Mandibular idiopathic osteosclerosis mimicking inferior alveolar nerve conflict

A 28-year-old patient was referred to the Oral Surgery and Implantology Unit at Geneva University Hospitals for extraction of the mandibular third molars following multiple episodes of pericoronitis. A two-dimensional panoramic radiograph (PAN) showed a subtle radiopaque image apparently superimposed on the roots of the third molar, projected over the course of the inferior alveolar canal, suggesting of a close relationship between the inferior alveolar nerve (IAN) and the apices of tooth 38 evoking a nerve conflict. To further assess this apparent anatomical relationship, a three-dimensional cone-beam computed tomography (CBCT) scan was performed. The CBCT demonstrated no direct contact between the mandibular third molar and the inferior alveolar nerve canal. Instead, it revealed a well-defined radiopaque lesion adjacent to the nerve canal, separate from the tooth roots, consistent with idiopathic osteosclerosis. This case highlights the limitations of two-dimensional imaging in evaluating complex anatomical relationships in the posterior mandible. When panoramic radiography shows equivocal findings due to superimposition and suggests a potential nerve–tooth conflict, three-dimensional imaging is essential for accurate diagnosis and treatment planning.