Optimizing the outcomes of third molar extraction: topical ozone vs PRF

The extraction of impacted mandibular third molars, particularly in Class II and Division B positions according to the Pell and Gregory classification, systematically exposes patients to predictable postoperative morbidity: pain, oedema, and trismus. While these complications are inherent to the surgical procedure, reducing their intensity and accelerating mucosal revascularization remain major clinical objectives for the implantologist and the oral surgeon.

This study, conducted over a two-year period at Gaziantep University, evaluated the efficacy of two adjuvant protocols in 120 patients. The specific objective was to compare the impact of topical ozone application and intra-alveolar placement of platelet-rich fibrin (PRF) on postoperative recovery kinetics.

The hypothesis tested was based on the ability of these two alternatives to significantly improve clinical parameters compared to a control group without adjuvant. The researchers notably analyzed whether ozone and PRF could differently modulate mucosal blood flow (measured by Laser Doppler flowmetry), the healing score (LTH), as well as linear measurements of edema and maximum mouth opening at D3 and D7.

Experimental protocol and study methodology

This retrospective study, conducted over a two-year period at Gaziantep University, analyzed data from 120 patients presenting an impacted third molar (Class II, Division B according to the Pell & Gregory classification). All patients underwent a routine surgical protocol before receiving, according to their choice, a specific postoperative procedure. The data were then divided into three groups of 40 subjects each:

• Ozone Group (n = 40): Topical application of ozone (31 women, 9 men, mean age 21.83 years).
• PRF Group (n = 40): Intra-alveolar application of platelet-rich fibrin (29 women, 11 men).
• Control Group (n = 40): No adjuvant therapy (28 women, 12 men).

Clinical follow-up was rigorously documented preoperatively, then at 3 days (D3) and 7 days (D7) postoperatively, using the following parameters:

• Pain: Evaluated by a visual analogue scale (VAS).
• Oedema: Measured by facial linear measurements.
• Trismus: Evaluation of maximum mouth opening.
• Mucosal blood flow: Measured by Laser Doppler Flowmeter.
• Healing: Wound assessment using the LTH score.

Statistical analysis compared the relative efficacy of ozone and PRF against the control group to identify the specific benefits of each approach on tissue recovery and patient comfort.

Results: Ozone vs PRF, distinct benefits

The analysis of the data collected from the 120 patients (divided into three groups of n=40) demonstrates that the topical application of ozone and the use of intra-alveolar PRF significantly improve postoperative outcomes compared to the control group (p < 0.050). Although both protocols are beneficial, the study highlights a specialization of effects depending on the technique used.

Inter-group comparisons and healing kinetics

Linear measurements of facial edema and Laser Doppler flowmetry readings reveal a marked superiority of PRF in vascular dynamics and soft tissue volumetric management. Specifically, the PRF group showed a significant advantage in mucosal healing and edema reduction compared to the ozone group (p < 0.050).

Conversely, topical ozone proved more effective for immediate patient comfort. Visual Analogue Scale (VAS) scores and maximum mouth opening measurements indicate that ozone more effectively reduces pain and trismus during the initial healing period (D3) compared to PRF.

• At D3 and D7: Both experimental groups maintain statistically better clinical values than the group without adjuvant treatment.
• Blood flow: PRF promotes faster revascularization at the surgical site, confirmed by mucosal flow measurements.
• Tissue healing: The LTH (Landry, Turnbull and Heasman) score validates superior mucosal closure quality in the PRF group.

Analysis of the clinical benefits of ozone and PRF

This retrospective study conducted on 120 patients demonstrates that the application of topical ozone and intra-alveolar PRF significantly improves postoperative outcomes compared to natural healing (p < 0.05). However, the benefits diverge depending on the chosen modality. Topical ozone is distinguished by superior efficacy in managing pain (VAS) and trismus during the early healing phase. For the practitioner, this suggests a rapid analgesic and muscle-relaxing effect, ideal for patients particularly anxious about immediate postoperative comfort.

Conversely, intra-alveolar PRF shows a marked superiority in tissue reconstruction parameters. The results indicate better mucosal healing (LTH score), a greater reduction in oedema, and an increase in blood flow measured by Laser Doppler. These data confirm the role of PRF as a growth factor concentrator facilitating angiogenesis and clot stabilisation, critical elements for preventing alveolar complications.

A notable limitation of the study lies in the selection protocol: although the final distribution was randomized, the initial choice of options was offered to the patients, which may introduce selection bias. Nevertheless, the robustness of the measurements (n=40 per group) confirms that ozone and PRF are not redundant but complementary: one acts on the symptom, the other on the biological repair process.

Concretely, for the practitioner:

• Prioritize topical ozone to improve immediate patient comfort, especially if you are aiming for a rapid reduction in trismus and pain scores (VAS) from the very first days.
• Insert intra-alveolar PRF for complex cases where the risk of edema is high and where rapid revascularization of the mucosa is necessary to secure healing.
• Consider complementarity: the study suggests that ozone is more effective at treating early functional symptoms, while PRF promotes tissue regeneration; combined use could offer the best overall recovery profile.

Technical Lexicon

Pell & Gregory Classification: Evaluation system for the position of an impacted third molar based on its depth and the available retro-molar space (class II-B indicates a position partially buried below the occlusal level).

Topical ozone: Application of triatomic oxygen used in oral surgery for its disinfecting properties and its ability to stimulate local cellular metabolism.

PRF (Platelet-Rich Fibrin): Second-generation platelet concentrate obtained by blood centrifugation, forming a fibrin matrix rich in growth factors.

Laser Doppler Flowmeter: Non-invasive measuring instrument using laser light to evaluate blood microcirculation within the gingival mucosa.

LTH Score: Soft tissue healing index (Landry, Turnbull, Heasman) evaluating clinical criteria such as colour, consistency and epithelialisation.

Trismus: Involuntary contraction of the masticatory muscles limiting mouth opening, common after wisdom tooth surgery.

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