
Manor et al.27 reoperated on some coronectomised roots
as part of a subsequent orthodontic treatment.
Follow up protocols
Each study had a different follow-up protocol of vari-
ous lengths. In particular there was marked differ-
ences in their follow-up radiographic protocol. The
individual studies’ follow-up protocols are sum-
marised in Table 4.
DISCUSSION
IAN disturbance
As the primary rationale for performing coronectomy is
to reduce IAN disturbances, it was reported by all
included studies. Five studies are in agreement that coro-
nectomy resulted in a lower risk of IAN disturbance
compared to complete extraction.2,13,21-23 One study
did not have any cases of neurological disturbance.27
These results are affected by several limitations.
Of the three case-control studies, two13,23 allocated
the intervention of coronectomy or complete extrac-
tion based on patient preference after advantages and
disadvantages for both options were discussed. The
third case-control study recommended coronectomy to
patients based on the absence of bone between the
roots and the IAN on CT scans.22 Patients were then
given a choice between coronectomy and complete
extraction, and a minority of the patients recom-
mended for coronectomy elected to have complete
extraction instead.22 The single prospective cohort
study did not specify how subjects were assigned but
did report the M3Ms in the coronectomy group had a
much higher proximity to the IAN.27 This resulted in
control groups with an inherently lower risk of IAN
disturbance. Despite having dissimilar control groups
which may skew the results against coronectomy,
their results indicate coronectomy still had a lower
rate of IAN disturbance.2,13,21-23
Collectively there were only two cases of IAN distur-
bance following coronectomy and both recovered.
Hatano et al.23 reported their single case recovered after
1 month. Leung and Cheung’s2 case recovered after
1 year. Conversely, there was a range of recovery rates
for IAN disturbance after complete extraction.2,13,21-23
Cilasun et al.22 reported 1 case which recovered after
1 month, Hatano et al.23 reported 3 of 6 recovered,
Kang et al.13 reported 4 of 6 recovered, Leung and Che-
ung2 reported 6 of 9 recovered while Renton et al.21
reported 17 of 19 such cases recovered.
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Roots can become mobilised during an attempted
coronectomy, leading the surgeon to revert to complete
extraction. Most investigators deemed this as a failed
coronectomy.2,13,21-23 In the RCT by Leung and
Cheung,2 171 M3Ms were assigned to the intended
coronectomy group but 16 of these failed intraopera-
tively. Differences in methodology led to variation in
the way these cases were accounted for in their analysis.
Cilasun et al.22 and Hatano et al.23 combined these to
the complete extraction group, Renton et al.21 created
a separate subgroup, Leung and Cheung2 excluded
these cases completely from statistical analysis while
Kang et al.13 did not make clear how their 9 failed cases
were analysed. These may introduce outcome reporting
bias into the studies and limit the extent that results can
be compared between studies.
Coronectomy may also fail due to postoperative
discoveries, such as residual enamel, wound dehis-
cence, infection, migration/exposure of the root,
mobile root or pulpitis.9 In a 2017 systematic review
by Dalle Carbonare et al.,9 failed coronectomies in
general had an incidence of IAN disturbance of
2.6%.9 Excluding cases of late root exposure, the inci-
dence of IAN disturbance of failed coronectomies is
4.0%.9 This compares to 0.5% for successful coronec-
tomies.9 These figures compares favourably with the
incidence of IAN disturbance for complete extraction
of high risk cases, which is reportedly as high as
35%.3 There is evidence that even failed coronec-
tomies have a lower incidence of IAN disturbance
compared to complete extraction.9
Lingual nerve disturbance
Of the studies which investigated lingual nerve distur-
bance, there were no reported cases.2,21,23 The inci-
dence of lingual nerve disturbance may be influenced
by whether lingual retraction was performed.28 The
coronectomy technique was not adequately reported
in the included studies. Renton et al.21 did not make
it clear if the lingual tissues were retracted but it was
reported that the surgeons avoided sectioning the
crown through completely, and levered off the crown
instead. Hatano et al.23 did not specify if lingual
retraction or incomplete sectioning was performed.
Leung and Cheung2 specifically mentioned no lingual
flaps were raised but the lingual aspect was protected
by a periosteal elevator. Further research to explore
what, if any, specific aspects of the coronectomy tech-
nique is protective of lingual nerve is indicated.
Pain
Most of the studies found coronectomies resulted in
either similar or less pain and swelling compared to
complete extractions.2,13,21,22,27 Hatano et al.23 was
© 2021 Australian Dental Association

Coronectomy of mandibular third molars: a systematic literature review and case studies
the exception, as their coronectomy group reported
higher levels of pain as measured on the visual analog
scale (VAS). The authors postulated this was the
result of increased pressure from tighter primary clo-
sure and pulpitis from the coronectomised roots.23
There was marked variation in the methodology for
assessing post-operative pain. Two studies reported
pain by VAS,2,23 one by health related quality of life
(HRQOL) questionnaire27 while another two simply
reported on the number of subjects complaining of
pain.21,22 Both the timeframe of reviews and the pre-
scribed analgesia regime also differed. The pain data
should be interpreted in view of such limitations. Fur-
ther refinement of the research protocol to reduce
confounding variables will strengthen the quality of
data.
Early postoperative infection
The included studies reported the incidence of postop-
erative infection after coronectomy to be between 0–
5.8%.2,21-23 This compares with 0–10.47% as
reported by other studies.4,9,29,30 Long et al.30
reported a risk ratio (RR) of 1.03 (95% CI = 0.54–
1.98) in their meta-analysis. O’Riordan3 found only 1
case of infection in a retrospective study of 52
patients while other papers reported no cases of infec-
tion.13,27,31 Other systematic reviews generally con-
clude that there were no statistically significant
differences in the rate of infection between coronec-
tomy and complete extraction.4,30,32 Root canal treat-
ment of coronectomised roots has been reported as
increasing the risk of complications.13,27,31 All
included studies did not perform any pulp treatments
on the coronectomised roots.2,13,21,22,23,27
Dry socket/Alveolar osteitis
Most studies found a lower incidence of dry socket
after coronectomies.2,13,22,23 Leung and Cheung2
attributed this to the smaller residual socket and a
more stable blood clot after coronectomies.
Renton et al.21 was the only study reporting the
opposite. It is worth considering if the technique for
surgical wound closure is correlated with the inci-
dence of dry sockets. Leung and Cheung2 and Renton
et al.21 did not specify if primary closure was
achieved. Cilasun et al.22 reported that flaps were
“tightly closed” while Hatano et al.23 specifically
mentioned primary closure was achieved. Kang
et al.13 achieved tension-free closure along with use of
gelatin sponge. Manor et al.27 did not specify tech-
nique for closure. As the technique was inadequately
reported, it is difficult to ascertain if the wound clo-
sure technique is a possible confounder. Future studies
with greater detail on the coronectomy technique may
© 2021 Australian Dental Association
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provide better insight as to its influence on dry
sockets.
Root migration
This review found a wide range of incidences for root
migration from 8.6% to 90.9%. This wide range is
consistent with other findings in the literature which
range from 2% to 85%.28,33 It has been suggested that
this is the result of different follow-up periods in the lit-
erature ranging from 6 months to 10 years.29,33 Three
of the four included studies reported root migration
was very common.2,13,23 Renton et al.21 was the only
study reporting relatively low numbers of root migra-
tions. The authors proposed that further root eruption
may eventuate with a longer follow-up period, however
their study had a longer follow-up period of 25 months
compared to the studies by Leung and Cheung2
(10.6 months) and Hatano et al.23 (13 months). Leung
and Cheung2 found 75% of root migrations ceased
between 12–24 months and none had erupted further
between 24–36 months. It is thought that by the
24 month mark, bone growth over the roots limits fur-
ther root migration.2 Thus it is possible other factors
may influence root migration.
Kang et al.13 found a statistically significant inverse
correlation between root eruption with vertical and dis-
toangular impactions (P = 0.003). Closer examination
at the types of impactions in the study by Renton
et al.21 reveal that it had a much higher proportion of
vertical and distoangular impactions (54.8%) com-
pared with Kang et al.13 (7.27%), Leung and Cheung2
(22.8%) and Hatano et al.23 (5.88%). This may be one
possible factor leading to low rates of root migration in
the study by Renton et al.21. Indeed reports in the liter-
ature indicate factors such as age,31 gender,34 root mor-
phology29 and depth of impaction34 may be correlated
with the incidence of root migration up to 24 month
postop. Such factors were inadequately reported in the
included studies to allow any strong conclusions to be
drawn. Further data to allow subgroup analysis in
future studies may provide better insight.
Root exposure
Whilst there was in general a high number of root
migrations, there were only very few cases of root
exposure reported. Leung and Cheung2 attributed this
to faster bony regrowth which outpaced the velocity
of root migration until further root movement ceases
in most cases.
Reoperation rate
Reoperation is only indicated when symptoms or root
exposure occurs.29 The low numbers of reoperation
143

A Mann and J Scott
noted in this review is consistent with findings in the
literature. In 2019, Barcellos et al.29 published a sys-
tematic review on parameters leading to reoperation
following coronectomy. They collated outcomes from
15 studies with a total of 1664 patients and reported
an overall low retreatment rate of 5.1%. Their data
showed the main reasons for reoperation were root
exposure (53.33%), infection (10.47%), pain (9.52%)
and residual enamel (9.52%).29 As most roots migrate
away from the IAN, the risk of IAN injury from reop-
eration is lowered,34,35 although there is one case
report where the IAN moved in unison with the
root.36
Follow-up protocol
There is no consensus regarding the method nor how
frequent coronectomised roots should be monitored.
Many of the included studies obtained serial radio-
graphs as part of their research protocol. Leung and
Cheung2 took OPGs at each review at 1, 3, 6, 9, 12
and 24 months. Similarly Renton et al.21 requested
radiographs at each review. Hatano et al.23 took CT
scans at 3 and 12 months postoperatively, whereas
Kang et al.13 took CBCT at 12 and 36 months post-
operatively. It is unknown whether repeated radio-
graphic exposures may have influenced the number of
patients lost to follow-up and whether this may lead
to bias. In any case, such research protocols are not
necessarily applicable to daily clinical practice.
Given residual enamel after coronectomy is associ-
ated with increased risk of complications,37 it seems
reasonable to obtain a radiograph soon after surgery to
check for any enamel inadvertently left in-situ.2,21-23,27
The benefit of any subsequent radiographs was not
well reported within the included studies. Within the
limits of this review, results indicate that very few
symptomatic exposure roots occur. In turn, there are
very few cases requiring reoperation. In keeping with
the ALARA concept, multiple sequential review radio-
graphs would seem unnecessary in normal clinical
practice.
Regarding the timing of reviews, of the included
studies which specified their protocol2,13,21,23 most
reviewed patients at 1, 3, 6, 9 and 12 months as a
minimum. Elsewhere in the literature, there is marked
variation in the follow-up length, ranging from 1 year
to 10 years.3,31,34,35 There is no agreement as to an
appropriate length of time for follow-up, and none of
the included studies offered any guidelines applicable
for routine clinical practice.
Studies mentioned most root migrations occurred
within first 2 years,29,33 although some may continue
to migrate up to 10 years later.9 Chapman and
Tong33 conducted a literature review focused on fol-
low-up protocols for coronectomies. They proposed a
144
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follow-up protocol based on their unit’s experience
with additional support from literature findings. They
recommend a radiograph within 7–10 days post-oper-
atively. For cases showing signs of infection and nerve
injury, three-monthly reviews are advocated in the
first year, followed by longer term annual follow-up
visits of no longer than 36 months. They suggest that
subsequent radiographs are only indicated if there are
symptoms, signs of infection or root exposure.33
Whilst generally migrating roots seldom cause
issues, the potential for such roots to cause marginal
bone loss or resorption of the adjacent molar has been
reported.38 Thus Pedersen et al.38 suggests that a fur-
ther radiograph 1 year postoperatively is not unrea-
sonable. As there is no consensus regarding
radiographic reviews for coronectomy, surgeons are to
use their best judgement in the context of patients’
individual circumstances in prescribing radiographic
reviews.
Short term follow-up should be conducted by the
operating surgeon. In a team approach, specialist sur-
geons can liaise with patients’ GDP regarding a suit-
able long term follow-up protocol such that these can
be incorporated into the general dental examinations.
Limitations
Ultimately the findings of this literature review are
affected by limitations of the included studies. In addi-
tion to limitations and risk of bias mentioned earlier,
the results should be interpreted with reference to the
age of the studies’ subjects. The average age of those
undergoing coronectomy varied from 26.5 years to
32.36 years of age.2,13,21-23,27 As the average ages
were all relatively low, it may limit to an extent their
application for other patients considering coronec-
tomy.
In this review, only studies with control groups
were included to reduce the influence of confounder
variables on the primary outcome. Due to this strict
criteria, the overall number of included studies are
reduced, limiting the sample sizes for analysis of cer-
tain secondary outcomes. Further studies focusing on
the incidence of root migration, root exposure and
reoperation rate will not require comparison with a
complete extraction group.
CASE STUDIES
To illustrate the application of coronectomy and fol-
low-up protocol in clinical practice, 2 case studies
referred by GDP for OMS management are presented.
In the case studies cited, the OMS was responsible for
the follow up of the patients. If this is not the case,
good communication between the GDP and OMS is
essential so that the GDP is aware of what has
© 2021 Australian Dental Association
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Coronectomy of mandibular third molars: a systematic literature review and case studies

eventuated in discussion with the patient, the outcome
of the surgery and any recommended reviews.
Case study 1
A 55 year old female with clear medical history was
referred to an OMS by her GDP for her symptomatic
lower left M3M. A panoramic radiograph showed a
radiolucency associated with the unerupted lower left
M3M (Fig. 2a,b). There is darkening of the root, indi-
cating likely impingement of the canal.5 There is also
an obvious change in the course of the canal, this
diversion of the canal indicates the canal is possibly
passing through the root.
Further imaging by CBCT revealed a radiolucency
18mm wide surrounding the crown of the lower left
M3M (Fig. 3a,b). A potential dentigerous cyst was
part of the differential diagnosis, but other odonto-
genic lesions could not be excluded, such as
ameloblastoma.
A bifid inferior alveolar canal was identified, with
one branch mildly compressed as it passes between
the buccal and lingual roots of the left M3M. The
nerve then runs medially along the medial aspect of
the M3M. Due to the intimate relationship between
the left M3M and the IAN, it was deemed high risk
for neurological disturbance. The patient was given
the option of no treatment, removal of the cyst with
either a coronectomy or complete extraction of the
left M3M. The risk, advantages and disadvantages of
all options were discussed as part of the informed
consent process. The patient elected to have a coro-
nectomy and enucleation of the cyst under general
anaesthetic (GA). The lining of the cyst was sent for
histopathological evaluation which confirmed the
diagnosis of a dentigerous cyst.
The patient returned for review 1 week postopera-
tively and healing was uneventful with no disturbance
of the IAN. The canal is less sharply diverted com-
pared to the preoperative state, indicating the move-
ment of the mandibular canal (Figs. 2a,b and 4a,b).
An OPG 12 months later revealed bony healing, with
no obvious signs of root migration nor further change
in the mandibular canal (Fig. 5a,b). Movement of the
mandibular canal following coronectomy is a rare
occurrence. To our knowledge there has only been
one other case published in the literature.36
Case study 2
A 24 year old female was referred by her GDP to an
OMS for opinion regarding her impacted third
molars. The maxillary third molars were partially
erupted whilst both M3Ms were impacted and symp-
tomatic. The OPG showed an intimate relationship
between both M3Ms and their respective IANs
(Fig. 6). The patient was given the option of no treat-
ment, coronectomy or complete extraction.

Fig. 2 (a) Cropped pre-operative OPG showing radiolucency associated with impacted left M3M with darkening of the root, diversion of the mandibular
canal (b) with IAN outlined.

Fig. 3 (a) Cropped pre-operative CBCT image showing radiolucency associated with impacted left M3M (b) with bifid IAN outlined.

© 2021 Australian Dental Association 145

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A Mann and J Scott

Fig. 4 (a) Cropped 12 months post-operative OPG showing migration of the mandibular canal (b) with IAN outlined.

Fig. 5 (a) Cropped 24 months post-operative OPG showing no further migration of the mandibular canal or root migration (b) with IAN outlined.

Fig. 6 Pre-operative OPG.

Fig. 7 Coronectomy of left M3M: (a) intraoral image of root after coronectomy – green arrows indicating the pulps of the 2 roots of left M3M; (b) sec-
tioned crown of left M3M.
146 © 2021 Australian Dental Association
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Coronectomy of mandibular third molars: a systematic literature review and case studies

Fig. 8 Post-operative OPG, 1 month after surgery.

Fig. 9 Post-operative OPG, 12 months after surgery.

The patient elected to have coronectomies for both
M3Ms. Under GA, flaps were retracted and the
crowns of the teeth exposed. Each crown was sec-
tioned from the roots using a No 8 oral surgical bur,
then the crown was divided superior to inferior to
effect its removal (Fig. 7a,b). The remaining roots
were then smoothed down with a large bur and the
incisions closed with resorbable sutures. The patient
was reviewed 1 week post-surgery and a radiograph
obtained 1 month post-surgery (Fig. 8). All was well
healed, with no sensory disturbance. A further OPG
was obtained 12 months post operatively showing
good bony healing (Fig. 9). A further OPG was coin-
cidentally available 6 years post operatively as the
patient had sought an orthodontic opinion which
shows further bony healing (Fig. 10).

Fig. 10 OPG for orthodontic opinion, 6 years after surgery.

© 2021 Australian Dental Association 147

A Mann and J Scott
CONCLUSION
Within the limitations of this systematic literature
review, there is medium quality evidence to demon-
strate that coronectomy significantly reduced the inci-
dence of IAN disturbances for M3Ms close to the
IAN but it was not completely avoidable. The rates of
other non-neurological complications were similar
between coronectomy and complete extraction. The
reoperation rate was generally low. After considering
risks and benefits, coronectomy should be considered
for those cases deemed at risk of neurological distur-
bance.
GDPs caring for patients with impacted M3Ms
should work with specialist surgeons and be aware of
the option of coronectomy, its relative merits, the
radiographic appearance of coronectomised roots and
be vigilant of any possible sequelae. More data is
needed to explore whether there is any correlation
between certain characteristics of an impacted M3M
and the likelihood of root exposure. Further studies
regarding the influence of specific aspects of the coro-
nectomy technique on treatment outcomes and con-
sensus on a follow-up protocol would further refine
the clinical application of this technique.
DISCLOSURE
Nothing to declare. This study does not involve fund-
ing.
ACKNOWLEDGEMENTS
None – no financial grants nor any external funding is
applicable.
CONFLICT OF INTEREST
Nothing to declare - Please see separate files for decla-
ration.
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Address for correspondence:
Dr. Alan Mann
555 Grange Road
Grange South Australia 5000
Australia
Email: dr.amann@protonmail.com
149