The objectives of this study were to evaluate the efficacy of additional cone beam computed tomography (CBCT) imaging on decreasing the risk of inferior alveolar nerve (IAN) injury during third molar removal in patients at high risk and to assess the surgical outcomes. The study sample included patients considered at high risk for IAN injury based on panoramic radiography (PAN) evaluation. The primary predictor was the type of imaging method (PAN only or with additional CBCT). The other variables were demographic and anatomical/radiographic factors. The primary outcome variable was IAN injury. The secondary outcome variables were the preoperative surgical plan and surgical results including IAN exposure and duration of surgery. The sample comprised 122 patients (139 teeth) aged 18-48 years. Postoperative temporary IAN injury was present in three (4.2%) cases in the CBCT group and 11 (16.4%) in the PAN group at 7 days after surgery. However, none of the patients had a permanent IAN injury at the 6-month follow-up. Additional CBCT imaging was not superior to PAN in reducing IAN injury after third molar surgery during long-term follow-up. Nonetheless, CBCT may decrease the prevalence of temporary IAN injury and improve the surgical outcomes in high-risk patients.