Impaction Predictors and Diagnostic Performance of CBCT Versus Panoramic Radiography for Supernumerary Teeth in a Romanian Multicenter Cohort

<b>Background:</b> Supernumerary teeth (ST) are developmental anomalies that may interfere with eruption, alignment, and occlusal balance. Their etiopathogenesis and management remain controversial. This multicentric study aimed to evaluate the epidemiological, morphological, and radiographic features of ST in a Romanian population and identify impact predictors. <b>Methods:</b> Between January 2020 and March 2025, 153 consecutive patients (91 males, 62 females; mean age 14.8 ± 6.2 years) with clinically and radiographically confirmed supernumerary teeth were evaluated across three Romanian academic centers: the University Dental Clinic, George Emil Palade University of Medicine, Târgu Mureș (<i>n</i> = 78 patients); the Department of Periodontology, Lucian Blaga University of Sibiu (<i>n</i> = 45 patients); and the Department of Dentistry, Dimitrie Cantemir University of Târgu Mureș (<i>n</i> = 30 patients). <b>Results:</b> A total of 185 ST were recorded, most frequently conical (48.6%) and mesiodens (56.2%). Complications were observed in 40.5% of patients. Multivariable analysis identified Angle Class III malocclusion (OR = 1.89; <i>p</i> = 0.039) and tuberculate morphology (OR = 2.93; <i>p</i> = 0.021) as the strongest independent predictors of impaction, alongside associations with younger age (<13 years) (OR = 3.12; <i>p</i> = 0.003) and male gender (OR = 1.78; <i>p</i> = 0.046). CBCT demonstrated high diagnostic concordance with OPG (κ = 0.89), but showed superior performance for complex cases, identifying 11 root resorptions and 9 vestibulo-palatal displacements that OPG missed. Multivariable analysis identified Angle Class III malocclusion (OR = 1.89; <i>p</i> = 0.039) and tuberculate morphology (OR = 2.93; <i>p</i> = 0.021) as the strongest independent predictors of impaction, alongside associations with younger age (<13 years) (OR = 3.12; <i>p</i> = 0.003) and male gender (OR = 1.78; <i>p</i> = 0.046). <b>Conclusions:</b> This multicentric study provides updated Romanian data and highlights novel risk factors and diagnostic selection guidelines that may support individualized treatment planning. Angle Class III malocclusion is a novel and critical independent predictor of supernumerary tooth impaction, alongside tuberculate morphology. This finding strengthens the rationale for utilizing CBCT specifically in Class III patients with ST to pre-emptively manage complex impactions and associated pathology.