Characterization of mandibular third molar impaction patterns and a CBCT-derived radiographic extraction difficulty in a Saudi cohort: A retrospective cross-sectional study

Mandibular third molar (MTM) impaction is the most frequent type of impacted tooth. Therefore, we aimed to report cone-beam computed tomography (CBCT)-based MTM impaction patterns in a Saudi cohort and to investigate the relationship between these patterns and a CBCT-derived radiographic extraction difficulty. This retrospective cross-sectional study screened 200 consecutive archived CBCT scans (May-October 2025) from King Khalid University Dental Hospital. Sixty-nine patients who had 1 or more impacted MTMs were analyzed and met the eligibility criteria. Impaction type (bony/partial), angulation of Winter (vertical/mesioangular/horizontal/distoangular), and the orientation of the buccolingual crown were measured. The elevator fulcrum-based depth surrogate was used to assess radiographic difficulty (mild/moderate/high) against the distal thirds of the roots of the second molar beside it. Among screened CBCTs, 69/200 (34.5%; 95% confidence interval: 28.3-41.3) demonstrated ≥1 impacted MTM. Within the analyzed cohort (n = 69), mesioangular angulation was the most frequent. Winter's angulation was associated with radiographic difficulty on the right side (χ2 = 27.85, df = 6, P = .0001; Holm-adjusted P = .0004) but not on the left after adjustment (χ2 = 13.54, df = 6, P = .035; Holm-adjusted P = .070). Buccolingual orientation was associated with radiographic difficulty on the right (χ2 = 23.80, df = 10, P = .008; Holm-adjusted P = .025) but not on the left (χ2 = 3.84, df = 8, P = .872). The metric of MTM angulation and the buccolingual orientation were found to be side-dependent, related to a CBCT-based radiographic difficulty grade. Since difficulty was measured radiographically (not relative to operative outcomes) and the impacted-case sample was modest, findings need to be taken with caution and confirmed prospectively using surgical time, complications, and patient-centered outcomes.