DENTOALVEOLAR SURGERY

Periodontal Healing Distally to Second

Mandibular Molar After Third Molar
Coronectomy
Elisabetta Vignudelli, DDS, MSc,* Giuseppe Monaco, DDS,y
Maria Rosaria Antonella Gatto, MD, PhD,z Simonetta Franco, DDS, MSc,x
Claudio Marchetti, MD, DDS,k and Giuseppe Corinaldesi, MD, DDS{
Purpose: Coronectomy of mandibular third molars is a procedure that still raises a number of questions.
The aim of the present study was to answer one unsolved question: the periodontal healing distal to the
mandibular second molar after third molar coronectomy.
Materials and Methods: A prospective cohort study was performed of 30 patients treated at the Unit of
Oral and Maxillofacial Surgery of the Department of Biomedical and Neuromotor Science of the University of
Bologna. The predictor variables were the probing pocket depth (PPD), the distance between the marginal
crest (MC) and the bottom of the osseous defect (BOD), and the distance between the cementum enamel
junction (CEJ) and the BOD. These clinical indexes were recorded on 3 points of the distal surface of
second molar: the distobuccal (DB), distomedial (DM), and distolingual (DL) sites. The other variables eval-
uated included root migration and postoperative complications. The Wilcoxon test for paired data and Ken-
dall’s tau-b correlation coefficient was used to evaluate all variables. The significance level was set at P = .05.
Results: The cohort was composed of 30 patients with 34 high-risk mandibular third molars (9 men and
21 women), with a mean age of 28  7 years. At 9 months, a statistically significant reduction in the PPD of
2  3, 1  2, and 2  2 mm and a statistically significant reduction in the MC-BOD distance of 4  4, 4  4,
and 4  5 mm for the DB, DM, and DL sites, respectively, was observed (P = .001). Also, the intraoperative
CEJ-BOD distance showed a statistically significant reduction for the DB, DM, and DL sites.
Conclusions: After coronectomy, restoration of a clinical healthy periodontium distal to the
second molar was observed. However, further studies are necessary to confirm these preliminary clinical
results and to compare periodontal healing between coronectomy and complete extraction.
Ó 2016 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 75:21-27, 2017

Coronectomy is a recognized surgical option for the
treatment of third molars close to the inferior alveolar
nerve (IAN).1-3 However, several outcomes with this
technique remain in question, one of which is
periodontal healing distal to the second molar after
third molar coronectomy.4
The question of periodontal healing has also been
debated regarding third molar extractions because of
the possibility of incomplete postextraction periodontal
healing,5-9 residual postoperative intrabony defects,10,11
and related risks.12 In addition, several studies
have investigated how to manage and improve

Received from Unit of Oral and Maxillofacial Surgery, Department of Address correspondence and reprint requests to Dr Vignudelli:
Biomedical and Neuromotor Science, University of Bologna, Unit of Oral and Maxillofacial Surgery, Department of Biomedical
Bologna, Italy. and Neuromotor Science, University of Bologna, Via San Vitale 59,
*PhD Student. Bologna 40125, Italy; e-mail: elisabetta.vignudelli@unibo.it
yVisiting Professor. Received February 11 2016
zResearcher. Accepted September 8 2016
xClinical Fellow. Ó 2016 American Association of Oral and Maxillofacial Surgeons
jjProfessor of Maxillofacial Surgery. 0278-2391/16/30818-7
{Assistant Professor. http://dx.doi.org/10.1016/j.joms.2016.09.011
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.

21
22
postextraction periodontal healing distally to
second mandibular molars using bioabsorbable or
nonresorbable membranes, grafting materials, or root
planing.5-9,13-15
The purpose of the present study was to analyze the
periodontal healing distal to the mandibular
second molar after coronectomy of the mandibular
third molar. One specific aim was to record the modi-
fications to the periodontal indexes distal to the
second mandibular molar 9 months after coronectomy
of the third molar. Postoperative complications and
the migration of retained roots were also evaluated.
Materials and Methods
STUDY DESIGN
To address the research purpose, we designed a pro-
spective cohort study. The study population consisted
of 30 consecutive healthy patients referred to the Unit
of Oral and Maxillofacial Surgery, Department of
Biomedical and Neuromotor Science, University of
Bologna, from November 2011 to June 2012, for the
extraction of mandibular third molars. The patients
underwent coronectomy in the same department
from November 2011 to June 2012.
The study was explained to the patients, who pro-
vided written informed consent before undergoing
any study-related procedure. The medical protocols of
the present study followed the Declaration of Helsinki,
and the ethics committee, AUSL Citt
a di Bologna, Italy,
approved this research (CE, 12098). The study was per-
formed in accordance with the current standards recom-
mended for the reporting of observational studies in
epidemiology (the strengthening the reporting of obser-
vational studies in epidemiology [STROBE] statement).
The study inclusion criteria were age 18 to 70 years,
American Society of Anesthesiologists physical status
classification system I, the presence of at least 1 third
mandibular molar requiring extraction because of previ-
ous episodes of pericoronitis, the presence on a pano-
ramic radiograph of at least 1 radiographic marker
considered highly predictive of close contact between
the IAN and third molar roots (eg, increased radiolu-
cency, narrowing or diversion, and interruption of the
radiopaque border), and direct contact between the
roots and mandibular canal owing to the absence of
cortical bone, as evaluated by cone-beam computed
tomography. The exclusion criteria were systemic con-
ditions that precluded surgical treatment, the use of
antibiotics or anti-inflammatory agents within 14 days
before surgery, third molars with caries, endodontic dis-
ease or premature apexes, tobacco use (>10 cigarettes
daily), a history of head or neck radiotherapy, poor
oral hygiene (full-mouth plaque score >25% calculated
as a percentage of all surfaces [4 aspects per tooth]
displaying plaque), and poor oral hygiene motivation.
PERIODONTALLY HEALING AFTER CORONECTOMY
STUDY VARIABLES
Predictor Variable
The primary predictor variable was the periodontal
healing distal to the mandibular second molar after
coronectomy of the mandibular third molar.
Outcomes Variables and Assessment
The primary outcomes variables used to assess peri-
odontal healing were the probing pocket depth (PPD),
the distance between the marginal crest of the
second molar (MC) and the bottom of the osseous
defect (BOD) (MC-BOD), and the distance between
the cementoenamel junction (CEJ) of the
second molar and the BOD (CEJ-BOD).
PPD: The PPD was defined as the distance between
the gingival margin and the bottom of the pocket,
measured before surgery and 9 months after surgery.
MC-BOD distance: The MC-BOD distance was
defined as the distance between the MC of the
second molar and the BOD. The MC of the
second molar was chosen as a reference point
instead of the CEJ because the gingival margin typi-
cally did not permit visualizing the CEJ of the
second molar. This was evaluated after third molar
crown removal and at 9 months postoperatively us-
ing bone sounding after local anesthesia to avoid
underestimation of the defect depth by the impact
between the probe and the third molar crown.
CEJ-BOD: The CEJ-BOD was defined as the distance
between the CEJ of the second molar and the BOD
and was evaluated during surgery, after third molar
crown removal, and 9 months postoperatively.
These measurements were recorded with the aid of
a resin template on 3 points of the distal surface of the
second molar: the distobuccal (DB), distomedial (DM),
and distolingual (DL) sites. In addition, to ensure cor-
rect measurements at 9 months after surgery, if
gingival tissue covered the CEJ after the healing phase,
the second molar crown’s vertical dimension (height)
was measured (the distance between the MC of the
second molar and the CEJ). This measurement enabled
evaluation of the CEJ-BOD by determining the differ-
ence between the MC-BOD distance and the height
(CEJ-BC = MC-BC).
Other Variables
The other variables evaluated were as follows:
Patient age
Patient gender
Third molar impaction pattern: fully or partially
impacted
Third molar impaction type: vertically impacted if
the inclination of the third molar axis was less
VIGNUDELLI ET AL 23

than 25 relative to the axis of the mesial tooth or
horizontally impacted if the inclination of the third
molar axis was more than 25 relative to the axis of
the mesial tooth
Root migration: the distance between the apex of the
retained root and the CEJ of the second molar,
measured on periapical radiographs taken using a
parallel technique and a Rinn film holder
(Dentsply-Rinn Corp, York, PA) immediately after
surgery and 9 months postoperatively later, with
root migration evaluated at 9 months postoperatively
Assessment of postextraction complications:
patients with 1 or more of the following diagnoses
were considered to have a postextraction complica-
tion:
Any subjective postoperative sensory change
Failed coronectomy, presenting as intraoperative
root mobilization
Any second surgery (with data on reason and type
collected)
Fever present for at least 2 days during the first
postoperative week
Dry socket, characterized by severe pain, loss of
the blood clot in the socket, and wound break-
down
Infection, diagnosed by the presence of swelling,
pain, and pus
CLINICAL CARE AND OPERATIVE TECHNIQUES
Preoperative Care
Before surgery, all patients underwent a profes-
sional tooth cleaning to decrease the bacterial load.
All patients received antibiotic prophylaxis (2 g of
amoxicillin plus clavulanic acid in tablet form)
1 hour before surgery.
Patient age, third molar impaction pattern and type,
and PPD distal to the second molar, measured using a
calibrated 15 University of North Carolina color-coded
probe, were recorded in the preoperative assessment.
using a fissure bur on a high-speed drill. The crown
was gently fractured, and the retained roots were
reduced at least 3 mm below the bony crest with a
round bur on a high-speed surgical drill. The exposed
root surfaces of the second molars were treated with
scaling and root planing using ultrasonic and hand in-
struments. After crown removal, the MC-BOD and CEJ-
BOD distances were recorded.
Retained root fragments were not endodontically
treated, and the socket was irrigated with saline
solution. A periapical radiograph with a parallel tech-
nique was taken, and the flap was sutured with 4-0
silk to obtain a primary tension-free closure (Fig 1).
Postoperative Care
After surgery, all patients received antibiotic therapy
(1 g of amoxicillin and clavulanic acid every 8 hours for
4 days), analgesic and anti-inflammatory therapy
(600 mg of ibuprofen, 2 tablets daily for 2 days), and
antiseptic therapy (0.2% chlorhexidine mouth rinse
from the day after surgery, twice daily, for 2 weeks).
DATA MANAGEMENT AND STATISTICAL ANALYSIS
Data Management
We used a data collection form and data manage-
ment system with Excel (Excel 2011 and Windows,
version 14.0.0; Microsoft, Redmond, WA). The data
were entered by a single operator. Before entry, the
data were evaluated for accuracy and completeness,
logical consistency was verified, and the range of quan-
titative data was computed. A hard copy of the data
entered was verified and stored in individual

Intraoperative Care
All surgical procedures were performed with the pa-
tient under local anesthesia with 2% mepivacaine and
1:100,000 epinephrine. All procedures and measure-
ments were performed by a single operator. For partially
impacted teeth, a triangular mucoperiosteal buccal flap
with a vertical releasing incision was raised distal to the
second mandibular molar. For fully impacted teeth, the
releasing incision was mesial to the second mandibular
molar. No lingual flap was raised in any case.
Ostectomy was performed with rotating instru-
ments under constant water irrigation to expose the
third molar crown. To avoid the risk of root mobiliza- FIGURE 1. Postoperative radiograph before suture placement.
tion, sectioning of the crown was performed first in Vignudelli et al. Periodontally Healing After Coronectomy. J Oral
the mesiodistal and then in the buccolingual direction, Maxillofac Surg 2017.
24
coronectomy files. The data were analyzed using SPSS
software, version 11.5 (SPSS, Inc, Chicago, IL).
For quantification of root migration, manually devel-
oped periapical radiographs (Kodak DF55 Ultra Speed,
2.4  4 cm; Kodak, Rochester, NY) were transformed
into computed images using an Epson Perfection V750
scanner (Epson, Suwa, Japan) to obtain 40,800 
56,160 pixel images at 4,800 dpi resolution. During
scanning, a piece of 1-mm paper was inserted under
each radiograph to permit calibration. The radio-
graphs were saved in jpeg format and analyzed using
Digora imaging software (Soredex, Tuusula, Finland)
by an external examiner.
Statistical Analysis
Using a precision of 0.5 mm and an estimated stan-
dard deviation of 1.32 mm (Hassan et al15), with a
95% confidence limit, a minimum of 27 patients was
deemed necessary; thus, 30 patients were enrolled.
All quantitative variables differed significantly from a
Gaussian distribution, except for the preoperative
PPD and the MC-BOD distance at 9 months concerning
the DB site (Kolmogorov-Smirnov test with Lilliefors
continuity correction; P > .05). All the CEJ-BOD
distances were normally distributed, except for the
DM site, at 9 months (P = .007).
Proportions, median and interquartile range, and
mean  standard deviation were used to describe the
data (nominal or quantitative scale). Kendall’s tau-b
correlation coefficient was used to evaluate the associ-
ation between bone gain and radicular migration. The
Wilcoxon test for paired data was used to compare the
PPD, MC-BOD distance, CEJ-BOD distance, and radic-
ular migration at baseline and 9 months postopera-
tively. The influence of the third molar impaction
pattern and type on the MC-BOD distance was evalu-
ated using bootstrapping, given the small size of the
groups. Bias-corrected and accelerated 95% confi-
dence intervals were determined, and the Mann-
Whitney exact test was used for comparisons between
groups. The significance level was set at P = .05.
Results
A total of 30 patients with 34 high-risk mandibular
third molars (9 men and 21 women) with a mean
age of 28  7 years (range, 17 to 56), underwent cor-
onectomy. Of the 34 third molars, 17 (50%) were fully
impacted and 17 (50%) were partially impacted and 14
(41%) were vertically impacted and 20 (59%) were hor-
izontally impacted.
Of the 30 patients (34 mandibular third molars), 28
(31 mandibular third molars) completed the 9-month
follow-up period. Of these 31 molars, 16 were fully
impacted and 15 were partially impacted, and 14
were vertically impacted and 17 horizontally impacted.
PERIODONTALLY HEALING AFTER CORONECTOMY
All the sites showed primary intention healing at the
suture removal visit. At 9 months, a statistically signif-
icant reduction in the PPD for all sites was recorded
(P < .05; Table 1). The median reduction in the PPD
was 2  3, 1  2, and 2  2 mm for the DB, DM,
and DL sites, respectively.
At 9 months, a statistically significant reduction in
the MC-BOD distance for all 3 sites was observed
(P < .05; Table 2). The median reduction in the
MC-BOD distance at 9 months was 4  4, 4  4, and
4  5 mm for the DB, DM, and DL sites, respectively.
Also, at 9 months, a statistically significant reduction
in the CEJ-BOD distance for all sites was observed
(P < .05; Table 3). The median reduction in the
CEJ-BOD distance at 9 months was 4.4  1.8, 3.3 
1.8, and 4.2  2.4 mm for the DB, DM, and DL sites,
respectively. However, neither the type nor the
pattern of third molar impaction correlated signifi-
cantly with the MC-BOD distance at 9 months (P =
.257 and P = .525, respectively; Table 4).
All retained roots, as observed radiographically, had
migrated away from the mandibular canal during the
first 9 months (Figs 2, 3). The median root migration
was 2.9  2.5 mm at 9 months and was statistically
significant (P = .001). No statistically significant
correlation was found between the reduction in the
MC-BOD distance and the degree of root migration
(P > .05).
A second surgery was necessary in 4 of 34 third mo-
lars (11.8%). In 1 case, the retained root was vertically
impacted and was extracted 8 months after the coro-
nectomy because the patient reported intermittent
pain. In 2 cases, the retained roots were vertically
impacted and were extracted because of eruption
into the oral cavity after migration. No neurologic
alteration was noted after these root extractions. In
the fourth case, a correction of the previous coronec-
tomy procedure was needed because the root frag-
ments, after migration, had impacted the distal
Table 1. PROBING POCKET DEPTH
Probing Pocket Depth (mm)
At 9 mo
Measurement Site At Surgery Postoperatively P Value
DB 6  3* 4  3y .004
DM 6  2* 4  2* .002
DL 5  1* 4  2* .001
Abbreviations: DB, distobuccal; DL, distolingual; DM,
distomedial.
* Data presented as median  range.
y Data presented mean  standard deviation.
Vignudelli et al. Periodontally Healing After Coronectomy. J Oral
Maxillofac Surg 2017.
VIGNUDELLI ET AL 25

Table 2. DISTANCE BETWEEN MARGINAL CREST AND Table 4. CORRELATION BETWEEN PATTERN AND TYPE
BOTTOM OF OSSEOUS DEFECT OF THIRD MOLAR IMPACTION AND DISTANCE
BETWEEN MARGINAL CREST AND BOTTOM OF
MC-BOD Distance (mm) OSSEOUS DEFECT

At 9 mo MC-BOD Distance (mm)

Measurement Site At Surgery Postoperatively P Value P
Impaction Mean SD Value
DB site 12.5  5.5* 8  2y .001
DM site 12.0  5* 7  2* .001 Pattern .257
DL site 11.0  6* 6  1* .001 Vertical 3.56 (2.54-4.59) 2.20 (1.61-2.53)
(n = 14)
Abbreviations: BOD, bottom of osseous defect; DB, distobuc- Horizontal 4.41 (3.15-5.61) 2.54 (1.91-2.93)
cal; DL, distolingual; DM, distomedial; MC, marginal crest. (n = 17)
* Data presented as median  range. Type .525
y Data presented as mean  standard deviation. Partial 4.28 (3.14-5.38) 2.14 (1.53-2.53)
Vignudelli et al. Periodontally Healing After Coronectomy. J Oral (n = 15)
Maxillofac Surg 2017. Full (n = 16) 3.79 (2.46-5.14) 2.66 (2.15-2.97)
Abbreviations: BOD, bottom of osseous defect; MC, marginal
surface of the second molar. In this case, the retained crest; SD, standard deviation.
roots were horizontally impacted; thus, more marked Vignudelli et al. Periodontally Healing After Coronectomy. J Oral
root grinding was performed after flap elevation to Maxillofac Surg 2017.
eliminate contact between the third molar root and
the second molar. nectomy, because postoperative residual periodontal
No neurologic injury to the IAN or lingual nerve, defects have been reported.10-12 To overcome
failed coronectomy, fever, or dry socket was observed. problems related to the difficulty of measuring on
One case developed an infection 1 month after coro- the distal surface of the second molar,7,8,13-16 we
nectomy that was treated with antibiotics and anti- decided to assess the reduction in the MC-BOD and
septic therapy. CEJ-BOD distances using bone sounding,17 instead of
measuring the clinical attachment level (CAL).18
Discussion
Coronectomy is one of the options for treatment of
third molars with a high risk of neurologic injury.1 The
technique also seems to be associated with a low rate
of complications; however, some questions regarding
this technique require further investigation.1,4
The aim of the present study was to evaluate peri-
odontal healing distal to the second molar after coro-

Table 3. DISTANCE BETWEEN CEMENTUM ENAMEL

JUNCTION AND BOTTOM OF OSSEOUS DEFECT

CEJ-BOD Distance (mm)

At 9 mo
Measurement Site At Surgery Postoperatively P Value

DB site 6.1  1.8* 1.7 1.6y .001

DM site 5.7  1.8* 1.4  1.8* .001
DL site 5.3  2.4* 1.1  2.3* .001

Abbreviations: BOD, bottom of osseous defect; CEJ,

cementum enamel junction; DB, distobuccal; DL, distolin-
gual; DM, distomedial.
* Data presented as median  range.
y Data presented as mean  standard deviation. FIGURE 2. Radiograph at 9 months after surgery.
Vignudelli et al. Periodontally Healing After Coronectomy. J Oral Vignudelli et al. Periodontally Healing After Coronectomy. J Oral
Maxillofac Surg 2017. Maxillofac Surg 2017.
26
FIGURE 3. View of clinical healing at 9 months after surgery.
Vignudelli et al. Periodontally Healing After Coronectomy. J Oral
Maxillofac Surg 2017.
During the first 9 months, a statistically significant
reduction occurred in the PPD for all sites. Statistically
significant reductions also occurred in the MC-BOD
and CEJ-BOD distances, with the normal distances
restored at 9 months. In the present study, we decided
not to use the CAL,18 because mesio-inclusion of the
third molar could lead to an underestimation of the
preoperative defect depth owing to the impact be-
tween the periodontal probe and the third molar
crown.7,8 Moreover, the CEJ of the second molar
could be located below the third molar crown or
subgingival because of the presence of redundant
tissue often related to partially or fully impacted
third molars.13
In addition, the position of the gingival margin could
change after surgery, resulting in gingival recession14
or coverage of the CEJ.15 Bone sounding seems to be
a valid method for subgingival CEJ identification,16
because it can estimate the alveolar bone level without
flap elevation.8,9,19-22 The MC of the second molar was
a readily identifiable reference point; thus, all
measurements were comparable.
The reduction of the MC-BOD distance by alveolar
bone healing at the DM site in the present study was
4  4 mm at 9 months. Hassan et al15 reported a
mean alveolar gain of 1.20  1.32 mm after third molar
complete extraction with no treatment of the postex-
traction socket compared with 3.59  1.14 mm with
xenograft treatment. Karapataki et al8,9 reported a
mean alveolar bone gain of 5.1  1.2 and 3.3 
2.0 mm using resorbable and nonresorbable
membranes, respectively. The gain in alveolar bone
in the present study appears comparable to those
after treatment with biomaterials or membranes
rather than to those after complete extraction
without socket treatment.8,9,15 This difference could
have resulted from the removal of less bone in a
coronectomy than in complete extraction, which
PERIODONTALLY HEALING AFTER CORONECTOMY
would improve periodontal healing. Also, the
postoperative alveolus after coronectomy is smaller
than a postextraction socket. Furthermore, in all
cases, primary closure of the flap was obtained.
Primary tension-free closure of the wound could
improve healing and bone formation coronally to the
sectioned roots and help minimize the risk of alveolus
contamination and postoperative infection.23
No significant effect from the type or pattern of
third molar impaction on the MC-BOD distance was
observed at 9 months postoperatively. The strict confi-
dence intervals of the standard deviation indicated low
variability despite the small size of the groups.
In the published data, the type of third molar impac-
tion and the 2 flap designs used in the present study to
obtain primary closure did not seem to be related to
periodontal healing in the short term.24 However,
the position of the impacted third molar is generally
considered a risk factor for bone loss after third molar
extraction. In the present study, the lack of statistical
significance could be related to the low periodontal
risk of the included third molars. Moreover, some
have suggested that clinical healing after coronectomy
could be related to coronal movement of the retained
roots, similar to orthodontic extrusion movement.25 In
the present study, all retained roots migrated coronally
an average of 2.9  2.5 mm at 9 months, consistent
with previous reports.1 However, in the present study,
no statistically significant correlation was found
between the amount of alveolar bone gain and the
amount of root movement, which could relate to the
small sample size and the difficulty in correlating radio-
graphic 2-dimensional data with 3-dimensional clin-
ical data.
Additionally, the present study had several limita-
tions that should be considered when interpreting
the results. First, good periodontal healing could also
be related to the low periodontal risk category of the
third molars included in our study. The risk factors
associated with bone loss after third molar extraction
include patient age, the position of the impacted third
molar, and preoperative clinical and radiographic peri-
odontal defects.6,7,10-12 Additionally, the present study
did not include a control group with which to confirm
and compare these preliminary results. However, it
was not appropriate to recruit a control group to be
treated by complete extraction owing the high
neurologic risk associated with third molars.
In the present study, in a sample of 34 coronecto-
mies, no permanent or temporary neurologic injury
to the IAN occurred and no coronectomy failed (no in-
traoperative root mobilization occurred). The low rate
of these complications could have been related to the
standardized surgical protocol.24 The postoperative
infection and dry socket rates were similar to those re-
ported in published studies.1,26,27
VIGNUDELLI ET AL
A second surgery to correct or extract retained roots
was necessary for 4 teeth (11.8%). This rate was higher
than that in previous studies, which reported a range
of 0 to 6%; this difference could have resulted from
the small sample size.1,26 However, pulpitis in
retained roots remains a rare complication if the
biologic bases of the technique have been respected.28
In conclusion, after coronectomy, satisfactory peri-
odontal healing distal to the second molar and restora-
tion of a normal periodontium were observed at
9 months postoperatively. This physiologic situation
could be related to the long-term maintenance of the
second molar. However, several limitations should be
considered when interpreting the results of our study.
Future studies should examine a large sample of pa-
tients with a high risk of developing second molar peri-
odontal defects to confirm these preliminary clinical
results and to compare periodontal healing between
coronectomy and complete extraction.
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