Apical Surgery of Mandibular Molar - Clinical Handling of Cystic Lesion Adjacent to the Inferior Alveolar Nerve: a Case Report

Objectives: Endodontic microsurgery in the mandibular molar region is associated with significant clinical challenges when large periapical cystic lesions are located near the inferior alveolar nerve. The purpose of this case report is to describe the clinical management and outcomes of a patient presenting with a cystic lesion in close proximity to the inferior alveolar nerve, illustrating the importance of advanced imaging in treatment planning and risk assessment.

Material and Methods: A 45-year-old female with persistent pain related to mandibular first molar previously treated with root canal therapy and restored with a metal-ceramic crown underwent radiographic and cone beam computed tomography examinations. A well-defined cystic lesion in direct contact with the inferior alveolar nerve was identified. Preoperative planning guided the surgical approach, which included elevation of a full-thickness mucoperiosteal flap, osteotomy, root-end resection, removal of a separated instrument, careful cyst enucleation to avoid nerve injury, ultrasonic root-end preparation, and retrograde obturation using a calcium silicate-based material. The surgical site was closed with 4-0 polypropylene sutures (Prolene^® - Ethicon, Inc.).

Results: At the three-month follow-up, the patient reported resolution of pain and absence of neurosensory disturbances. Radiographic imaging indicated favourable early bone healing of the surgical site.

Conclusions: Careful preoperative evaluation with cone beam computed tomography and meticulous microsurgical techniques are essential for mitigating risks and achieving successful outcomes in the management of periapical cysts adjacent to the inferior alveolar nerve. Clinicians should consider ongoing clinical and radiographic monitoring to evaluate long-term success following surgical intervention.

J Oral Maxillofac Res 2026;17(2):e5

doi: 10.5037/jomr.2026.17205

Accepted for publication: 30 June 2026

Keywords: cone-beam computed tomography; cysts; endodontics; inferior alveolar nerve; microsurgery.