also...any links to useful information regarding nerve damage and wisdom teeth extraction would be so helpful. i can't seem to find anything good. thanks!

Coronectomy: A technique to protect the inferior alveolar nerve

M. Anthony Pogrel, DDS, MD*Corresponding Author Informationemail address, J.S. Lee, DDS, MD, MS†, 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.

http://www.joms.org/article/S0278-2391(04)01157-7/abstract
Journal of Oral and Maxillofacial Surgery

Coronectomy: A time to ponder or a time to act?

Coronectomy is defined by Pogrel, Lee, and Muff in this month’s issue of JOMS as “a procedure to remove the crown and upper third of the roots of a lower third molar.”1 The purpose of this procedure is to reduce the risk of injury to the inferior alveolar nerve. The result of coronectomy is the deliberate vital root retention of the impacted third molar.

While the overall incidence of inferior alveolar nerve injury resulting from odontectomy is low, Pogrel et al selected cases for coronectomy where “there was radiographic evidence of a close relationship between the roots of the tooth and the inferior alveolar nerve.”1 In this case series, one (2%) of the patients had a transient lingual nerve injury and none had inferior alveolar nerve injury.1

Since the beginnings of third molar surgery, surgeons have been aware of the risk of inferior alveolar and lingual nerve injury. Risk factors for nerve injury are now known to include radiographic proximity, surgeon experience, surgical procedures, patient age, and preexisting disease. Techniques that appear to reduce these risks gain the worthy attention of patients and surgeons contemplating elective third molar removal.

On the face of the issue, coronectomy would seem to make sense. As clinicians we usually rely upon empiricism to make clinical decisions. We have used a method, and in a sufficient number of patients it has worked well, but only in our hands. We then report our success to our colleagues. This empirical approach to the problem of selecting coronectomy relies on personal experience and personal observations alone.

Empiricism does not rise to the level of scientific evidence of a prospective, randomized, double-blind clinical trial. In such a trial, at-risk patients (or sides/teeth) would be randomly selected to undergo either coronectomy or odontectomy. The patient would not know which procedure had been performed (because of the subjective nature of reporting paresthesia). The surgeon would not know the procedure to be performed until the random selection was made. Independent observers, blinded to the procedure performed, would carry out the postoperative neurologic evaluation. The study would be subject to power analysis, which for a condition with a 1% incidence would require thousands of enrollees with a high number of exclusion criteria, causing perhaps tens of thousands of screenings of prospective study subjects. If experience in our specialty’s clinical research is any predictive measure, it is unlikely that such a study will ever be funded or performed.

Thus, JOMS presents outcome studies as case series, not as the final answer to a clinical question, but as a clinical assessment of what might work. JOMS gratefully accepts empirical studies, which appear as case series that observe the outcome of a method in a cohort of patients and by an unblinded group of surgeons. Indeed the surgeons may develop advocacy for the procedure over the course of the study, since if advocacy is lost the study may not be completed and/or published. Hence, the reader must assess these studies as a means to ponder a clinical approach but not as the final answer to a clinical issue. Assessing the unanswered questions that remain regarding Pogrel, Lee, and Muff’s investigation might reveal some of the limits of observational case series.

Will inferior alveolar nerve injury indeed occur at a lower rate with this technique? While conventional wisdom might imply this as axiomatic, the use of rotary instruments deep within the socket could produce the unexpected outcome of producing a higher risk of inferior alveolar nerve injury. With only 41 patients in this current study, no conclusions can be made in this regard. In addition the roots must be sectioned from the crown without mobilizing the roots. This might force a more complete sectioning of the roots with rotary instruments during the primary procedure, perversely placing the lingual nerve at greater risk. A secondary procedure to remove symptomatic roots might place the inferior alveolar nerve and lingual nerve at either greater or less risk.
Will coronectomy produce cases of complicated infections or osteomyelitis, possibly producing later inferior alveolar nerve paresthesia?

Will the antibiotic needs of patients undergoing coronectomy differ from those undergoing odontectomy?

What are the risks of increased antibiotic use in this cohort of patients?

What is the long-term fate of migration of the root remnant?

Will some root remnants become symptomatic due to pulp necrosis?

Will repeated radiographs and clinical evaluation over the course of years be necessary?

Will the periodontal outcomes of coronectomy differ from odontectomy?

Are the favorable outcomes of coronectomy surgery performed by these surgeons reproducible if the technique were to gain general use?

Are there medical indications and contraindications for this procedure (eg, bisphosphonate use, diabetes)?

Perhaps the most vexing issue will be examining the medical-legal implications of the emergence of this procedure. Does coronectomy need to be included in the informed consent as a reasonable alternative? Should it be selected for patients at risk? Current evidence would indicate that coronectomy is not proven to be a method of reducing nerve injury, yet this valuable case series combined with the intuitive sense that it would be helpful will certainly lead some toward this contention. We can be sure that some will also attempt to misuse this information in the face of adverse outcome after odontectomy.

All surgical procedures contain risks; hence the surgeon and patient often trade one risk for another in deciding on a surgical procedure. Coronectomy demonstrates this inevitable trade off in risk as a new set of competing needs and issues emerge. While it is certainly time to ponder coronectomy, the time to act will depend upon the individual needs of patients, the abilities of the surgeon, and the advancement of necessary scientific evidence.

http://www.joms.org/article/S0278-2391(04)01322-9/fulltext
Journal of Oral and Maxillofacial Surgery

I am at just over a year now and I am at 90+%. I recently typed out 'my story' on the other forum. I wrote I wouldn't wish this on my worst enemy.

If you have to get them out them you have to! I still have one more on the bottom and was told that I need to get that dealt with or in the future, they would be pulling out with wisdom tooth and the one in front of it. I am still gun shy!

You will make the right decision!

Deb