btw, I thought I wouldn't have been a candidate for this procedure, mav, because my wisdom tooth was laying horizontally. But, this article says that horizontally impacted third molars "may" be considered for this! I wish I would have known this before I had my surgery. I'm pretty sure my tooth was sectioned anyway during my surgery - I'll find out when I meet with the OS in a few days. If I'm understanding this correctly, would it have been possible to remove just part of my wisdom tooth, leaving alone the remaining part of the tooth, thus possibly avoiding the damage to my IAN?

Quote from the article - "Teeth that are horizontally impacted along the course of the inferior alveolar nerve may be unsuitable for this technique because sectioning of the tooth itself could endanger the nerve (see Fig 9). The technique is therefore better utilized for vertical, mesioangular, or distoangular impactions where the sectioning itself does not endanger the nerve."

Coronectomy: A Technique to Protect the
Inferior Alveolar Nerve
M. Anthony Pogrel, DDS, MD,* J.S. Lee, DDS, MD, MS,† and D.F. Muff, DDS, MD‡

Purpose: Damage to the inferior alveolar nerve when extracting lower third molars is often caused by the intimate relationship between the nerve and the roots of the teeth. The technique of coronectomy,
or intentional root retention, may minimize this problem.

Patients and Methods: Forty-one patients underwent coronectomy on 50 lower third molars with follow-up of at least 6 months. The technique of coronectomy deliberately protected the lingual nerve
as part of the surgical procedure. All roots were left at least 3 mm below the buccal and lingual plates of bone. All patients were radiographed preoperatively, immediately postoperatively, and after 6 months.

Results: There were no cases of inferior alveolar nerve–involved damage in this study of 41 patients
who underwent 50 coronectomies. There was 1 case of transient lingual nerve involvement, probably from the use of the lingual retractor. One patient required subsequent removal of the roots of both lower third molars because of failure to heal, and 1 patient required subsequent removal of a root because of subsequent migration to the surface. Root migration was noted in approximately 30% of patients over a 6 month period.

Conclusion: Coronectomy appears to be a viable technique in those cases where removal of the whole tooth might put the inferior alveolar nerve at considerable risk of damage. The technique appears to be associated with a low incidence of complications, but subsequent migration of the roots may be an issue in the long term.

© 2004 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 62:1447-1452, 2004

http://www.triangleoms.com/data/Coronectomy_JOMS1204.pdf

....I have personally needed to remove two wisdom teeth within the last year, when a general dentist attempted this procedure.
>OMFS

So has Dr. Progrel (or anyone else) done more indepth studies since 2004? If not, what is the dental profession waiting for? This seems to be a viable (in Dr. Progrel's words) alternative treatment for an deeply impacted third molar in older people...why not STUDY it and find out if people like me could have this procedure and avoid IA nerve injury?

Even to me, it's pretty obvious that a general dentist should not be attempting this procedure...did you report these two dentists?

I agree with you that most IA nerve injuries are rare, and occur due mostly to patients putting off the removal of third molars until they feel it is necessary, rather than taking their dentist's advice, often many years prior. At this point, most who have problems, as you know are beyond the age of low surgical risk and are now faced with the pressing need for extraction. The often-overlooked point is that since their age has increased, so to have the surgical risks. Now, there, it becomes a matter of choosing between two evils. As a GP, in my hands and, I think, like practically all other GP's, I like to catch 8's while they're 1/2-2/3's formed just like the texts say. I think it is fair to say that about 50% of people referred to an OMFS at this point don't heed the warning and more often than not are guilty of placing themselves in harm's way due to advancing age. It's an unfortunate tendency of human nature I would say, as from my perspective, it's not the referring dentist that is culpable for that late referral but the decision of the patient to not accept his once timely recommendations. As you would expect here, most of the patients that have suffered surgical complications are probably in the over 30 crowd. Further, I would expect in this day and age, anyone snagging 8's would clearly be doing an OS consult before any extraction which would clearly spell out all surgical complications. At this conclusion of this consultation, an open offering for referral of the surgery is given, even for the very simple extractions, should a patient be more comfortable with that route.

And, best of luck with all the flaming arrows regarding Articaine that are about to darken your door. I'd venture that you use lidocaine almost exclusively, as I do for 8's as the maximum allowable cartridge number is higher. Just a thought. Thanks again.

Regarding Articaine / Septocaine- my rule is simply not to use it for IA blocks. I'll use it for infiltration without hesitation. Unlike "Dr." B, I do not feel it should be taken off of the market. It has bee a godsend for many patients with "hot" pulps and periapical infections (but since she only practices prosthetic dentistry when he's not in the courtroom, what would she know of patients in desperate clinical situations? If she would only limit her "expert" diatribe to matters of which she has some practical experience, we would get along just fine...) No doubt, some dentists mis-use Septocaine, but it would not be fair to throw the baby out with the bath water by taking an excellent option for local anesthetic off of the market .
Finally, I would say that most, but not all of the 35+ year old patients I see that are just getting around to getting their impacted third molars removed, were told by their dentist years earlier to have them removed. On the other hand, I've seen my share of dentists completely ignore impacted thirds. More than a few times, I've seen second molars completely reconstructed- endo., post & core, porcelain crown- without the neighboring impacted third THAT CAUSED THE DECAY IN THE FIRST PLACE being removed. No way to blame that garbage on the patient. That was the call of a dentist. But after 14 years, is clear to me that the vast majority of my dental colleagues are compassionate, competent, knowledgeable, and happy professionals.

Can Coronectomy of Wisdom Teeth Reduce the Incidence of Inferior Alveolar Nerve Injury?

ClinicalTrials.gov processed this record on November 28, 2008

Coronectomy is a procedure intentionally aiming to remove only the crown of an impacted mandibular third molar, leaving the root undisturbed, and thus avoiding possible direct or indirect damage to the IAN. This technique was first described by Knutsson et al. in 1989 in a retrospective study of 33 patients. 6 more papers about coronectomy were published to date, with 3 case reports and 2 retrospective studies, and one randomized controlled trial by Renton et al. in 2005. In this last study, 128 patients were randomized to undergo either extraction or coronectomy of wisdom teeth.

The group undergoing extraction was found to be significantly more common in experiencing IAN deficit after surgery than the coronectomy group, while no significant differences could be concluded in terms of other surgical morbidities. The other studies also drew similar conclusions.

One common finding, however, was the slow superficial migration of the wisdom tooth root after coronectomy. It had been suggested the root is only indicated to be removed only if it is exposed intraorally, but the risk of IAN damage of the second surgery is reduced as the root has migrated away from the nerve

http://clinicaltrials.gov/ct2/show/NCT00752284

I was never once told in check-ups up until I turned 28 that my wizdom teeth needed extraction, and it was only until a socket started forming on the LHS lower that dentist on-referred me to OS for removal.

Despite being given the warning speech etc, my OS did not look at my OPG in my presence, and there is no record on my medical file pertaining to it.

Would you ever speak to a propsective patient without referring to the OPG in his/her presence?

Recently, studies have been done the United States on an alternative to complete removal of the wisdom tooth--the coronectomy.

Coronectomy
The procedure known as “coronectomy” (corona=crown; -ectomy=to cut out) involves removing the “crown”, the top or biting portion of the tooth, while leaving the roots in place. The purpose is to decrease the possibility of damaging the nerve when the roots are removed.

What happens to the root?
The expectation after removing the top of the tooth is that the root will remain in place and eventually cover with bone. Roots encased in bone can remain buried in the jaw for years, and rarely cause problems.
The literature and my personal experience has shown that in a significant percentage of cases, these roots begin to drift upward, away from the nerve, before being covered with bone. In my experience, this has been clinically insignificant.

What else could happen to the root?
It would be possible for the root to drift to the surface of the jaw. If this root irritated the tissue or the adjacent tooth, or otherwise became symptomatic, it would necessitate removal. Even though a second surgery would need to be performed, the possibility of nerve damage should be negligible, since the root would have migrated away from it's original resting place next to the nerve. Since the purpose of the coronectomy is to avoid this damage, this goal would have been accomplished, even though a second surgical procedure was necessary to remove the remaining portion of the tooth.

The root tip could also become infected in the post-operative phase and necessitate removal. Antibiotics are normally given pre-operatively or at the time of surgery, as well as post-operatively, to minimize this risk.
http://www.ivoralsurg.com/procedures/coronectomy.html

This post should be removed as it is offensive to patients who have been injured and are hurting from their injuries. There are good doctors and their are bad doctors. If you have nothing to defend, why post such things? You would think that a good doctor would be in support of all these folks who are honestly hurt and need help.

The energy that a surgeon would take to come to a nerve injury website like this, only to bash patients who most likely he doesn't know nor will he ever see, is unbelievable. The pain that we all go through is bad enough and to think that we are not safe to post our feelings without being slammed by a disgruntled Oral Surgeon who clearly does not seem to value patient/doctor relationships much nor care about the integrity of the profession is an insult.

This particular exchange here between dentists, oral surgeons and patients willing to provide research I think is invaluable. It actually provides some definitive answers on the practicality of intentional coronectomy which other dentists, surgeons and patients can hopefully benefit from. The fact that surgeons and dentists ever frequent this site at all should be regarded as a plus as such input can shape the thinking of those injured and ultimately educate people on the reality and limitations of these surgeries. Just an opinion of course but the first amendment is the first for a reason.

You are not here to help the injured patients, and that is my problem.

A little empathy at best, would be more appropriate. Keeping your generalized personal opinions of people who pay your bills to yourself might win you more friends and less enemies here.

There is a lot to be learned by those patients, if you are smart enough to listen and learn, rather than make cutting remarks in defense of your own inadequacies. I do understand your position as an Oral Surgeon, in that removing wisdom teeth is not always an easy task, and sometimes nerve injury is impossible.

Why can't they come up with a Laser technique?

I guess some people never get them? Both of my kids didn't have them until they were in their twenties also.

http://www.exodontia.info/Coronectomy.html

http://www.exodontia.info/Biography.html