The surgical removal of lower third molars is a very common surgical procedure that is associated with postoperative pain, swelling, trismus and other complications such as alveolar osteitis and infection. Platelet-rich fibrin is a biological platelet concentrate rich in growth factors that promote wound healing. A number of studies have been carried out using platelet-rich fibrin in third molar surgery and have shown variable results. The aim of this review was to assess whether platelet-rich fibrin (PRF) reduced postoperative complications following lower third molar surgery.
Searches were conducted in the Cochrane Library, Medline/PubMed, Embase, Scopus and Web of Science databases. This was supplemented by searches in www.opengrey.eu, www.greylit.org, on www.clinicaltrials.gov and the journals, International Journal of Oral and Maxillofacial Surgery, British Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery and Journal of Cranio-Maxillofacial Surgery. Double-blind randomised controlled trials (RCTs) comparing application of PRF against no intervention in patients over 16 years of age were considered. Two reviewers independently screened and selected studies extracted data and assessed study quality using the Cochrane domains-based tool. studies considered to be of good or moderate quality were included in a descriptive synthesis and meta-analysis.
- 6 RCTs were included.
- 4 studies evaluated post-operative pain with a meta-analysis of 3 RCTs showing no statistically significant difference in pain at 1, 3 or 7 days
- 1-day; Mean difference (MD) = -0.65 (95%CI; -1.83 to 0.54)
- 3-days; MD = -0.76 (95%CI; -1.75 to 0.22)
- 7-days; MD = -0.71 (95%CI; -1.79 to 0.38).
- 3 studies reported on alveolar osteitis (AO) with all 3 demonstrating statistically significant reductions in AO although meta-analysis was not possible.
- 3 studies reported on the effect of PRF on post-operative oedema again demonstrating statistically significant reductions, but meta-analysis was not possible.
- Soft tissues healing was also reported in 3 studies using different measurement approaches with divergent findings.
The authors concluded: –
the current systematic review and meta- analysis provides moderate to good evidence that there is a beneficial effect of PRF use to reduce the frequency of AO and an unclear effect on post-operative pain levels, oedema, and wound healing after mandibular third molar surgery. Due to the relatively small number of included clinical studies, it is still not possible to perform a comprehensive evaluation of the effects of PRF after surgical extraction of the mandibular third molar. Future clinical studies should focus on a higher methodological quality to produce reliable and comparable results.
The authors have searched a good range of sources to identify relevant studies. The decided to only include double-blind RCTs and only included studies considered to be of good or moderate quality in the narrative synthesis and meta-analyses. This means that only a small number of studies could be included. It is interesting to note that we recently looked at another review by Bao et al (Dental Elf – 1st Oct 2021) looking at the same topic that included all RCTs without exclusion on quality. The Bao et al review included 10 RCTs only 3 of which are common to both reviews. In our blog on the Bao review we also highlighted an earlier review that considered the use of PRF to improve third molar surgery outcomes. The available reviews are consistent in the finding that PRF derivative may lead to improvements in postoperative outcomes from third molar surgery. However, the studies are generally small and of low quality so in future studies need to be well conducted and reported and of appropriate size and in line with the SPIRT and CONSORT statements to improve the value of research in this area.
Snopek, Z, Hartlev, J, Væth, M, Nørholt, SE. Application of platelet-rich fibrin after surgical extraction of the mandibular third molar: A systematic review and meta-analysis. Oral Surg. 2021; 00: 1– 12. https://doi.org/10.1111/ors.12681
Dental Elf – 1st Oct 2021