DENTOALVEOLAR SURGERY

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Evaluation of Treatment Outcome AfterImpacted Mandibular Third Molar SurgeryWith the Use of Autologous Platelet-Rich

Fibrin: A Randomized ControlledClinical Study

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yProfeszSeniorxProfeskReade{PG Tr

Nilima Kumar, MDS,* Kavitha Prasad, MDS,y Laitha Ramanujam, MDS,zRanganath K, MDS,x Jayashree Dexith, MDS,k and Abhishek Chauhan, MDS{

Purpose: To assess the effect of platelet-rich fibrin (PRF) on postoperative pain, swelling, trismus, peri-

odontal healing on the distal aspect of the second molar, and progress of bone regeneration in mandibular

third molar extraction sockets.

Materials and Methods: Over a 2-year period, 31 patients (mean age, 26.1 yr) who required surgical

extraction of a single impacted third molar and met the inclusion criteria were recruited. After surgical

extraction of the third molar, only primary closure was performed in the control group, whereas PRF

was placed in the socket followed by primary closure in the case group (16 patients). The outcome vari-

ables were pain, swelling, maximummouth opening, periodontal pocket depth, and bone formation, with

a follow-up period of 3 months. Quantitative data are presented as mean. Statistical significance was

inferred at a P value less than .05.

Results: Pain (P = .017), swelling (P = .022), and interincisal distance (P = .040) were less in the case

group compared with the control group on the first postoperative day. Periodontal pocket depth

decreased at 3 months postoperatively in the case (P < .001) and control (P = .014) groups, and thisdecrease was statistically significant. Bone density scores at 3 months postoperatively were higher in

the case group than in the control group, but this difference was not statistically important.

Conclusions: The application of PRF lessens the severity of immediate postoperative sequelae,

decreases preoperative pocket depth, and hastens bone formation.

� 2015 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 73:1042-1049, 2015

The optimal management of impacted mandibular

third molars continues to challenge clinicians.1

Numerous indications for surgical extraction of third

molars have been outlined, one of which is the preven-

tion or repair of periodontal defects in adjacentsecond molars. A partially impacted third molar

exposed to the oral environment is more susceptible

from the Department of Oral and Maxillofacial Surgery,

iah Dental College and Hospital, Bangalore, Karnataka,

inee.

sor and Department Head.

Professor.

sor.

r.

ainee.

1042

to periodontal infection and thus to greater peri-

odontal attachment loss.2 There appears to be a sub-

population of patients having third molars removed

that are at ‘‘high risk’’ for periodontal defects after third

molar removal (ie, >26 yr of age; pre-existing peri-odontal defects [attachment level, >3 mm; probing

depth, >5 mm]; and horizontal or mesioangular

Address correspondence and reprint requests to Dr Kumar:

Department of Oral and Maxillofacial Surgery, Room no 10, M.S.

Ramaiah Dental College and Hospital, Bangalore 560054, Karnataka,

India; e-mail: nilima.kumar@rediffmail.com

Received March 13 2014

Accepted November 15 2014

� 2015 American Association of Oral and Maxillofacial Surgeons

0278-2391/14/01720-0

http://dx.doi.org/10.1016/j.joms.2014.11.013

KUMAR ET AL 1043

impaction). When these 3 risk factors are present

concurrently, there does appear to be a predictable

benefit to reconstructing the dentoalveolar defect at

the time of extraction.3

The immediate postoperative sequelae after third

molar surgery include pain, swelling, and trismus,

and delayed sequelae are seen mostly on the distal

surface of the second molar owing to distal boneloss, which include prolonged sensitivity due to root

exposure or increased probing depth. Autologous

platelet concentrates, such as platelet-rich plasma

(PRP) and platelet-rich fibrin (PRF), are widely used

for superior wound healing. PRF, a second-generation

platelet concentrate, has been shown to have a more

sustained release of growth factors; it is a simplified

processing techniquewithminimal biochemical bloodhandling compared with PRP.4 Evidence of the effect

of PRF on postoperative sequelae after third molar

surgery is sparse. Therefore, this study was under-

taken to assess the influence of PRF on wound-

healing characteristics of the socket and the defect

distal to the second molar after surgical extraction of

mesioangular or horizontal impactions.

Materials and Methods

This study included patients reporting to an outpa-

tient department for the surgical removal ofmesioangu-lar or horizontally impacted mandibular third molars

from December 2011 to July 2013. The protocol for

the study was approved by the institutional ethics com-

mittee. After preoperative evaluation and obtaining

written informed consent, 31 male and female patients

who could follow postoperative instructions were

selected for the study. Inclusion criteria were healthy

patients 19 to 35 years old, mesioangular or horizontalmandibular third molar impaction, and a preoperative

platelet count higher than 150,000/mm3. Exclusion

criteria were patients in whom the second molar was

missing or was indicated for extraction, patients with

any underlying systemic disease or compromised

immunity, and pregnant or lactating women.

Patients were randomized by the closed-envelope

method and divided into 2 groups. In the case group(16 patients), the impacted mandibular third molar

was surgically removed and 5 mL of venous blood

was drawn and centrifuged at 3,000 rpm for 10

minutes to prepare the PRF, which was placed into

the extraction socket followed by flap approximation.

The control group (15 patients) was treated with sur-

gical removal of the impacted mandibular third molar

and flap reapproximation.Patients were not started on any preoperative anti-

microbials or other drugs that might influence healing,

and a common protocol of investigations and interven-

tions was followed for all patients. Preoperative inves-

tigations included an intraoral periapical radiograph

(IOPAR) of the impacted third molar by the parallel-

cone technique, a panoramic radiograph (OPG), and

platelet count. Oral prophylaxis was performed for

all patients preoperatively. The Silness-Loe gingival

and plaque index was recorded. Pocket depth was

measured using a UNC 15 periodontal probe taken

from the margin of the gingiva to the base of thepocket along the distal surface of the mandibular

second molar at 3 points (distobuccal, mid-distal, and

distolingual) by a single evaluator.

OPERATIVE PROCEDURE

A standardized operative procedure was carried out

by a single right-handed operator for all patients after

appropriate preoperative evaluation. Under strict

aseptic precautions, 2% lignocaine with 1:200,000

adrenalin was used and an inferior alveolar nerve block

was given. A modified Ward incision was performed

and a full-thickness mucoperiosteal flap was raised.

The tooth was exposed with a round bur, after whichbuccal guttering was performed using a straight fissure

bur. Tooth sectioningwas performed as deemed neces-

sary after preoperative radiographic evaluation and the

tooth was delivered with elevators. After tooth extrac-

tion, the socket was thoroughly irrigated and freed

from pathologic tissue (eg, granulation tissue), follic-

ular remnants, and bony spicules. In the case group,

after the tooth was delivered, 5 mL of venous bloodwas drawn and centrifuged at 3,000 rpm for 10minutes

and PRF was obtained. The PRF was inserted into the

extraction socket and then closure was performed

using 3-0Mersilk. In the control group, primary closure

was performed using 3-0 Mersilk sutures. The average

operative time from incision to suturing was 30 to

45 minutes. Postoperatively, all patients were started

on a 3-day course of amoxicillin 500 mg thrice daily,metronidazole 400 mg thrice daily, a combination of

aceclofenac and paracetamol twice daily, and chlorhex-

idine mouthwash thrice daily. All patients were given

instructions on the importance of maintaining oral

hygiene and jaw physiotherapy postoperatively. Suture

removal was performed on postoperative day 7.

FOLLOW-UP

Patients were evaluated and compared preopera-

tively, postoperatively on the first postoperative day,

at 1 month, and at 3 months. Pain and swelling were

recorded on a visual analog scale according to Pasqua-

lini et al5 on the first postoperative day, at 1month, andat 3 months. Interincisal distance was evaluated using

a divider and a scale on the first postoperative day, at

1 month, and at 3months. Pocket depthwasmeasured

at 1 and 3 months postoperatively and compared with

preoperative values. Radiographic evaluation of the

1044 PLATELET-RICH FIBRIN FOR THIRD MOLAR SURGERY

extraction socket was performed using IOPARs and

OPGs at 1 and 3 months postoperatively (Fig 1A-D).

STATISTICAL ANALYSIS

One-way analyses of variance were used to test thedifference between groups. The Student t test was

used to determine a statistical difference between

groups in the parameters measured. Proportions

were compared by c2 test with Yates correction,

if required.

Results

Age, gender distribution, type of impaction

(Table 1), site of impaction (left or right), preoperative

periodontal pocket depth, and preoperative plaque

score in the case and control groups were comparable

and no statistical difference was noted between the 2

groups. A P value less than .05 was considered statisti-cally significant.

In this study, pain (P = .017), swelling (P = .022),

and interincisal distance (P = .040) were less in the

case group compared with the control group on the

FIGURE 1. Preoperative and 3-month postoperative intraoral periap

Kumar et al. Platelet-Rich Fibrin for Third Molar Surgery. J Oral Maxillo

first postoperative day and this difference was statisti-

cally significant (Table 2). Periodontal pocket depth

decreased from the preoperative baseline in the case

(P < .001) and control (P = .014) groups to 3 months

postoperatively and this decrease was statistically sig-

nificant (Table 3). The difference between the 1- and

3-month postoperative values for periodontal probing

depth also was statistically significant in the casegroup compared with the control group, suggesting

a greater rate of decrease of pocket depth in the case

group (P < .001; Table 4).

Bone density, recorded as lamina dura, overall den-

sity, and trabecular pattern scores at 1 and 3 months

postoperatively, was greater in the case group

compared with the control group, but this difference

was not statistically important (Table 5).

Discussion

Socket healing is a highly coordinated sequence of

biochemical, physiologic, cellular, and molecular

responses involving numerous cell types, growth fac-

tors, hormones, cytokines, and other proteins, which

ical radiographs of A, B, case group and C, D, control group.

fac Surg 2015.

Table 1. DISTRIBUTION OF IMPACTION IN CASE ANDCONTROL GROUPS

Classification

Total P ValueMesioangular Horizontal

Control 10 5 15

Case 9 7 16 .552

Total 19 12 31

Note: A P value less than .05 was considered significant.

Kumar et al. Platelet-Rich Fibrin for Third Molar Surgery. J Oral

Maxillofac Surg 2015.

KUMAR ET AL 1045

are directed toward restoring tissue integrity and func-

tional capacity after injury. It is a specialized example

of healing by second intention.6

The presence and removal of impacted third molars

can negatively affect the periodontium of adjacent

second molars as reflected in the disruption of the

periodontal ligament, root resorption, and pocketdepth associated with loss of attachment.3 Periodontal

defects, as assessed by pocket depths, increase with

increasing age in the presence of retained third

molars.3 The present study included young healthy

patients 19 to 35 years old. The mean age of the case

group was 25.25 � 4.20 years and that of the control

group was 27.00 � 5.27 years and no statistical differ-

ence was noted between the 2 groups, suggesting thatthey were comparable. The literature suggests that the

incidence of postoperative morbidity after third molar

Table 2. DISTRIBUTION OF PAIN, SWELLING, AND MEAN INTON FIRST POSTOPERATIVE DAY

Pain

None Mild Slight

Control 6 (40.0%) 6 (40.0%)

Case 14 (87.5%) 2 (12.5%)

Swelling

None Mild Slight

Control 7 (46.7%) 5 (33.3%)

Case 13 (81.3%) 3 (18.8%)

Mean Interincisal Distance

n Mean SD

Control 15 31.07 3.195

Case 16 33.00 1.592

Abbreviations: Max, maximum; Min, minimum; SD, standard devi* Statistically significant (P < .05).

Kumar et al. Platelet-Rich Fibrin for Third Molar Surgery. J Oral Maxillo

removal is higher in patients older than 25 years.3,7

Other studies on third molar surgery and the use of

PRP in the extraction socket have reported a similar

age range for their patients.6,8-12

The preoperative existence of an intrabony defect,

age of the patient, and level of plaque control could

serve to predict adverse outcomes.3 In the present

study, periodontal pocket depth was recorded preop-eratively and 1 and 3 months postoperatively. When

there is a close association between the second and

third molars, it might be difficult to judge the probing

depth appropriately because the cusps of the

impacted tooth could prove a hindrance, and in such

cases, the postoperative probing depth might be

greater than the preoperative value. The preoperative

pocket depth in the 2 groups was recorded (mean, 5.9� 0.87 mm in case group; mean, 6.09 � 1.28 mm in

control group), and the difference between the 2

groups was not statistically different, indicating that

the 2 groups were comparable. In other studies

conducted on the use of PRP in the extraction socket

of third molars,6,8,10 a preoperative periodontal

pocket of at least 7.5 mm was mandatory, because

they addressed deep mesioangular impactions.Kan et al13 identified 3 possible risk indicators asso-

ciated with localized increased probing pocket depth,

namely mesioangular impactions, pre-extraction

crestal radiolucency, and inadequate postextraction

plaque control. In agreement with the findings of

Kan et al,13 all 31 patients included in the present

study had a mesioangular or horizontal impaction

ERINCISAL DISTANCE IN CASE AND CONTROL GROUPS

Total P ValueSevere

3 (20.0%) 15 (100.0%) .017*

0 (0%) 16 (100.0%)

Total P ValueSevere

3 (20.0%) 15 (100.0%) .022*

0 (0%) 16 (100.0%)

Max P ValueMin

26 36 .040*

30 35

ation.

fac Surg 2015.

Table 3. COMPARISON OF MEAN POCKET DEPTH INCASE AND CONTROL GROUPS PREOPERATIVELY AND1 AND 3 MONTHS POSTOPERATIVELY

Group n Mean SD Min Max P Value

Control

Preoperatively 15 6.09 1.28 4 9

Month 1

postoperatively

15 5.24 1.04 3 7 .014*

Month 3

postoperatively

15 4.78 1.20 3 7

Case

Preoperatively 16 5.94 0.87 4 7

Month 1

postoperatively

16 4.88 0.64 3 6 <.001*

Month 3

postoperatively

16 3.40 0.49 3 4

Abbreviations: Max, maximum; Min, minimum; SD, standarddeviation.* Statistically significant (P < .05).

Kumar et al. Platelet-Rich Fibrin for Third Molar Surgery. J Oral

Maxillofac Surg 2015.

1046 PLATELET-RICH FIBRIN FOR THIRD MOLAR SURGERY

with an increased probing depth on the distal aspect

of the third molar, and their plaque scorewas recorded

to ensure pre- and postextraction plaque control. The

plaque score of the patients was recorded preopera-

tively to rule out any pre-existing periodontal compro-

mise owing to poor oral hygiene. The difference

between plaque scores at different intervals was notstatistically meaningful, suggesting that oral hygiene

was maintained throughout the study duration in the

2 groups. Thus, plaque was not a risk factor for the

persistence of pocket depth postoperatively.

Postoperative sequelae, such as pain, swelling, and

mouth opening, were recorded for all patients preoper-

atively and postoperatively at first postoperative day, at

1 month, and at 3 months. There was no pain in all 31patients preoperatively and at 1 and 3 months postop-

Table 4. COMPARISON OF MEAN POCKET DEPTH INCASE AND CONTROL GROUPS PREOPERATIVELY TO1 MONTH POSTOPERATIVELY AND PREOPERATIVELYTO 3 MONTHS POSTOPERATIVELY

Group Visit

Mean

Difference

P

Value

Control preoperative vs month 1 0.844 .135

preoperative vs month 3 1.311 .011*

month 1 vs 3 0.467 .530

Case preoperative vs month 1 1.063 <.001*

preoperative vs month 3 2.542 <.001*

month 1 vs 3 1.479 <.001*

* Statistically significant (P < .05).

Kumar et al. Platelet-Rich Fibrin for Third Molar Surgery. J Oral

Maxillofac Surg 2015.

eratively. On the first postoperative day, pain and

swelling were considerably less in the case group

compared with the control group. In the case group,

87.5% of patients complained of mild pain, 12.5% com-

plained of slight pain, and none complained of severe

pain, whereas in the control group, 40% complained

of mild pain, 40% complained of slight pain, and 20%

complained of severe pain. This difference betweenthe 2 groupswas statistically significant (P= .017), indi-

cating that the application of PRF in the extraction

socket aided in decreasing patients’ postoperative

pain (Table 2).

There was no swelling in all 31 patients preopera-

tively and at 1 and 3months postoperatively. On the first

postoperative day, swelling was noted in the 2 groups.

In the case group, 81.3% complained of mild swelling,18.8% complained of slight swelling, and none com-

plained of severe swelling; in the control group,

46.7% complained of mild swelling, 33.3% complained

of slight swelling, and 20.0% complained of severe

swelling. This difference between the 2 groups was sta-

tistically significant (P = .022), indicating that the appli-

cation of PRF in the socket decreased the postoperative

swelling experienced by the patients (Table 2).Interincisal distance was recorded in all patients

preoperatively, on the first postoperative day, and at 1

and 3 months postoperatively to assess restriction in

mouth opening in the 2 groups. All 31 patients

recorded no restriction in mouth opening preopera-

tively or at 1 and 3 months postoperatively. The

mean preoperative mouth opening in the case group

was 40.50 � 1.71 mm and that in the control groupwas 39.93 � 2.57 mm, and the difference between

the 2 groups was not important, indicating they were

comparable. On the first postoperative day, mouth

opening was 33.00 � 1.59 mm in the case group and

31.07 � 3.19 mm in the control group, and this differ-

ence was statistically significant (P = .040), indicating

that the use of PRF influenced the degree of restriction

of mouth opening (Table 2).This finding was in contrast to a similar case-and-

control study conducted by Ogundipe et al6 on the

use of autologous PRP gel to increase healing after

surgical extraction of mandibular third molars. In

that study, the PRP group had decreased pain,

swelling, and trismus compared with the control

group, but this difference was statistically important

only for postoperative pain. Therefore, PRF seems tohave a more positive influence on postoperative

sequelae. There is no other study on the use of PRF

after surgical extraction of mandibular third molars

and the simultaneous assessment of subjective and

objective postoperative sequelae.

Sammartino et al8 stated that the extraction of

mesioangular impacted third molars can cause multiple

periodontal defects at the distal root of the

Table 5. DISTRIBUTION OF LAMINA DURA, OVERALL DENSITY, AND TRABECULAR PATTERN IN CASE AND CONTROLGROUPS AT 3 MONTHS POSTOPERATIVELY

Lamina Dura

Total P ValueWithin Normal Limits Absent Substantially Thinned

Control 0 (0%) 9 (60.0%) 6 (40.0%) 15 (100.0%) .576

Case 0 (0%) 8 (50.0%) 8 (50.0%) 16 (100.0%)

Overall Density

Total P ValueWithin Normal Limits Mild to Moderate Increase Severe Increase

Control 0 (0%) 14 (93.3%) 1 (6.7%) 15 (100.0%) .083

Case 0 (0%) 11 (68.8%) 5 (31.3%) 16 (100.0%)

Trabecular Pattern

Total P ValueWithin Normal Limits Somewhat Coarser Substantially Coarser

Control 1 (6.7%) 14 (93.3%) 0 (0%) 15 (100.0%) .115

Case 1 (6.3%) 11 (68.8%) 4 (25.0%) 16 (100.0%)

Statistically significant (P < .05).

Kumar et al. Platelet-Rich Fibrin for Third Molar Surgery. J Oral Maxillofac Surg 2015.

KUMAR ET AL 1047

second molar. In the present study, the mean preopera-

tive pocket depth in the case group was 5.9 �0.87 mm and that in the control group was 6.09 �1.28 mm, and the difference between the 2 groups was

not statistically important, indicating that the 2 groups

were comparable. The 1-month postoperative pocket

depth in the case group was 4.88 � 0.64 mm and that

in thecontrolgroupwas5.24�1.04mm,andat3months

postoperatively it was 3.40� 0.49mm in the case group

and 4.78� 1.20 in the control group (Table 3). Postoper-

ativepocketdepth recordedat 1 and3monthswas less inthecasegroupcomparedwith thecontrol group, but this

difference was statistically significant only at the end of

3 months (P < .001), indicating better periodontal heal-

ing in the case group compared with the control group.

These resultswere comparable to other reported studies

in the literature.6,8,10 Sammartino et al8 reported that PRP

was effective in inducing and accelerating bone regener-

ation for the treatment of periodontal defects at the distalroot of themandibular secondmolar after surgical extrac-

tion of amesioangular, deeply impactedmandibular third

molar and recorded a pocket depth of 4.13� 1.34mmat

12 weeks, whereas in the present study a probing depth

of 3.40 � 0.49 mm was noted at the end of 3 months

(12 weeks). In 2009, Sammartino et al10 performed

another study on the use of PRP alone and PRP with

resorbable membrane for the prevention of periodontaldefects after deeply impacted lower third molar extrac-

tion and found the PRP with Bio-Gide (Geistlich

Biomaterials, Wolhusen, Switzerland) membrane

showed early signs of bone maturation, but not a higher

grade of bone regeneration.10

Further statistical analysis between the follow-up

visits showed that mean pocket depth was 5.94 �0.87 mm preoperatively, 4.88 � 0.64 mm at 1 monthpostoperatively, and 3.40� 0.49 mm at 3 months post-

operatively in the case group (P < .001) and 6.09 �1.28 mm preoperatively, 5.24 � 1.04 mm at 1 month

postoperatively, and 4.78� 1.20 mm at 3 months post-

operatively in the control group (P = .014). This

decrease in pocket depth was statistically important

in the 2 groups, suggesting a decrease in pocket depth

postoperatively in the case and control groups afterextraction of the impacted third molar (Fig 2). As pre-

sented in Table 4, the control group showed a decrease

in pocket depth from preoperatively to 1 and 3months

postoperatively, but this difference was statistically

important only at 3 months. In the case group, the

decrease in pocket depth from the preoperative value

was noted at 1 and 3months, and this decreasewas sta-

tistically important at the 2 intervals, indicating a fasterrate of decrease of pocket depth in the case group.

In the present study, IOPARs, obtained with the

parallel-cone technique, and OPGs were used for the

radiographic evaluation of the distal bone defect in

relation to the lower second molar preoperatively and

for the 1- and 3-month postoperative follow-ups as

described by other investigators.6,8,10,11 The IOPARs

and OPGs in the present study were converted todigital images and studied by a single radiologist who

was blinded to the study group. The evaluation of

bone density in this study was performed using a

scoring system suggested by Ogundipe et al6 in which

scores were listed for the lamina dura, overall density,

FIGURE 2. Comparison of mean pocket depth in case and control groups preoperatively and 1 and 3 months postoperatively.

Kumar et al. Platelet-Rich Fibrin for Third Molar Surgery. J Oral Maxillofac Surg 2015.

1048 PLATELET-RICH FIBRIN FOR THIRD MOLAR SURGERY

and trabecular pattern appreciable on an IOPAR. The

lamina dura, overall density, and trabecular pattern

scores were higher in the case group compared with

the control group, indicating a greater bone density in

the case group. This difference was not statistically

different between the 2 groups (Table 5). The higher

scores in the case group suggested a faster rate ofbone deposition compared with that in the control

group,whichwas similar to the results of other studies.6

In contrast to these findings, a scintigraphic evalua-

tion of osteoblastic activity in extraction sockets

treated with PRF was carried out by Gurbuzer et al14

in 14 patients with bilateral soft tissue impacted

mandibular third molars; they reported that PRF ex-

hibits the potential characteristics of an autologousfibrin matrix, but might not lead to enhanced bone

healing in soft tissue impacted mandibular third molar

sockets 4 weeks after surgery. This difference could be

due to the varied technique of preparation of PRF in

the study conducted by Gurbuzer et al.14 In their

study, they had used a centrifugation rate of

2,030 rpm for 10 minutes, whereas the standard prep-

aration suggested by Dohan et al15 is 3,000 rpm for10 minutes. In a systematic review conducted by Del

Fabbro et al16 on the use of autologous platelet con-

centrates in postextraction socket healing, favorable

soft and hard tissue healing and a postoperative

decrease in discomfort were reported by various

researchers, but owing to the lack of standardization

of the technique for the preparation of these concen-

trates, their true regenerative effects were unknown.

To summarize, this study evaluated the effectiveness

of PRF in third molar extraction sockets for wound

healing by assessing postoperative pain, swelling,

mouth opening, periodontal healing, and bone regen-eration clinically and radiographically. Because the

literature suggests PRF is superior to PRP4,17,18 in

inducing soft and hard tissue healing owing to a

sustained release of growth factors, PRF was chosen.

A statistically important decrease in pain, swelling,

and restriction in mouth opening was noted in the

case group. Periodontal pocket depth was seen to

decrease in the 2 groups postoperatively, but theextent of decrease was statistically different in the

case group compared with the control group.

Radiographic evaluation of the bone formation

showed that scores were higher in the case group,

but this difference was not statistically important.

These results indicated that in the case group the

postoperative sequelae experienced by the patients

were less compared with the control group. Therealso was accelerated periodontal healing and bone

formation in the case versus control group.

In the present study, the case group had less pain,

swelling, and trismus on the first postoperative day

compared with the control group. The decrease in pain

KUMAR ET AL 1049

and swelling, although statistically important, should be

considered with caution because these are based on a

subjective visual analog scale score. Also, increased and

faster periodontal healing was observed in the case

group, with a statistically important decrease in probing

depths at the distal root of the mandibular second molar

after surgical extractionofmesioangular andhorizontally

impacted mandibular third molars. Bone density scoresalsowere higher for the case group, although not statisti-

cally different. Therefore, PRF can be considered a viable

option for socket healing after surgical extraction of

impacted mandibular third molars. This study had the

limitationof a small sample and a short follow-up.A study

with a larger samplewith a longer follow-up iswarranted

to obtain a more statistically meaningful result with

respect to bone regeneration.

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