Jomnal of Orthodontics. 'Vol.

39, 2012, 117-121

CLINICAL
SECTION

Coronectomy for infraoccluded lower

first permanent molars: a report of two
cases
Elinor Chalmers, Christine Goodall and Alastair Gardner
Glasgow Dental Hopsital, Glasgow, UK

Two cases of infraoccluded lower first permanent molars were treated at Glasgow Dental Hospital and School with a joint
orthodontic and surgical approach. Coronectomy, a technique usually reserved for deeply impacted lower third molars, was
carried out in both cases; these are discussed.
Key words: Submergance, infraoeclusion, reinclusion, reimpaction, lower first molars, coronectomy, orthodontics, secondary,
retention
Received 23 February 2011: accepted 13 March 2012

Introduction

involvement.^ Secondary retention involves the unexplained

cessation of further eruption after a tooth has penetrated the
Infraoeclusion is the clinical manifestation ofthe failure of a
oral mucosa.^** Clinically, secondary retention is suspected
tooth to continue to erupt.' The etiology of infraoeclusion is
when a molar is in infraoeclusion at an age when the tooth
not well understood, but ankylosis is considered to be an
would normally be in occlusion.'' The term primary failure
important factor in primary molars. Data concerning the
of eruption is also used in reference to tooth eruption
mechanism of infraoeclusion in the permanent dentition are
failure,^ with the most comprehensive analysis of prirnat7
insufficient, although again ankylosis has been suggested.^
failure of eruption suggesting that this condition demonAnkylosis is defined as the fusion of cementum and alveolar
strates tnost, if tiot all, ofthe following characteristics: (1)
bone.'' Hypercementosis, deficient alveolar bone growth and
posterior teeth are more commonly involved than anterior;
the presence of pulpo-periodontal canals are potential
(2) teeth may erupt into initial occlusion and then cease to
causative factors reported in the literature." Systemic causes
erupt further, or may fail to erupt entirely; (3) both primary
of infraoeclusion, include patients with developmental
and permanent molars may be affected; (4) may be
syndromes, whilst familial rcinclusion of permanent molars
unilateral or bilateral; (5) involved permanent teeth tend
has also been reported.'^ The prevalence of infraoccluded
to become ankylosed; (6) application of orthodontic force in
permanent molars is low compared with primary molars.'
an attempt to bring the affected teeth into the arch leads to
Biederman studied 221 submerged teeth and found that only
ankylosis rather than normal tooth movement; and (7) the
%.VVa were permanent and only fotir were lower first condition tends to occur in isolation, with an absence of
permanent molars.~^ In the normal population, failure of
affected family members.'" A diagtiosis of ankylosis can be
eruption of first permanent molars is rare, with a prevalence
made by percussing the tooth, where a solid percussion
of O.Ol'M).^' The severity of infraoeclusion can be measured as
sound can be recorded if over 20% of the root is ankylotic. ' '
the distance in millimetres betweeti the occlusal surface of
Radiographie examination may not be useful for the
the tooth and the occlusal plane of the relevant arch.^ The
detection of ankylosis in multi-rooted teeth, because small
result of infraoeclusion may be clinical problems such as
areas of ankylosis are not visible due to overlapping of
malocclusion and loss of neighbouring teeth due to caries
strtictures. Thus, infraoeclusion of a molar at an age when it
and periodontal disease."*
would normally be in occlusion is the only reliable clinical
criterion.^
Infraoeclusion affecting the permanent teeth may be
described as either primary or secondary retention, or
The treatment of choice for secondary retetition
primary failure of eruption. Primary retention of permanent
depends on the age of the patient, the extent of the
teeth is an isolated condition associated with a localized
infraoeclusion and the malocclusion.^ Rarely, a secondafailure of eruption but no other local or systematic
rily retained molar tooth may re-erupt spontaneously,'"
Address for correspondence: E. Chalmers, Glasgow Dental
Hopsital. Glasgow, UK.
Email: elinorchalmers84@googlemail.com
2012 British Orthodontic Society

DOI 1O.1179/14653I2512Z.00OOO0OOOI4

118

s:esi&\ .TJS

Chalmers et a!.

(a)
Figure 1

/ O June 2012

(b)

(C)

Case 1 pre-treatment: (a) lower arch; (b) left buccal occlusion: (c) panoramic radiograph

more usually orthodontic movement of the infraoccluded

molar is not possible due to the altered periodontal
ligament,' and the following options apply:
1. If secondary retention develops prior to the growth
spurt, immediate removal of the affected molar
followed by orthodontic alignment of the neighbouring teeth is the suggested treatment.
2. If secondary retention develops during the growth
spurt, the molar should be observed at 6 monthly
intervals^ and treatment based on the severity of the
developing infraocclusion.
3. If retention develops after the growth spurt, the
extent of infraocclusion and its progression is
limited. Because of these factors, the retained molar
can be built up to restore occlusal and proximal
contacts to prevent tilting of neighbouring teeth and
elongation of the antagonists.'"' Luxation of the
secondarily retained molar has been described and
used with some success."* In other cases, the affected
molar should be removed.'
Coronectomy is a surgical technique more commonly
used for impacted lower third molars with radiological
evidence of close proximity to the inferior alveolar
nerve. It is used as an alternative to complete extraction
when the inferior alveolar nerve is deemed to be at 'high
risk', the tooth is vital, and in patients who are fit and
well. The objective is to prevent inferior alveolar nerve
damage and the outcome is that the roots are retained
in situ. The technique involves using a buccal fiap
approach with removal of buccal bone using a bur down
to the level of the amelo-dentinal junction. The crown is
part sectioned from the root using the bur, and the
crown elevated. The remaining tooth is then reduced so
that the roots are 3 ^ mm below the level of the bone
and the flap completely closed. The roots are left
undisturbed thereby avoiding direct or indirect damage
to the inferior alveolar nerve.''* There is no indication
for endodontic treatment of the roots.'^ The only

proviso with this technique is that if the roots are seen

to be mobile at the time of coronectomy they should be
removed as mobile roots may be associated with a
higher risk of infection.'^ Nine relevant studies of this
technique have been published all of evidence level three
or above.'"* All of the papers advocate merit and
recommend the use of the method to reduce inferior
alveolar nerve damage.
This report presents two patients where the coronectomy technique was used to manage infraoccluded lower
first permanent molars. Both patients were referred to
the Orthodontic Department at Glasgow Dental
Hospital and School.

Case1
A 14-year-old boy was referred from a specialist
orthodontic practice. His presenting complaint was that
he had 'squinty teeth" and he was medically fit and well.
Assessment
On examination he had a class II division I incisai
relationship on a class II skeletal base. His FMPA was
average and his lips were incompetent. The lower arch
was well aligned with retroclined incisors. The upper
arch was mildly spaced with proclined incisors. Oral
hygiene was good. The overjet was 10 mm and the
overbite was 90% complete. The molar and canine
relationship on the right hand side was a 'A unit class II
and on the left hand side was a full unit class II. The
centrelines were coincident and there were no mandibular displacements. The LL6 was infraoccluded and
gave a dull note on percussion (Figures la and lb).
A dental panoramic radiograph was taken and showed
UR8, LL8, and LR8 to be present and unerupted. The
LL6 was seen to have curved mesial root with apices in
close proximity to the inferior alveolar canal. A surgical
opinion was sought (Figure lc).

Imical Section

Figure 2

Coronectomy for infraocciuded lower first molars

119

Case 1 post-twin block treatment: (a) left buccal occlusion: (b) panoramic radiograph

Treatment options
1, Monitoring the infra-occluded LL6;
2, Surgical removal of LL6;
3, Coronectomy of LL6.
The risks of infection if left in situ or damage to the
inferior alveolar nerve if extracted were explained to the
patient and the accompanying parent.

Treatment
A decision was made to decoronate the LL6 under
intravenous sedation. The procedure was carried out in
the standard manner, Vicrly Rapide^"^ (Ethicon, NJ,
USA) sutures were used for closure. Post-operative
analgesia and chlorhexidine gluconate 0,2%, 10 mL
mouthwash twice daily was prescribed.
Follow-up
There were no immediate post-operative complications
and the decoronated LL6 root remains asymptomatic
15 months post-surgery. The patient has since had
orthodontic treatment with a twin block and is currently
undergoing flxed appliance therapy. The LL6 space has
been maintained as it is not possible to close with the
roots in situ. The patient is currently unconcerned
about the space; a restorative opinion will be sought if
his opinion was to change. Clinical photographs were
taken after completion of functional appliance therapy
(Figure 2a), A 15-month post-operative radiographie
review and report showed that there had been some
mesial drift of the decoronated roots but there has been
no significant eruption (Figure 2b), Alveolar bone is seen

to cover the retained roots to a depth of approximately

10 mm. There was no associated pathology.

Case 2
A 14-year-old girl was referred from a specialist
orthodontic practice with an infraoccluding LL6 rst
molar. Her presenting complaint was of a 'sinking tooth,
which is not causing any pain'. Medically she was fit and
well.
Assessment
On examination she had class I incisors on a skeletal I
base. The lower arch was well ahgned and lower incisors
had an average inclination. The upper arch was mildly
crowded with incisors of average inclination. The overjet
was 4 mm and the overbite was increased and complete.
The molar relationship on the right was class I and on
the left a Vi unit class II, The canine relationship on
the right was class I and on the left VA unit class II.
The upper centreline was to the right. The LL6 was
infraocciuded and gave a dull note on percussion. The
LL5 was tipped distally and the LL7 tipped mesially
(Figures 3a and 3b), A dental panoramic radiograph
supplied by the specialist orthodontic practitioner
confirmed the presence of third molars, Occlusal caries
was observed radiologically in the LL6; however, there
was no evidence of periapical involvement and the roots
appeared to be in close proximity to the lower border of
the mandible. There were no obvious signs of hypercementosis or ankylosis (Figure 3c).

(a)

(b)

(c)

Figure 3 Case 2 pre-treatment: (a) lower arch; (b) left buccal occlusion; (c) panoramic radiograph

Initial treatment options

1.

2.

3.

4.

Accept the current situation, restore caries and

monitor infraocclusion. Maintain meticulous oral
hygiene.
As per option (1) but obtain restorative opinion on
building up the occlusal surface of LL6 to provide
some occlusal contact but this may make maintaining oral hygiene more difficult.
Complete surgical removal of LL6 and orthodontic
space closure. This would potentially mean loss ofa
substantial amount of bone from the lower left
quadrant and there would be risk of damage to the
inferior alveolar nerve.
Complete surgical removal of LL6, but no orthodontic treatment and accept the residual space.

The patient and her parent opted for option 1. The

patient was reviewed after one year and at that point the
LL6 had infraoccluded further with the mesial aspect
almost below the mucosa. A surgical and restorative
opinion was sought.
Eurther treatment options
1. Continue to monitor;
2. Extract LL6 surgically;

3. Decoronate LL6 and leave space or restore space

with a resin retained bridge pontic.
The risks of infection if the infraoccluding tooth was to
be left in situ or damage to the inferior alveolar nerve
if extracted were explained to the patient and the
accompanying parent. They opted to have it decoronated and then review the options for space restoration.
Treatment
The LL6 was decoronated under anaesthetist led
intravenous sedation. Vicryl Rapide^'^ sutures were
used for closure. Post-operative analgesia and chlorhexidine gluconate 0.2%, 10 mL mouthwash twice daily,
was prescribed.
Eollow-up
The patient experienced some initial post-operative
discomfort that resolved quickly. No other complications were noted and the patient is currently asymptomatic 15 months post-surgery. Six months following
surgery the patient's general dental practitioner requested an orthodontic review as the LL7 had begun to
drift mesially and lingually and was out of occlusion.
The patient was offered fixed appliance therapy to
upright the LL7 which she consented to. This treatment

Figure 4 Case 2 post-treatment: (a) left buccal occlusion; (b) panoramic radiograph

%hical Section

was successful and the patient is now in orthodontic

retention (Figure 4a). An 18-month post-operative
radiographie review and report showed that the
decoronated roots have moved mesially and there was
no evidence of vertical eruption (Figure 4b). There is
bony coverage of the roots LL6, but due to the
difference in angulation of the orthopantomogram
machines bone height could not be accurately assessed.
There was no associated pathology.

Discussion
Infraoccluded permanent molars are an uncommon
problem, but when present pose a treatment planning
challenge. More superficially displaced teeth may be
routinely extracted. Surgical removal of deeply submerged lower permanent molar teeth poses a risk of
anaesthesia or paraesthesia to the inferior alveolar
nerve. Coronectomy can help reduce this risk and can
be beneficial, but success requires both good patient
selection and operator technique.'^ It has been reported
that the incidence of persistent neuropathy is 0.65%
of patients undergoing coronectomy of third molars
compared with 5.10% in patients undergoing complete
removal.'^ No other studies have reported neuropathy
following coronectomy.'^
Leaving the decoronated roots in situ is not ideal from
an orthodontic perspective, but the risks of potential
inferior dental nerve damage must be considered.
Subsequent root migration of third molars that had
undergone coronectomy is mentioned in all the papers
with a range of values of 5 to 81%'^ and this may allow
their safe removal at a later date. Pogrel observed that
30% of roots erupted in the first year post-operatively
and could be removed with no associated morbidity, as
all roots had migrated away from the nerve.'^

Conclusions
Coronectomy is a potentially useful management technique in a patient with an infraoccluded lower permanent
molar close to the inferior dental nerve, and who has tio
medical contraindications. However, the implications of
leaving retained roots in situ have to be carefully
considered and incorporated into the treatment plan.

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Coronectomy for infraoccluded lower first molars

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