Extracting impacted mandibular third molars (M3M) is a complex procedure influenced by bone density, tooth angulation, and proximity to anatomical structures. Traditional imaging modalities like panoramic radiography and cone-beam computed tomography (CBCT) provide anatomical details but lack quantitative assessment of trabecular bone quality. Fractal dimension (FD) analysis has emerged as a promising tool for objectively evaluating bone microstructure, offering reproducible data correlating with surgical outcomes. This review examines the role of FD analysis in M3M extraction, focusing on methodological standardization, clinical applications, and demographic considerations. Key findings include the strong association between FD values and surgical complexity, with elevated FD (>1.6) linked to longer procedure times and lower FD (<1.3) associated with higher fracture risks. Despite its potential, variability in measurement protocols and ROI selection limits widespread clinical adoption. Future directions emphasize the integration of AI for automated analysis, multicenter validation studies, and the development of international guidelines. By addressing these challenges, FD analysis could enhance preoperative planning, improve risk stratification, and optimize patient outcomes in oral surgery.