Impacted mandibular first molar with root encircling the inferior alveolar nerve and an odontogenic cyst formation.

BACKGROUND: Dentigerous cysts are among the most common benign lesions encountered in oral and maxillofacial surgery. While these cysts typically develop in association with impacted mandibular third molars, their occurrence in relation to mandibular first molars represents an exceptionally rare clinical entity. This study aims to systematically describe the surgical management, standardized postoperative care protocols, and long-term follow-up strategies for this rare presentation. CASE PRESENTATION: A 35-year-old female patient presented to our institution with a 12-month history of persistent buccal swelling in the left posterior mandibular region. Panoramic radiography demonstrated an impacted tooth #36 situated between teeth #35 and #37, surrounded by a well-defined unilocular radiolucent lesion measuring approximately 2.5 cm in diameter. Cone-beam computed tomography (CBCT) further revealed a deeply impacted tooth #36 with complete circumferential encasement of the inferior alveolar canal by the tooth roots. Surgical management included en bloc cyst enucleation under local anesthesia, followed by minimally invasive extraction of tooth #36 using piezoelectric ultrasonic instrumentation. Postoperative pharmacological intervention comprised a 3-day methylprednisolone protocol (4 mg once daily) to control inflammation and mecobalamin supplementation (0.5 mg three times daily) to support neural recovery. One-year follow-up clinical and radiographic examinations confirmed complete resolution of the lesion with no evidence of recurrence or neurosensory deficits. CONCLUSION: The impaction of mandibular first molars with concurrent odontogenic cysts represents a clinically rare entity, particularly when complicated by complete root encirclement of the inferior alveolar neurovascular bundle. Following cyst enucleation, clinicians should consider orthodontic traction for functionally viable teeth or select surgical extraction when preservation is contraindicated. Preoperative CBCT evaluation remains mandatory to delineate three-dimensional root-neural topography. Staged surgical intervention-incorporating precision osteotomy, cyst decompression, and neurovascular liberation-effectively mitigates risks of neural injury and osseous defects.