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Available online at www.sciencedirect.com

British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx

Evaluation of the effects of platelet-rich fibrin and

piezosurgery on outcomes after removal of ımpacted
mandibular third molars
K. Bilginaylar ∗ , L.O. Uyanik
Department of Oral and Maxillofacial Surgery, Near East University Faculty of Dentistry, Nicosia, Cyprus

Accepted 18 March 2016

Abstract

We compared postoperative outcomes after the removal of 80 impacted mandibular third molars in 59 patients. In the control group, osteotomies
were done with traditional burs (n = 20). The second group had traditional osteotomies and platelet-rich fibrin (PRF) placed into the socket
of the extracted tooth (n = 20). The third group had piezosurgery (n = 20), and the fourth had piezosurgery and PRF placed in the extraction
socket (n = 20). Baseline variables were assessed preoperatively and included pain, the number of analgesics taken, trismus, and swelling.
These were also assessed on postoperative days 1, 2, 3, and 7. There was a significant reduction (p < 0.05) in pain on days 1, 2, and 3, and in
the number of analgesics taken on days 2 and 3 in both PRF groups. However, in the piezosurgery alone group this was the case only on day
3. There was no significant difference in swelling and trismus between the control and other groups.
© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Platelet rich fibrin; Piezosurgery; Impacted third molar surgery; Pain; Swelling; Trismus

Introduction Joseph Choukroun was the first to use platelet-rich fibrin

Operations to remove impacted mandibular third molars
typically cause pain, swelling, and trismus in the early post-
operative period,1–3 and surgeons should develop strategies
that will reduce their severity and improve healing.4
Piezoelectric devices, which can be used instead of
conventional burs,5–7 may be beneficial for operations at
complex sites because they can preferentially cut mineralised
structures.8 Pain, swelling, and trismus after the extraction
of mandibular third molars have been reported to be reduced
when they have been used.4,5,8
(PRF) in oral and maxillofacial surgery.9,10 He argued that
sockets would heal more quickly and pain would be reduced
if autogenous platelet concentrate was applied to the area.
PRF, which is a second-generation immune and platelet con-
centrate, gathers all the components of blood that support
healing and immunity on just one fibrin membrane.11
We compared the outcomes of operations to remove
mandibular third molars using rotatory instruments and
piezoelectric surgery, with and without application of PRF
to the extraction sockets.

Patients and methods

∗ Corresponding author at: Department of Oral and Maxillofacial Surgery.

Tel.: +903926802030; fax: +903926802025. We studied 59 patients aged between 18 and 31 years who
E-mail addresses: kani blgnylr@hotmail.com (K. Bilginaylar), had impacted third molars removed at the Near East Uni-
lokmanonur@gmail.com (L.O. Uyanik). versity Faculty of Dentistry in Nicosia, Cyprus, between
http://dx.doi.org/10.1016/j.bjoms.2016.03.016
0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Bilginaylar K, Uyanik LO. Evaluation of the effects of platelet-rich fibrin and piezosurgery on outcomes
after removal of ımpacted mandibular third molars. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.03.016
YBJOM-4833; No. of Pages 5
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2 K. Bilginaylar, L.O. Uyanik / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
January 2014 and January 2015. A total of 21 patients (10
female, 11 male) had bilateral extractions and 38 (27 female,
11 male) had unilateral extractions. Patients aged 18 or over
who had bilateral or unilateral, vertically impacted lower third
molars that required extraction for prophylactic reasons, were
included. None had systemic diseases or had taken opioids
for a long period. They did not smoke or drink alcohol, were
not pregnant, and were not allergic to penicillin or other drugs
used during standard postoperative treatment. Those taking
antibiotics for a current infection, those with acute pericoroni-
tis or severe periodontal disease at the time of the operation,
or whose teeth needed to be sectioned, were excluded. All
required an osteotomy. Extractions were of moderate diffi-
culty (class I, level C), and were assessed according to the
classification by Pell and Gregory.12,13
Operations were divided into 4 main groups that each
included 20 teeth and 20 patients. In the control group (10
men, 10 women), osteotomies were done with traditional
burs. The second group (7 men, 13 women) had traditional
osteotomies and platelet-rich fibrin (PRF) placed into
the socket of the extracted tooth. The third group had
piezosurgery (6 men, 14 women), and the fourth (10 men,
10 women), piezosurgery and PRF placed in the extraction
socket. Patients who had bilateral impaction had the second
operation a minimum of 21 days after the first to allow
the variables to return to the preoperative baseline. The
technique used in each case was randomly selected. Pain,
the number of analgesics taken, trismus, and swelling of
the cheek, were evaluated before, and after operation on
days 1, 2, 3, and 7. Only the assessor was blinded when
measurements were taken.
Patients were told about the operation, the expected post-
operative course and possible complications, and all provided
written, informed consent. The design of the study was
approved by the local ethics committee (project number,
NEU/2014/19–101).
Preparation of PRF gel
PRF was prepared according to the technique described by
Dohan et al.14 About 15 minutes before the operation, blood
samples were taken without anticoagulant in 10 ml glass-
coated plastic tubes, which were immediately centrifuged
(Elektro-mag M415P, Istanbul, Turkey) at 3000 rpm (about
400 g) for 10 minutes. We discarded the platelet-poor plasma
that accumulated at the top of the tubes and collected the PRF
from roughly 2 mm below its contact point with the red cor-
puscles to include any remaining platelets.15 A clot of PRF,
which was produced in a 10 ml tube, was enough to fill the
socket of each patient.
Operation
Patients had a radiological examination, including panoramic
radiography, and all were treated by the same surgeon and
assistant under local anaesthesia. A triangular incision was
Please cite this article in press as: Bilginaylar K, Uyanik LO. Evaluation of the effects of platelet-rich fibrin and piezosurgery on outcomes
after removal of ımpacted mandibular third molars. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.03.016
used to avoid involvement of muscle (Archer flap). Nerve
blocks to the inferior alveolar, lingual, and buccal nerves con-
tained 0.012 mg/ml adrenaline hydrochloride and 40 mg/ml
articaine hydrochloride (2 ml Ultracaine® D-S Forte Ampul,
Sanofi Aventis). After raising a full-thickness mucoperiosteal
flap, the surgeon used an identical approach during both types
of operation, changing only the instruments. Osteotomies
in the control group were made with a 1.6 mm round
bur mounted on a surgical high-speed hand piece (W&H
Implantmed, W&H, St Albans, UK) at 40 000 rpm under
abundant irrigation. All parts of the tooth were loosened
with a lever and removed. In the second group, osteotomies
were made with a bur, and PRF was placed in the extrac-
tion socket. In the third group, a piezoelectric device (Piezon
Master Surgery® , EMS Electro Medical Systems, Nyon,
Switzerland) was used with an SL 2 cutting insert. In the
fourth group, piezosurgery was used and PRF was placed in
the extraction socket.
In all cases, the residual cavity was cleaned with sterile
physiological saline solution that contained no antibacte-
rial agents. Wounds were closed with 3-0 silk sutures (4
stitches) that were removed after 7 days. A gauze pack was
pressed against the surgical site for the patient to bite on
for 30 minutes, and an icepack was applied to the surgi-
cal area for 6 hours (15 minutes on and 15 minutes off). No
patients had had pharmacological treatment or antibiotics
before operation. They were all told to have a soft and cold
diet for 24 hours, and were prescribed amoxicillin 500 mg
3 times/day for 5 days and an antiseptic (7.5% povidone-
iodine) mouthwash 3 times/day for 7 days. They were also
advised to take paracetamol 500 mg as required (500 mg
every 4-6 hours).
Evaluation
We assessed pain postoperatively using a visual analogue
scale (VAS) (0: no pain to 100: severe pain),16 and recorded
the number of analgesic tablets taken. We assessed trismus
by measuring the distance between the mesial incisal cor-
ners of the upper and lower right incisors during maximum
mouth opening as described by Üstün et al,17 and recorded
swelling using the modified method by Gabka and Mat-
sumara described by Üstün et al.17,18 Three preoperative
measurements between 5 reference points: tragus to soft tis-
sue pogonion, lateral corner of the eye to the angle of the
mandible, and tragus to the outer corner of the mouth, were
repeated on postoperative days 1, 2, 3, and 7. The sum of the
3 preoperative measurements was taken as the baseline for
that side, and the difference between each postoperative mea-
surement and the baseline gave the value for facial swelling
and trismus on that day.17 Daily changes were recorded as
a percentage. The operating time was considered to be the
period between the first incision and termination of suturing.
Patients were seen on each of the 4 postoperative days, and
all measurements were assessed by the same person (not the
operating surgeon), at roughly the same time of day.
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Statistical analysis Duration

The normality of the data was tested with Shapiro Wilk’s test.
When data were normally distributed (p > 0.05), a one-way
ANOVA test was used to compare differences between more
than two independent variables. If the results were significant
(p < 0.05), Dunnett’s test was used to compare the differences
between the control and other groups. When the data were
not normally distributed (p < 0.05), the Kruskal-Wallis test
was used because it corresponds to the one-way ANOVA test
in non-parametric tests. If results were significant, the Mann-
Whitney U test with the Bonferroni correction was used for
pairwise comparisons of differences between the control and
other groups (this correction is used for a bilateral compari-
son whenever the interaction number is greater than 2). The
chi square test was used to compare categorical variables.
Probabilities of less than 0.05 were accepted as significant.
Statistical analyses were done using the R statistical software
package (version 2.14.0)
Results
All patients tolerated the medication well, and there were
no serious complications (alveolitis, paraesthesia, infection,
or side effects). Differences in mean ages between the
groups were not significant (A: 22.50; B: 21.75; C: 21.55;
and D: 22.15) (F(3,76)=0.562, p = 0.64). The sex distri-
butions of the groups were similar (x2 = 2.631, p = 0.452,
df = 3).
There was no significant difference in operating time among
the groups. Extractions took a mean (SD) of 22.83 (10.95)
minutes in the control group, 21.97 (9.30) in the tradi-
tional with PRF group, 27.31(16.21) in the piezosurgery
group, and 32.42(16.20) in the piezosurgery with PRF group
(F(3,76) = 2.516, p = 0.065).
Pain
There were significant differences in the total VAS pain scores
(sum of values on days 1, 2, 3, and 7) between the control and
traditional with PRF groups (p = 0.001) and between the con-
trol and piezosurgery with PRF groups (p = 0.0001), but not
between the control and piezosurgery only groups (Table 1).
There were significant differences between the scores of the
control and traditional groups, and between those of the con-
trol and piezosurgery with PRF groups on days 1, 2, and 3,
and between the control and piezosurgery only groups on day
3 (p = 0.041) (Table 2).
There was a significant difference in the total number of
analgesic doses taken (sum of days 1, 2, 3, and 7) between
the control and traditional groups, (p = 0.017), and between
the control and piezosurgery with PRF groups (p = 0.009),
but not between the control and piezosurgery only groups
(Table 3). The mean number of analgesic doses taken was sig-
nificantly different between the control and traditional groups
and between the control and piezosurgery with PRF groups
on days 2 and 3, and between the control and piezosurgery
only groups on day 3 (p = 0.01) (Table 4).

Side of operation Trismus and swelling

A similar number of sides were operated on (A: 10 left, 10 There were no significant differences in the extent of tris-
right; B: 8 left, 12 right; C: 8 left, 12 right, and D: 13 left, 7 mus or swelling between the control and other groups
right) (x2 = 3.352, p = 0.340, df = 3). (Tables 5 and 6).

Table 1
Comparison of total visual analogue scale (VAS) pain scores between the control and other groups (sum of days 1, 2, 3, and 7) (20 patients in each group).
Groups Range Mean (SD) F p Dunnett (p)
Control (A) 12.0–149.5 72.30 (38.94) - - 0.001 (A–B)
Traditional+PRF (B) 3.50–79.5 30.28 (22.75) 8.647 0.0001 0.06 (A–C)
Piezosurgery (C) 12.5–106.0 51.13 (16.76) - - 0.0001 (A–D)
Piezosurgery+PRF (D) 0–121.0 32.95 (27.30) - - -

PRF: platelet-rich fibrin.

Table 2
Comparison of visual analogue scale (VAS) pain scores on days 1, 2, 3, and 7 between the control and other groups (n = 20 patients).
Day Control group Traditional+PRF group Piezosurgery group Piezosurgery +PRF group

Mean (SD) Mean (SD) p value Mean (SD) p value Mean (SD) p value
1 43.05 (19.70) 22.93 (17.05) 0.004 38.45 (24.14) 0.068 19.75 (15.59) 0.0001
2 19.20 (16.67) 5.98 (6.09) 0.01 9.68 (10.18) 0.056 8.55 (10.01) 0.032
3 9.85 (10.52) 1.30 (2.70) 0.0001 3.00 (2.75) 0.041 2.27 (3.58) 0.002
7 0 0 - 0 - 0 -

PRF: platelet-rich fibrin.

Please cite this article in press as: Bilginaylar K, Uyanik LO. Evaluation of the effects of platelet-rich fibrin and piezosurgery on outcomes
after removal of ımpacted mandibular third molars. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.03.016
YBJOM-4833; No. of Pages 5
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4 K. Bilginaylar, L.O. Uyanik / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx

Table 3
Comparison of the total number of analgesic doses taken between the control and other groups (sum of days 1, 2, 3, and 7) (n = 20 patients in each group).
Group Range Mean (SD) X2 p Z p
Control (A) 3.0–20.0 9.45 (5.36) - - -2.382 (A–B) 0.017 (A-B)
Traditional+PRF (B) 1.0–10.0 5.75 (3.06) 9.415 0.024 -1.659 (A–C) 0.097 (A-C)
Piezosurgery (C) 0.0–10.0 6.7 (4.07) - - -2.60 (A–D) 0.009 (A-D)
Piezosurgery+PRF (D) 1.0–15.0 5.0 (3.34) - - - -

PRF: platelet-rich fibrin.

Table 4
Comparison of the number of analgesics taken on days 1, 2, 3, and 7 between the control and other groups (n = 20 patients in each group).
Day Control group Traditional+PRF group Piezosurgery group Piezosurgery+PRF group

Mean (SD) Mean (SD) p value Mean (SD) p value Mean (SD) p value
1 4.60 (2.23) 4.05 (1.76) 0.721 4.35 (2.34) 0.961 3.35 (1.63) 0.133
2 2.60 (2.11) 1.30 (1.38) 0.031 1.6 (1.46) 0.124 1.2 (1.23) 0.018
3 1.8 (1.47) 0.35 (0.81) 0.0001 0.75 (1.41) 0.01 0.40 (0.75) 0.001
7 0 0 - 0 - 0 -

PRF: platelet-rich fibrin.

Table 5
Comparison of trismus on days 1, 2, 3, and 7 among groups. Data are mean (SD) percentage (n = 20 patients in each group).
Day Control group Traditional+PRF group Piezosurgery group Piezosurgery +PRF group p value
1 25.99 (17.67) 17.97 (17.28) 14.74 (14.52) 13.66 (13.93) 0.07
2 19.93 (16.94) 15.59 (14.85) 12.54 (11.57) 10.96 (10.34) 0.358
3 15.86 (15.51) 12.06 (12.94) 7.34 (9.93) 7.11 (8.19) 0.160
7 7.75 (12.21) 5.69 (8.14) 2.42 (4.64) 1.73 (4.48) 0.458

PRF: platelet-rich fibrin.

Table 6
Comparison of swelling on days 1, 2, 3, and 7 among groups. Data are mean (SD) percentage (n = 20 patients).
Day Traditional group Traditional+PRF group Piezosurgery group Piezosurgery+PRF group p value
1 2.98 (1.80) 2.36 (1.28) 2.64 (1.49) 2.30 (1.22) 0.452
2 2.44 (1.51) 1.86 (1.07) 2.19 (1.57) 1.85 (1.08) 0.437
3 1.65 (1.26) 1.06 (0.77) 1.20 (1.04) 1.24 (1.00) 0.179
7 0 0.01 (0.06) 0 0 0.392

PRF: platelet-rich fibrin.

Discussion possibly because our method of calculation (percentage of

A VAS is a reliable, sensitive, and straightforward way
to record pain after oral operations.3–5,8,11,17,19 Many
authors have reported that use of PRF effectively reduces
pain,6,10,11,20–22 but further studies are needed to discover
the mechanism by which this occurs.
Kumar et al23 reported that, according to VAS results,
patients treated with PRF had significantly less pain than
those in the control group the day after impacted mandibular
third molars had been removed (patients were evaluated and
compared on the first postoperative day, and at one month and
3 months). Our results for pain were similar on the first post-
operative day, but we found no difference in swelling between
the PRF and control groups. This could be because we used
a tape measure to measure the swelling. Unlike Kumar et
al, we found no significant difference in trismus on day one,
restriction compared with maximal opening) was different.
We found significant differences in pain and in the num-
ber of analgesics taken between the control and piezosurgery
groups on day 3 only. The mean total pain scores and total
number of analgesic doses taken, and the values for trismus
and swelling, were lower in the piezosurgery group than in
the control group, but not significantly so. Our findings for
pain, oedema, and trismus were similar to those of Sivolella
et al.7
Our data agreed with those of Barone et al5 who reported
no significant difference in pain on days 1, 3, 5, and 7
between the piezosurgery and control groups. Their findings
for swelling on days 1, 3, and 7 also agreed with our data.
However, contrary to our results, they reported significant dif-
ferences in the total number of analgesic doses over 7 days,
and in trismus on days 1, 3, and 7.

Please cite this article in press as: Bilginaylar K, Uyanik LO. Evaluation of the effects of platelet-rich fibrin and piezosurgery on outcomes
after removal of ımpacted mandibular third molars. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.03.016
YBJOM-4833; No. of Pages 5
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K. Bilginaylar, L.O. Uyanik / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Pain and the number of analgesics taken were significantly
reduced when PRF was used with traditional techniques or
with piezosurgery.
Conflict of Interest
We have no conflict of interest
Ethics statement/confirmation of patient permission
All of the patients were told about the operation, healing
time, and possible complications. The protocol design was
approved by the local ethics committee.
All participants provided written informed consent.
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