When Is CBCT Required? Insights From Oral and Maxillofacial Surgeons on Radiographic Signs of Maxillary Sinus Involvement in Upper Third Molar Extractions

ABSTRACT Background The extraction of upper third molars carries a risk of oroantral communication due to their proximity to the maxillary sinus. Panoramic radiography is widely used for initial assessment, but its limitations may affect risk perception and the decision to request cone beam computed tomography (CBCT). Methods This cross‐sectional observational study analysed 25 panoramic radiographs containing at least one upper third molar. Twenty‐one oral and maxillofacial surgeons (OMSs) evaluated the images, classifying the risk of oroantral communication and completing a questionnaire addressing radiographic signs, tooth inclination and vertical relationship to the adjacent second molar. Associations between these variables and CBCT referral were examined. Results Projection of the tooth root into the maxillary sinus with cortical disruption was strongly associated with a higher perceived risk of oroantral communication. Mesioangular inclination and higher vertical positioning relative to the second molar also increased perceived risk. In cases judged high risk, 84.8% of OMSs recommended CBCT, underscoring the influence of panoramic findings on imaging decisions. Nonetheless, surgeons tended to underestimate critical radiographic signs when relying solely on panoramic radiography. Conclusions Radiographic signs, third molar inclination, and vertical position significantly influenced OMSs' perception of risk and subsequent CBCT referral. These findings support practical criteria for safer surgical planning while minimizing unnecessary radiation exposure.