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Oral Surgery ISSN 1752-2471


Cryotherapy application in third molar surgery:

a review of the literature
P. Taneja1, H.K. Chowlia2, M. Ezzeldin2 & S. Kaur2

Department of oral surgery, Birmingham Dental Hospital, Birmingham, UK

School of Dentistry, University of Birmingham, Birmingham, UK

Key words:
cold application, cryotherapy, third molars
Correspondence to:
Mr P.Taneja
Birmingham Dental Hospital
St Chads Queensway
West Midlands B4 6NN
Tel.: 0121 466 5156
Fax: 0121 466 5151
Accepted: 5 November 2014

Aim: To review the literature on the different methods and application
regimes of cryotherapy, and investigate its effects with respect to the
removal of third molars.
Materials and methods: A search was conducted through PubMed, Embase
and the Cochrane electronic databases. The publications included for the
review were those that investigated any form of cryotherapy and the
removal of third molars. Additionally a manual search of the reference lists
of included articles were reviewed.
Results: The literature search resulted in 111 articles, of which 10 met the
inclusion criteria. Outcomes of interest included body temperature, efficacy
of pain control, facial swelling, neurological scores, occurrence of inflammation, pain patient, satisfaction, quality of life, trismus and wound healing.
Conclusion: The review has found that there have been a variety of cooling
methods investigated, with the effects assessed postoperatively. Cryotherapy in the form of continuous cooling was shown to have significant
effects on postoperative mouth opening, pain, swelling and improved
patient satisfaction over conventional cooling.

The surgical removal of third molar (M3) is a
common procedure in oral surgery, involving the
handling of soft and hard tissues. These procedures
cause a local inflammatory response often accompanied by, but not limited to, morbidity including pain,
swelling and trismus1. Therefore, there is a need for
techniques to help reduce the effects of the inflammatory response, which could potentially improve
post-operative morbidity. A suggested method of
controlling the immediate inflammatory response is
As first described by Hippocrates, cryotherapy or cold
therapy (CT) is the local or systemic application of cold
for therapeutic reasons2. There have been a variety of
cooling methods described in the literature, including
the passive application of packs of gel, ice and cold comOral Surgery 8 (2015) 193--199.
2014 The British Association of Oral Surgeons and John Wiley & Sons Ltd

press and mechanically supported continuous cooling

with face masks. The physiological effects of CT have
been reported to show a reduction in pain, spasm,
metabolism, blood flow, inflammation, oedema and
Cryotherapy can have effects locally and at the level of
the spinal cord through neurological and vascular
mechanisms3. Its local response involves reducing the
temperature of tissues to a depth of 24 cm; this can help
to reduce the threshold for activation of nociceptors and,
therefore, the conduction velocity of pain nerve signals3.
In addition, frequent reference to CT in reducing
tissue metabolism (lowering the activity of inflammatory enzymes), inflammation and haemorrhage has
also been described in orthopaedic rehabilitation and
physiotherapy literature4,5. However, there has been
limited scientific evidence in the dental literature to
consolidate its use6.

Cryotherapy in third molar surgery

Taneja et al.

The primary objective of this article is to review the

literature on the different methods and application
regimes of CT and investigate its effects with respect to
the removal of M3. This would help to identify the beneficial uses of its application, in assisting in reducing the
post-operative morbidity associated with M3 surgery.

of the reference lists of the included full-text articles. A

summary of the included articles are reported in
Table 1, with the main outcomes of interest reported in
Table 2.

Body temperature

Material and methods

A literature search of articles published from 1974 to
June 2014 was conducted through the Cochrane electronic database, Embase, Ovid Medline and PubMed.
The publications included for the review were those
that investigated any form of CT and the removal of
M3s. Additionally, manual searches of the reference
lists of included articles were reviewed. Excluded articles were those that did not investigate a form of CT
with the removal of an M3.

The literature search resulted in 111 articles, of which
26 were duplicates. From the remaining articles, 10
met the inclusion criteria of CT and M3 removal. There
were no any additional articles found following review

One study assessed body temperature as a main

outcome of interest following bilateral lower third
molar (LM3) removal7. This was determined by the use
of an intraoral thermometer pre-operatively between
patients that had cold dressings placed following LM3
removal on one side of their mouth compared with the
other, and on the 1st and 7th days post-operatively.
There was little change in body temperature, with
identical mean temperatures on the 1st post-operative
day (36.9C), and on the 7th post-operative day
(36.7C), the findings were not statistically significant
(P > 0.05). Although not a main outcome of interest,
Filho et al. stated that patients within their study had a
drop of body temperature declined by approximately
8C, with skin temperature declining by approximately
27C8. There was no statistical analysis for this, and no
report on how temperature was measured.

Table 1 A summary of included articles


Study type

Number of

Teeth removed

system used

Cryotherapy regime

Bastian et al.



Bilateral LM3


Courage et al.

Prospective study


Bilateral LM3

Cold packs

Filho et al.



Bilateral LM3

Cold pack

Forouzanfar et al.
Forsgren et al.



Unilateral LM3
Bilateral LM3

Ice compression
Cold dressing

Gelesko et al.

Prospective study


All M3

Cold wrap

Osunde et al.
Rana et al.

Literature review


Not specied
All M3

Ice packs
i) Cold compress
ii) Continuous

Sortino et al.
Van der Westhuijzen
et al.

Literature review


Not specied
Bilateral LM3

Ice packs
Bilateral face ice

Cryotherapy probe to all bone subjected to drilling

or the use of an elevator, as well as intra-alveolar
bone. 26 cycles at a time for 30 sec at 89C
(liquid nitrous oxygen)
Chemical cold pack following LM3 removal
(duration not stated) and plastic bag with ice
chips to use at home for 24 h.
Blocks of ice enveloped by a band, applied 30 min
every 1.5 h for 48 h while awake.
Ice pack at 2C applied for 45 min post-operative
Refreezable cold bags at 4C replaced every
15 min for 2 h post-operatively
Wrap to be passively applied and worn
post-operatively for 24 h
(temp not stated)
Not stated
i) Cold compress applied 45 min post-operatively
(temp not stated)
ii) Continuous cooling at 15C applied through a
pre-shaped mask for 45 min post-operatively,
via a device called Hilotherm
Not stated
Placed within 15 min post-operatively and worn for
24 h (patient replacing the ice when thawed)

RCT, randomised control trial; M3, third molars; LM3, lower third molar; UM3, upper third molar.


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2014 The British Association of Oral Surgeons and John Wiley & Sons Ltd

Cryotherapy in third molar surgery

Taneja et al.

Table 2 Main outcomes of interest of included articles*

Bastian et al.
Courage et al.
Filho et al.
Forouzanfar et al.
Forsgren et al.
Gelesko et al.
Rana et al.
Van der Westhuijzen et al.

Efcacy of
pain control



Occurrence of



Quality of
life (QOL)



*Osunde et al. and Sortino et al. have not been included as they are reviews of the literature.

Efcacy of pain control

Van der Westhuijzen et al. found a statistically significant difference (P = 0.015) between treatment groups of
ice therapy and no ice therapy, with regard to the subjective perception of the efficacy of pain control postoperatively within a 24 h period (n = 18 in ice therapy
group and n = 8 in non-ice therapy group, reporting
excellent control of pain)9. Bastian et al. also found
a statistically significant difference in the patient
evaluation of discomfort between CT and no CT
(P < 0.01, n = 77 for CT and n = 57 for no CT reporting
moderate or no pain and n = 30 for CT and n = 50 for no
CT reporting severe pain)2.

Facial swelling
Six studies investigated post-operative facial swelling
following LM3 removal7,9,10. Filo et al. measured swelling from linear distances from the angle of the mandible to the tragus, eye angle, alar nose angle, corner of
the mouth and pogonion. Measurements were taken
pre-operatively and at 24 and 48 h post-operatively.
Statistically significant differences (P < 0.05) were
found in pre-operative linear distances with those
taken at 48 h post-operatively from gonion to tragus
(treated side: 0.13 0.12 cm, control side: 0.26
0.24 cm) and from gonion to pogonion (treated side:
0.16 0.18 cm, control side: 0.44 0.34 cm)8.
Rana et al. used a three-dimensional optical scanner
to measure facial swelling in volume in millilitres (mL).
Three-dimensional scans were recorded at 5 points:
before surgery, directly after surgery, and postoperatively on the 2nd, 10th, and 28th days. The study
compared two forms of CT (cold compress and continuous cooling) and concluded that the continuous
cooling method had a statistically significant reduction
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2014 The British Association of Oral Surgeons and John Wiley & Sons Ltd

in swelling on the 2nd (continuous cooling 72.2

14.9 mL, conventional 96.6 20.9 mL, P = 0.005) and
10th (continuous cooling 23.3 6.1mL, conventional
46.7 12.7 mL, P < 0.001) post-operative day, compared with conventional cooling. There was no statistical significant difference from the 28th day
(P = 0.57)10.
Bastian et al. calculated swelling based on clinical
experience of a dental surgeon (independent of the
surgical procedure), on day 8 following LM3 removal.
The article reported 94 patients that received CT
experienced mild to moderate swelling and 13 patients
with severe swelling. When not receiving CT, 81
patients experienced mild to moderate swelling and
26 patients experienced severe swelling. This was
reported as statistically significant (P < 0.05)2. Courage
et al. also assessed swelling from the perspective of a
clinician. The operator decided if swelling was severe
(involving the entire side of the face, extending from
the zygomatic arch to the submandibular region),
moderate (involving the tissues of the face immediately
overlying the mandible and extends to the submandibular area) or minimal (swelling of the tissues overlying the M3 region only). The majority of patients
experienced a lesser degree of swelling in the side
treated with CT than on the control side11. Nonetheless
there was no statistical calculation for significance.
Forsgren et al. assessed facial swelling as a parameter
at the 1st and 7th post-operative day. A mechanical
device with eight measuring pins was used to measure
the contours of the face. Swelling was calculated by the
sum of the difference in readings7. Van der Westhuijzen
et al. used Vernier-clinrated sliding pointers on the
horizontal extensions of a modified facebow to calculate facial swelling9. Both studies showed no significance (P > 0.05) in facial swelling for patients that had
CT compared with those that had none.

Cryotherapy in third molar surgery

Neurological analysis
Neurological analysis and scores following surgery
were investigated in only one study10. This was performed by the cotton test for touch sensation, the pinprick test for sharp pain and with the use of a blunt
instrument for testing pressure. The regions of the skin
of the infraorbital, mental region and upper and lower
lip were evaluated. The neurological score was assessed
at 3 points: before surgery, and on the 2nd and
28th post-operative days. There was no statistically
significant difference between the two groups (conventional cooling with a cold compress and continuous
cooling) concerning the neurological scores at the 2nd
(P = 0.8) and 10th (P = 0.6) day post extraction. There
was however a highly significant decrease in the neurological score observed after 10 days compared with
the 2nd post-operative day for both groups (continuous cooling, 2nd day 1.2 0.6 vs. 10th day 0.07 0.3,
P < 0.001; conventional, 2nd day 1.1 0.6 vs. 10th day
0.1 0.4, P < 0.001).

Occurrence of inammation
Bastian et al. found inflammation requiring treatment
to have occurred in nine patients on the side that
received CT and 16 patients on the side not given CT2.
There was no statistical analysis calculate for this.

Eight of the 10 studies assessed pain as an
outcome2,6,7,8,9,10,11,12. This was measured by a visual
analogue scale (VAS)2,6,8,9,10, pain-line7, Likert-type scale
anchored with verbal descriptive anchors12, number of
paracetamol consumption during the investigation
period,7 the mean consumption of ibuprofen in
mg/patient per 24 h6 and pain catergorised by intensity
and duration until relief by analgesia11. Two studies
found no statistical difference (P > 0.05) in the use of CT
for the reduction of pain following removal of M37,9.
Bastian et al. reported on patients that had LM3
removed under a general anaesthetic or a local anaesthetic. This study found a significant difference following LM3 removal between moderate and severe pain
with cryotherapy than without (P < 0.01, CT:
moderate/no pain = 77 and severe pain = 30, no CT:
moderate pain = 57 and severe pain = 50)2. Filho et al.
also found a significant difference between the CT
treated side and the control side following LM3
removal. A significant increase (P < 0.05) was found in
pain values 5 days following surgery; in both sides,
however, the increase was smaller in the treated side8.

Taneja et al.

Forouzanfar et al. discovered that from the average

pain score from day 2 (20.7 18.5) and over 7 days was
significantly lower (P < 0.05) in the patients subjected to
45 min of repeated ice compression (18.6 15.0) compared with no compression (28.6 20.2)6. There was no
statistical significance in the mean consumption of ibuprofen in mg/patient per 24 h between the groups6.
Gelesko et al. reported that passively applied CT
resulted in a distributional shift in pain scores away
from the most severe pain levels, as reported by
patients on the 1st to 3rd post-operative days12. The
study compared CT with topical minocycline and no
adjunctive therapy following M3 removal. For all three
groups, the distribution of pain outcomes was significantly different for worst pain and affective words
(P = 0.04). The distribution of responses for the treatment groups were towards the lower scores for average
pain on post surgery day 1 to 312. This was also seen by
Courage et al., who found that more patients experienced severe pain in the control side (n = 16) than the
side treated with CT (n = 5)11. However, randomisation
for both of these studies was not carried out.
Rana et al. investigated the effect of pain on patients
with conventional cooling and continuous cooling
after extractions of all four M3s10. Pain was measured
using a VAS ranging from 0 to 10. The study identified
that there was a significant down-regulated pain score
seen in patients that were exposed to continuous
cooling compared with conventional cooling on the
2nd (continuous cooling 3.4 1.5 and conventional
4.8 1.6, P < 0.05) and 3rd (continuous cooling
2.9 1.1 and conventional 3.7 1.2, P < 0.05) postoperative days. However, the study did not have any
comparison with the use of no CT following M3

Patient satisfaction
Rana et al. assessed satisfaction by providing patients
with a questionnaire to complete on the 10th postoperative day10. However, the article reported that the
questionnaire was in fact completed on the 2nd postoperative day and reported a statistically significant
difference (continuous cooling 1.9 0.2 and conventional 3.1 0.3, P = 0.003) was found between the
groups9. Bastian et al. also reported that the majority of
patients found CT to be better and would prefer to have
it again if given the choice over no CT (n = 57), but
there was no report on statistical significance2.

Quality of life
Forouzanfar et al. provided patients with a quality
of life questionnaire that was completed 1 week
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Taneja et al.

post-surgery6. The study found that only scores from

questions relating to social activity were significantly
lower (P = <0.05) in patients that had no compression
compared with groups that had ice compression and
compression alone.

Filho et al. measured mouth opening from the maxillary incisive edge to the mandibular incisive edge, using
a millimetre scale8. A significant decrease (P < 0.05) in
maximum mouth opening 24 h after surgery was
found in both sides (mean reduction 1.72 cm on CT
side and 1.6 cm on control side). However, there was
no statistical significance found between the CT
and the control sides during directly after surgery and
at 48 h.
Forsgren et al. and Van der Westhuijzen et al. used a
vernier gauge to measure mouth opening from
between the upper right and lower right central incisors7,9. Both studies concluded that there was no significant difference (P > 0.05) in trismus between the
sides treated with CT and the sides not treated with CT.
Rana et al. measured mouth opening in millimetres
(mm) at 5 points: before M3 surgery, directly after
surgery, and post-operatively on the 2nd, 10th and
28th days, respectively10. The study reported a significantly greater mouth opening directly after surgery
(continuous cooling 22.8 0.7 mm and conventional
17.1 0.7 mm, P = 0.01) and on the 2nd post-operative
day (continuous cooling 25.1 2.4 mm and conventional 22.0 1.9 mm, P = 0.002) in the group receiving
continuous cooling.

Wound healing
Forsgren et al. investigated wound healing on the 7th
post-operative day7. Assessment for infection, loose
mucoperiosteal flaps and the occurrence of alveolitis
were recorded. The study reported alveolitis in six cases
after post-operative treatment with cold dressings, and
four cases after operations when no cold dressings were
used. There were two patients who developed postoperative infections that required antibiotics and one
patient with a loose mucoperiosteal flap observed
when cold dressings were not used. There were not any
conclusions that could be made regarding the benefits
of CT from the differences observed.

The surgical removal of M3s typically results in morbidity including, but not limited to, pain, swelling and
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Cryotherapy in third molar surgery

trismus. It is well known that pharmacological methods

help reduce symptoms associated with morbidity and
are, therefore, normally recommended, with the
application of cold also advised.
Cryotherapy has been reported in the literature to
provide a therapeutic method for the management of
soft tissue damage following surgery by reducing cell
metabolism, slowing the biochemical reactions associated with pain and inflammation and promoting vasoconstriction, with the greatest intensity at 15C6,7,10.
The additional effect of decreased tissue temperatures is
the reduction of nerve conduction velocity10,12. Hence,
it would be expected that a reduction in pain and
inflammation should be seen in patients involved in
studies using CT following M3 removal.
Although there is a rapid reduction in temperature of
the superficial tissues in contact with the CT device,
deeper tissues are cooled less slowly9,13. Possible risks
with the prolonged placement of ice packs or similar
conventional cooling methods are that reducing tissue
temperatures to approximately 0C could cause prolonged vasoconstriction, ischaemia and capillary
thrombosis resulting in tissue death9. Therefore, CT is
used in caution in patients that suffer from cold hypersensitivities or impaired circulation or peripheral vascular disease such as Raynaud disease or type 1 diabetes
mellitus1,9,12. This issue questions if practitioners should
advise the general use of ice/cold packs following oral
surgery in patients with such medical conditions, and
whether or not set guidelines should also be given with
post-operative instructions for CT use to avoid the
aforementioned complications?
All but one of the studies used CT in a form of cold
being applied to extra oral soft tissues. An alternative
approach was seen by Bastian et al., who investigated
CT with the application of a cryotherapy probe (at a
temperature of 89C) to exposed bone. The rationale
was an increased analgesic effect and freezing causing
thrombosis of the smaller blood vessels, reducing the
risk of haemorrhage2. In addition, the modified
inflammatory response and destruction of peripheral
nerve endings caused by freezing could reduce pain2.
Although the study reported no cases of bone necrosis,
at such low temperatures, cell necrosis is expected and
would be cautioned without further investigation.
The review has identified that benefits with the use
of CT have been efficacy of pain control, facial swelling,
pain, patient satisfaction and trismus2,6,810,12. When
comparing continuous cooling versus conventional
cold application following M3 removal, the benefits
included a statistically significant reduction in postoperative pain, reduction of swelling, improved patient
satisfaction and trismus10. The clinical significance this

Cryotherapy in third molar surgery

presents is that the study has possibly identified a

superior method of CT. A limitation is that it does not
include a control group that did not receive CT and, so,
any conclusions over M3 removal between CT and
non-CT groups cannot be made. In contrast Forsgren
et al. and Van der Westhuijzen et al. used cold dressings
and bilateral face ice packs respectively and had control
groups that received no form of CT7,9. Both studies
found no significance on the effects of trismus as well as
swelling post-operatively following M3 removal.
As pain following M3 removal is of a localised
inflammatory nature with maximum intensity during
the first 12 h14, it would be expected that a locally
acting treatment should help to reduce pain with a
faster onset. Although the majority of studies that
investigated pain found that there was a significant
difference in the use of CT, very few articles compared
against non-CT controls. Forouzanfar et al. reported a
significant decrease in pain between groups of patients
that had ice compression compared with no compression by day 2 following M3 surgery6. However, the
study also found a significant decrease in pain score for
patients that were subjected to 45 min of repeated
compression without ice from day 3. Hence, it is not
clear if the effects seen are as a result of the CT or of the
compression. As previously discussed, CT works by
vasoconstriction, reducing blood flow that reduces
inflammatory and pain mediators. Compression could
also limit blood flow by the force applied, creating the
same effect to a tissue area6.
Pain intensity seemed to have improved by day 57
with two articles having reported patients to have felt a
lesser amount of pain on the side treated with CT in
comparison with the control side2,8. Although it would
have been interesting to have seen the pain scores for
patients post surgery and through the days following so
as to gain an understanding of the extent of difference
between CT and no CT.
The patients perception of post-operative control of
symptoms over the first 24 h after LM3 removal was
reported as significant when comparing ice therapy
with no ice therapy9. However, the study, which used
refillable ice packs over the first 24 h, also provided
participants with perioperative and post-operative
anti-inflammatory and analgesic regime for 24 h. This
can affect the sensitivity of the study to CT as its
effects may be less pronounced through the use of
background medications. The latter can also be considered for studies that assessed swelling following M3
removal. Using CT has shown a significant reduction
in swelling from 48 h; however, the prescription of
non-steroidal anti-inflammatory drugs was also

Taneja et al.

No conclusions can be drawn for occurrence of

inflammation2, wound healing7 and quality of life6,12 for
the use of CT.

The consistent outcomes of pain, swelling and dysfunction on post-operative recovery following M3
removal provides a good model for studying the efficacy of an intervention, such as cryotherapy12. This
review has found that there are limited findings in the
use of CT in reducing post-operative morbidity.
However, with the variety of CT methods that were
reviewed, it has been interesting to see that continuous
cooling has shown to have significant effects on a
number of conditions including post-operative mouth
opening, pain, swelling and improved patient satisfaction over conventional cooling. This method of CT
would also have the benefits of controlling the temperature and preventing it from falling too low or,
conversely, as seen with ice packs, from warming following contact with the facial tissues as time passes.
Continuous cooling also relies on a fixed facial mask
that would eliminate the compliance required in the
repeated changing of ice/cool packs, making it easier
for patients to sustain. In order to achieve this, specialist equipment may be required with possible training
and cost implications. In addition, further research is
required to further support these findings.
Another benefit that may require further investigation is the role of compression. As discussed, compression has shown to have a significant effect in reducing
post-operative pain following M3 removal, and further
investigations could clarify if there is a synergistic effect
with CT.
With all of the studies reviewed, CT was performed
post-operatively. If cell metabolism is reduced through
the application of cold, then it may be worth considering applying CT for a period prior to surgery, or even
during surgery (CT method permitting). In this way,
tissues will be at the ideal temperature for slowing the
biochemical reactions that lead to inflammation. In
addition, the effects of CT on vasoconstriction and
reduction of nerve velocity could be advantageous in
terms of decreased bleeding associated with the operative field for the surgeon and decreasing pain for the
The accumulated data from the review provide an
understanding of how the different modalities of CT
provide an alternate method with simple and safe
treatment of some of the post-operative symptoms following M3 removal. When one of the alternate
approaches are to simply ingest a medication, studies of
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Taneja et al.

CT effects need to show a vast improvement in postoperative morbidity before it is likely to convince both
clinicians and patients.

Conflict of interest
The authors confirm that they have no conflict of

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