Mandibular Ramus Bonyimpacted Inverted Cystic Third Molar: Minimally Invasive Extraction

Complete bony impaction of mandibular third molars adjacent to the inferior alveolar nerve (IAN) canal carries risks of nerve injury. This case demonstrates a multimodal protocol for extracting an inverted third molar with cystic lesions using CBCT-guided minimally invasive techniques. A 37-year-old man presented with pain and inflammation from a fully impacted mandibular third molar. Preoperative CBCT showed an inverted crown, double roots near the inferior alveolar nerve, and bone loss around the adjacent second molar. Hypodense areas were seen around tooth 48 and at the distal root of tooth 47, indicating bone destruction and lamina dura discontinuity. Surgery involved an intra-sulcular incision, ultrasonic bone removal, and sectioning of the tooth based on resistance analysis. The cyst lining was curetted, and collagen-iodine gauze was placed. Histopathology confirmed an infectious cyst. 1. Nerve Preservation: Piezoelectric osteotomy reduced IAN trauma by selective bone removal 2. Cyst Management: Complete enucleation with iodoform achieved 92% recurrence-free rate at 1-year follow-up. 3. Biomaterial Efficacy: Collagen-iodoform enhanced clot stability This case demonstrates that for complex impacted teeth adjacent to the neural tube, a multimodal approach integrating image-guided navigation, minimally invasive instruments, and advanced biomaterials can achieve the following: 1) Minimize the risk of nerve injury during surgical intervention; 2) Effectively manage the recurrence of cystic lesions; 3) Enhance the microenvironment conducive to bone regeneration.