What does 'mesioangular impaction' mean?

Mesioangular impaction is the most common pattern — about 40–45% of impacted lower third molars. The tooth is tilted forward, with its crown angled toward the adjacent second molar. It is also the impaction most often associated with decay or periodontal damage on the second molar's back surface because the angled crown traps plaque and food in a space that is essentially impossible to clean. Moderately difficult to remove surgically.

Which impaction type is hardest to remove?

Horizontal and distoangular impactions, particularly when classified as Class C (deep) or Class III (mostly within the ramus) by the Pell-Gregory system. The geometry resists conventional elevation; significant bone removal and tooth sectioning are usually required; case duration runs longer; the inferior alveolar nerve is more often in close anatomic relationship to the roots. Surgeon experience matters substantially for this difficulty level.

Do all impacted wisdom teeth need to come out?

No. A deeply impacted, asymptomatic, fully bony-covered third molar in an adult with no symptoms and no nearby pathology can be left alone with periodic imaging. The AAOMS White Paper specifically does not recommend prophylactic extraction of all asymptomatic impactions. Indications for extraction are symptomatic — pericoronitis, decay or periodontal damage to the second molar, cysts, persistent pain — not the impaction itself.

Will I need a CBCT before extraction?

For straightforward impactions (vertical, Class A position), a panoramic X-ray is usually sufficient. For difficult impactions (horizontal or distoangular, Class B/C depth, Class II/III ramus relationship), particularly any case where the panoramic suggests root proximity to the inferior alveolar nerve canal, a cone-beam CT is appropriate before surgery. It shows the 3D relationship the panoramic cannot and changes surgical planning when nerve proximity is identified.

How risky is impacted wisdom tooth removal?

Risk profile depends on the classification. Vertical Class A impactions in healthy young adults have very low complication rates. Horizontal or distoangular Class C impactions, particularly in patients over 40 with mature root anatomy near the nerve canal, carry meaningfully higher risk of nerve disturbance (temporary paresthesia in single-digit percentages; permanent rarer), dry socket, prolonged swelling, and longer recovery. The classification is a useful predictor.

What's the difference between soft tissue and bony impaction?

A soft tissue impaction has the tooth emerged through bone but still partly covered by gum; partial bony has part of the crown still covered by bone in addition to gum; full bony has the entire tooth still encased in bone with no oral communication. Surgical fees in the US are typically tiered by this classification, with full bony at the top of the scale because they take longer and involve more bone removal.

Impacted Wisdom Teeth: Types of Impaction and What Each Means

The short version, if you only read one thing

Impacted third molars are classified along two axes that any oral surgeon will reference: angulation (which way the tooth is leaning) using the Winter classification, and depth and position (how deep it sits and how it relates to the jawbone) using the Pell and Gregory classification. The classifications are not academic — they predict surgical difficulty, time in the chair, complication rate, and whether a cone-beam CT is appropriate before surgery. Roughly: vertical impactions are the easiest, mesioangular (tilted forward) are the most common and moderately difficult, horizontal (lying down) and distoangular (tilted backward) are the hardest. The deeper and further back the tooth sits, the more bone has to be removed and the higher the risk of meaningful complications. Knowing your specific classification before the consult lets you ask better questions and recognise when the case warrants imaging or a referral to a more experienced surgeon.

How a tooth becomes impacted in the first place

An impacted tooth is one that fails to erupt fully into its normal functional position. For third molars, this is overwhelmingly common: in the adult population, somewhere between a third and three-quarters of people have at least one impacted wisdom tooth depending on the dataset and the definition used. The mechanism is straightforward — the human jaw has been getting smaller across evolutionary time while the dentition has not, and the third molars are the last teeth to develop. When they try to erupt in the late teens, they often arrive at a space that is too small, in front of a second molar that is unwilling to move, with surrounding bone that has finished growing. The tooth gets stuck. Sometimes it pushes partway through the gum and stalls there. Sometimes it stays fully under the gumline. Sometimes it angles itself into the path of least resistance, which often happens to be sideways or forward.

None of this is unusual. None of it is automatically a problem. Many impacted teeth, especially deeply buried ones with no eruption pathway and no symptoms, can stay where they are for a lifetime. The classification system exists not because every impacted tooth needs to come out, but because when one does, the geometry tells the surgeon what they are dealing with.

The Winter classification — which way is the tooth leaning?

The first axis describes the angle of the tooth's long axis relative to the long axis of the second molar in front of it. This is the Winter classification, named after the British dental surgeon George Winter who described it in 1926. Four categories cover most of the cases you will see described on a radiograph.

Vertical. The tooth sits roughly upright, in the same axis as if it had erupted normally. It just hasn't completed eruption — perhaps the gum tissue still covers part of the crown, perhaps the second molar is in the way of full eruption. These are the most straightforward extractions of the four. The tooth can usually be elevated out along its own long axis with minimal bone removal. Vertical impactions account for roughly 30 to 40 percent of impacted third molars in most populations studied.

Mesioangular. The tooth is tilted forward, with its crown angled toward the second molar in front of it. This is the single most common pattern — somewhere between 40 and 45 percent of cases in most large series. It is also the impaction most often associated with damage to the adjacent second molar, because the inclined crown sits against the second molar's distal surface and traps food, plaque, and bacteria in a space that is almost impossible to clean. Surgically, mesioangular impactions are moderately difficult: the surgeon usually has to section the tooth into pieces to release it without traumatising the second molar.

Distoangular. The tooth is tilted backward, with its crown angled toward the ramus of the jaw behind it. This is the least common and one of the most surgically difficult patterns — perhaps 5 to 10 percent of cases. The geometry resists the normal direction of elevation; the tooth wants to be removed by being pulled through the ramus, which is impossible. Distoangular impactions almost always require significant bone removal and tooth sectioning to release.

Horizontal. The tooth is lying on its side, with its long axis roughly parallel to the floor of the mouth. Perhaps 10 to 15 percent of cases. The crown faces forward, often directly against the root surface of the second molar, and the roots point backward toward the ramus. Horizontal impactions are the most difficult to remove cleanly because everything about the geometry resists conventional elevation. They are also the impactions most likely to be sitting in intimate contact with the inferior alveolar nerve canal that runs through the lower jaw.

40–45%

Approximate share of impacted third molars that fall into the mesioangular pattern in most large radiographic surveys. This is also the pattern most strongly associated with caries and periodontal damage on the distal surface of the adjacent second molar — the single most common reason to remove a third molar for a real clinical indication rather than for prophylaxis.

The Pell and Gregory classification — how deep and how far back?

Where Winter describes the angle, Pell and Gregory describe the position. Their system was published in 1933 and remains the standard for grading depth of impaction and relationship to the surrounding bone. It has two parts.

The first part grades the depth of impaction relative to the occlusal plane — the level at which the rest of your teeth meet. Class A: the highest part of the impacted tooth sits at or above the occlusal plane of the second molar. The tooth is close to the surface; the surgeon does not have far to go to expose it. Class B: the highest part of the impacted tooth sits between the occlusal plane and the cervical line (the gumline area) of the second molar. Moderately deep. Class C: the highest part of the impacted tooth sits below the cervical line of the second molar. Genuinely deep impaction. More bone removal required, longer surgery, generally higher complication rates.

The second part grades the ramus relationship — how much space is available between the distal surface of the second molar and the anterior border of the ramus (the upright part of the lower jawbone). Class I: there is sufficient space for the third molar's full mesiodistal width to sit anterior to the ramus. Plenty of room for delivery. Class II: about half the tooth sits within the ramus. The available space is constrained but workable. Class III: the tooth is mostly or entirely embedded in the ramus. The least surgical space; significant bone removal almost always required.

So a typical surgical note describing a lower third molar might read: "Mesioangular impaction, Pell & Gregory Class II, Position B." Anyone trained in the system reads that as: tilted forward, moderately deep, the available space against the ramus is constrained. Difficulty grade: moderate to high.

Soft tissue, partial bony, full bony — the depth language

Patients also encounter another set of terms that describe what is covering the tooth. Soft tissue impaction means the tooth has emerged through the bone but is still partly covered by gum tissue. Partial bony impaction means part of the crown is still covered by bone in addition to the gum. Full bony impaction means the entire tooth is still encased in bone, with no communication into the oral cavity. The deeper the bone coverage, the longer the surgery and the higher the surgical fee in most American practices. Full bony impactions are billed at the top of the scale and take the longest to remove.

Why the classifications matter for the consent conversation

The reason a thoughtful patient should understand these systems is not to second-guess the surgeon's classification, but to recognise which procedures genuinely warrant the higher tier of preparation and which can be handled at a more routine level. A vertical, Class I, Position A soft-tissue impaction in a healthy young adult is a brief, low-risk procedure that most general dentists with surgical training can manage well. A horizontal, Class III, Position C full-bony impaction in a forty-five-year-old, with roots that imaging shows running near the inferior alveolar nerve, is a fundamentally different operation that benefits significantly from an oral and maxillofacial surgeon who does cases at this difficulty level routinely.

The corresponding investigations differ as well. For straightforward impactions, a panoramic X-ray is usually sufficient pre-operative imaging. For deeper or more anatomically complex impactions — particularly any case where the panoramic suggests the third molar roots may be in contact with the inferior alveolar nerve canal — a cone-beam CT scan should be ordered. The CBCT shows the three-dimensional relationship between the roots and the nerve in a way that flat radiographs cannot, and it allows the surgeon to plan the osteotomy and the order of root sectioning before touching tissue. Asking, before surgery, whether the imaging plan is appropriate for the classification of the impaction is a reasonable question.

Nerve risk — the conversation the classification is really about

The single most consequential factor in lower third molar surgery is the proximity of the tooth roots to the inferior alveolar nerve canal, which carries the sensory nerve to the lower lip and chin on each side. Disturbance of this nerve during extraction is the most clinically significant complication, ranging from temporary altered sensation (usually resolves over weeks to months) to, rarely, permanent numbness. The classification systems are not formal predictors of nerve risk, but they are correlated with it. Deep impactions, horizontal impactions, and impactions in older patients with mature root anatomy are all more likely to involve nerve proximity.

For the patient, this means that when the radiograph and the classification together suggest a difficult case — anything with bone coverage classified C, with horizontal or distoangular angulation, with imaging that shows the white line of the nerve canal overlapping the root shadow — the right pre-operative conversation includes specific questions about nerve risk, about the imaging plan, and about the surgeon's experience with cases at this difficulty level.

Two things worth asking before surgery on a difficult impaction

The first is whether a cone-beam CT scan is being ordered. For any impaction graded as moderately difficult or higher, particularly any case where the panoramic radiograph suggests possible nerve involvement, a CBCT is the standard of care for risk-stratification. If a surgeon is planning to extract a Class C, horizontal, lower wisdom tooth on the basis of a panoramic alone, that is a fair conversation to push back on. For straightforward cases — vertical, Class A, no anatomic concerns — a CBCT may genuinely not be needed.

The second is the surgeon's specific volume of difficult cases. A surgeon who removes ten difficult impactions a week will have a different complication curve than one who removes ten a year. For high-grade impactions, that gap in experience is the single largest factor you, as a patient, can do anything about. The volume question is worth asking and a confident surgeon will answer it specifically.

Upper impactions — different geometry, different conversation

Most of the classification literature focuses on lower third molars because they are surgically more demanding and the consequences of difficulty are higher. Upper impactions exist on the same spectrum but the geometry is different. The upper jaw bone is thinner and more cancellous, so even deeply impacted upper third molars are usually less difficult to remove than their lower counterparts of similar grade. The major anatomic concern shifts from the inferior alveolar nerve (lower jaw) to the maxillary sinus, which sits just above the roots of the upper third molars. Communication into the sinus during extraction is the equivalent complication conversation for upper teeth — usually heals on its own with appropriate management, but worth knowing about.

The classification systems described above were developed primarily for lower teeth and apply with some adaptation to uppers. The angulation terminology is the same; the depth grading is interpreted relative to the floor of the maxillary sinus rather than the jawbone proper.

The numbered question hierarchy for a difficult impaction

If you have just had an X-ray that revealed a difficult impaction and you are about to head into a surgical consult, here is the order in which the questions tend to most usefully come up.

What is the classification? Get the surgeon to describe the impaction in their own terms — angulation, depth, ramus relationship, soft tissue versus bony coverage. A thoughtful surgeon will already be naming these as they look at the imaging with you.
What does the imaging show about the inferior alveolar nerve? For any lower impaction, this is the conversation that matters most. The surgeon should be able to describe the relationship specifically — anterior, posterior, in contact, or in intimate contact with the nerve canal — and what that means for your case.
Is a CBCT indicated? For difficult cases, the answer should be yes; for straightforward ones, the answer can legitimately be no. A surgeon who can explain why is one who has thought about the case rather than applying a default policy.
What is the expected difficulty grade and time in the chair? A 20-minute case and a 50-minute case are different operations. The pre-op estimate gives you a calibration for how the day will go.
What is the surgeon's experience with this difficulty level? Volume matters. Asking is appropriate. A confident answer is reassuring; a vague answer is information too.

The bottom line

The Winter and Pell-Gregory classifications are the lingua franca for impacted third molars because they reliably predict the variables a surgeon needs to plan around: how much bone to remove, how to section the tooth, how close to the nerve, how long the case will take, how to set the patient's expectations. They are not predictions of complications in any rigid sense, and they are not verdicts about whether extraction is necessary. They are descriptions of geometry. The geometry matters because it determines the operation.

For the patient, the practical value of understanding the classification is that it lets you read the consent conversation accurately. A simple impaction in a healthy young adult is a routine procedure with a small risk profile, and the conversation should be brief. A difficult impaction — graded C, angled horizontally or distoangularly, with imaging that suggests nerve proximity — is a different operation that deserves a more detailed pre-op conversation, more careful imaging, and a more experienced surgeon. The right question is not whether the surgery is "safe." The right question is whether the surgery, at its specific difficulty, is being matched to the specific level of care it needs.

If you are heading into a consult for an impacted wisdom tooth, the most useful preparation is to ask the surgeon to walk through the classification of your specific impaction, what the imaging shows about the nerve relationship, and what the difficulty grade implies for the procedure plan. A clinic that welcomes those questions is a clinic that is comfortable being precise about the case. Find a clinic near you on Smyleee or browse oral surgeons by location to start the conversation with someone whose work you can actually evaluate.

Frequently asked questions

What does 'mesioangular impaction' mean?: Mesioangular impaction is the most common pattern — about 40–45% of impacted lower third molars. The tooth is tilted forward, with its crown angled toward the adjacent second molar. It is also the impaction most often associated with decay or periodontal damage on the second molar's back surface because the angled crown traps plaque and food in a space that is essentially impossible to clean. Moderately difficult to remove surgically.
Which impaction type is hardest to remove?: Horizontal and distoangular impactions, particularly when classified as Class C (deep) or Class III (mostly within the ramus) by the Pell-Gregory system. The geometry resists conventional elevation; significant bone removal and tooth sectioning are usually required; case duration runs longer; the inferior alveolar nerve is more often in close anatomic relationship to the roots. Surgeon experience matters substantially for this difficulty level.
Do all impacted wisdom teeth need to come out?: No. A deeply impacted, asymptomatic, fully bony-covered third molar in an adult with no symptoms and no nearby pathology can be left alone with periodic imaging. The AAOMS White Paper specifically does not recommend prophylactic extraction of all asymptomatic impactions. Indications for extraction are symptomatic — pericoronitis, decay or periodontal damage to the second molar, cysts, persistent pain — not the impaction itself.
Will I need a CBCT before extraction?: For straightforward impactions (vertical, Class A position), a panoramic X-ray is usually sufficient. For difficult impactions (horizontal or distoangular, Class B/C depth, Class II/III ramus relationship), particularly any case where the panoramic suggests root proximity to the inferior alveolar nerve canal, a cone-beam CT is appropriate before surgery. It shows the 3D relationship the panoramic cannot and changes surgical planning when nerve proximity is identified.
How risky is impacted wisdom tooth removal?: Risk profile depends on the classification. Vertical Class A impactions in healthy young adults have very low complication rates. Horizontal or distoangular Class C impactions, particularly in patients over 40 with mature root anatomy near the nerve canal, carry meaningfully higher risk of nerve disturbance (temporary paresthesia in single-digit percentages; permanent rarer), dry socket, prolonged swelling, and longer recovery. The classification is a useful predictor.
What's the difference between soft tissue and bony impaction?: A soft tissue impaction has the tooth emerged through bone but still partly covered by gum; partial bony has part of the crown still covered by bone in addition to gum; full bony has the entire tooth still encased in bone with no oral communication. Surgical fees in the US are typically tiered by this classification, with full bony at the top of the scale because they take longer and involve more bone removal.

Sources & further reading

Winter GB. "Principles of Exodontia as Applied to the Impacted Mandibular Third Molar." St. Louis, Missouri: American Medical Book Co. 1926.
Pell GJ, Gregory BT. "Impacted Mandibular Third Molars: Classification and Modified Technique for Removal." Dental Digest. 1933;39:330–338.
Marciani RD. "Third molar removal: An overview of indications, imaging, evaluation, and assessment of risk." Oral and Maxillofacial Surgery Clinics of North America. 2007;19(1):1–13.
American Association of Oral and Maxillofacial Surgeons. "Management of Third Molar Teeth." AAOMS White Paper.
Almendros-Marqués N, Berini-Aytés L, Gay-Escoda C. "Influence of lower third molar position on the incidence of preoperative complications." Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2006;102(6):725–732.
Akinbami BO, Ekowo OA. "Patterns of mandibular third molar impaction: A clinical evaluation." Journal of Dentomaxillofacial Research. 2015;1(2):1–4.

How we wrote this

This piece draws on the peer-reviewed sources and authoritative guidelines listed below, and where appropriate also on patient-facing materials from the relevant professional bodies and the National Institutes of Health. Each substantive claim links to its source via the inline footnote next to it — click any number to jump to the citation. Where the evidence is genuinely uncertain or contested, the text says so rather than presenting one position as settled. We do not accept clinic, device, or pharmaceutical sponsorship for the content of editorial articles.

This article was last medically reviewed in June 2026 by the Smyleee Medical Advisory Board. We update when significant new evidence emerges or when published guidelines change. If you have feedback on a specific claim or believe an updated source warrants inclusion, please contact our editorial team.

Editorial note. This article is provided for general informational purposes and is not a substitute for individualised medical or dental advice. It reflects the evidence and clinical reasoning current at time of publication; specific decisions about extraction, imaging, anaesthesia, and post-operative care should be made in consultation with a licensed dentist or oral and maxillofacial surgeon who has assessed your own imaging and history. Reviewed by the Smyleee Medical Advisory Board.