Infected Complex Odontoma Associated With a Dentigerous Cyst Presenting as a Cutaneous Fistula in the Mandibular Angle: Surgical Management Using Piezoelectric Surgery

Odontomas are the most common benign odontogenic hamartomatous tumors. Although typically asymptomatic, they can occasionally lead to severe infectious complications. This report describes a rare case of an infected complex odontoma manifesting as a cutaneous fistula, emphasizing the surgical challenges associated with its anatomical location. A 22-year-old male presented with a 1-month history of a cutaneous fistula at the left mandibular angle and intraoral bone exposure. Radiographic evaluation (panoramic and CBCT) revealed a voluminous radiopaque mass at the mandibular angle, which had severely displaced the third molar toward the inferior border of the mandible. The proximity to the inferior alveolar nerve and the thinness of the remaining bone posed a significant risk of iatrogenic fracture. The patient underwent surgical enucleation of the lesion and extraction of the displaced molar. To mitigate the risk of mandibular fracture and nerve injury, piezoelectric surgery was utilized. The use of ultrasonic inserts allowed for a precise, selective osteotomy and a safe extraction, preserving the structural integrity of the weakened mandible. Histopathological analysis confirmed the diagnosis of a complex odontoma associated with dentigerous cyst. At the 6-month follow-up, the cutaneous fistula had completely resolved with excellent healing and no sign of recurrence. This case highlights that for large, infected odontogenic lesions, the synergy between 3D imaging and minimally invasive technologies like piezosurgery is essential to achieve successful clinical outcomes while minimizing surgical morbidity.