When lower wisdom teeth are positioned near the inferior alveolar nerve, surgical removal requires advanced imaging, experience, and careful technique.

These cases often appear on OPGs as horizontally or mesioangularly impacted molars with overlapping root shadows near the mandibular canal.

Attempting removal without CBCT evaluation may increase the risk of temporary or permanent paraesthesia.

Referral is advised when:

- The tooth’s roots are close to or crossing the nerve canal.

- The patient reports numbness or altered sensation.

- The tooth is deeply embedded or partially erupted with infection.

In an oral and maxillofacial surgery setting, such cases are assessed with CBCT, nerve-mapping tools, and microsurgical instruments to minimise trauma.

In high-risk cases, coronectomy may also be considered to further reduce the likelihood of nerve injury.

Sedation options allow safe and comfortable removal, even in anxious patients.

Referring early prevents complications such as nerve injury, dry socket, or secondary infection.

When to refer: Any mandibular third molar within approximately 2 mm of the canal, or where OPG suggests close proximity - CBCT evaluation is recommended before attempting removal, or if surgical access appears limited.