Background: Removal of impacted mandibular third molars carries a risk of inferior alveolar nerve (IAN) injury due to the anatomical proximity of the tooth roots to the mandibular canal. The key and technically most challenging step of the operation is the creation of surgical access and the elevation of the mucoperiosteal flap, especially in the retromolar area, where dense periosteal adhesion to the bone and the presence of tendinous fibers of the temporalis muscle predispose to instrument slippage. Objective: To present a clinical case of successful use of an individualized surgical navigation template for creating operative access during removal of a highly complex impacted 4.8 tooth. Methodology: A digital planning protocol was used: cone-beam computed tomography (CBCT), intraoral scanning, data fusion in software, and 3D printing of the template from sterilizable photopolymer. Surgery was performed to remove impacted tooth 4.8 (Winter class – C, Pell-Gregory – class III) in a 25-year-old patient. Outcomes were assessed clinically (pain using a visual analogue scale (VAS), neurological status, flap condition) and radiographically at 3, 10, 30 days, and 3 and 6 months. Results. The template enabled precise incisions and guided flap elevation without instrument slippage, providing excellent visualization of the osteotomy site. Tooth extraction was performed with minimal trauma. Total operation time was 22 minutes, flap elevation time was less than 2 minutes. The postoperative period was uneventful with no neurological complications; VAS pain scores were 3 on day 1, 1.5 on day 3, and 0 on day 10. At 6 months, CBCT showed complete bone regeneration of the socket. Conclusion. The use of an individualized surgical navigation template resolves the problem of difficult mucoperiosteal flap elevation in the retromolar area, minimizes the risk of periosteal elevator slippage, and improves visualization of the surgical field.
Kvyatkovskaya et al. (Mon,) studied this question.