J Oral Maxillofac Surg

68:319-324, 2010

Use of Therapeutic Laser After Surgical

Removal of Impacted Lower Third Molars
E. Daro Amarillas-Escobar, DDS,*
J. Martin Toranzo-Fernndez, DDS,
Ricardo Martnez-Rider, DDS, Miguel A. Noyola-Fras, DDS,
J. Antonio Hidalgo-Hurtado, DDS, Vctor M. Fierro Serna, DDS,
Antonio Gordillo-Moscoso, MD, PhD,# and
Amaury J. Pozos-Guilln, DDS, PhD**
Purpose: To evaluate the effectiveness of a therapeutic laser in the control of postoperative pain,

swelling, and trismus associated with the surgical removal of impacted third molars.
Patients and Methods: A double-blind, randomized, controlled clinical trial was conducted in 2 groups of
15 patients each undergoing surgical removal of impacted lower third molars under local anesthesia. The
experimental group received 4 J/cm2 of energy density intraorally and extraorally, with a laser with a diode
wavelength of 810 nm and output power of 100 mW in a continuous wave. The control group received only
standard management. The degree of postoperative pain, swelling, and trismus was registered for both groups.
Results: The experimental group exhibited a lower intensity of postoperative pain, swelling, and
trismus than the control group, without significant statistical differences. Patients of both groups
required rescue medication; however, the time lapse between the end of the surgery and the administration of the medication was shorter for the control group.
Conclusion: The use of therapeutic laser in the postoperative management of patients having surgical
removal of impacted third molars, using the protocol of this study, decreases postoperative pain,
swelling, and trismus, without statistically significant differences.
2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:319-324, 2010
12 to 48 hours, resolving between the fifth and seventh days.4 Several studies have shown that therapeutic laser evokes cellular bio-stimulation, helping to
accelerate tissue regeneration and wound healing and
decrease pain and swelling.5
The biological effects of laser were first studied in
1967 by Inyushin,6 and the laser therapy concept

Third molar surgery is the most common procedure

performed by oral and maxillofacial surgeons. The
surgical trauma of this procedure causes postoperative pain, swelling, and trismus.1 The pain reaches
maximum intensity 3 to 5 hours after surgery, continuing for 2 to 3 days, and gradually diminishing until
the seventh day.2,3 Swelling reaches peak intensity in
*Resident, Service of Oral and Maxillofacial Surgery, Hospital
Central, Dr. Ignacio Morones Prieto, San Luis Potos, Mexico.
Professor and Head, Service of Oral and Maxillofacial Surgery,
Hospital Central Dr. Ignacio Morones Prieto, San Luis Potos, Mexico.
Professor and Head, Department of Oral and Maxillofacial Surgery, Facultad de Estomatologa, Universidad Autnoma de San
Luis, Potos, San Luis Potos, Mexico.
Associate Professor, Department of Oral and Maxillofacial Surgery, Facultad de Estomatologa, Universidad Autnoma de San
Luis, Potos, San Luis Potos, Mexico.
Associate Professor, Department of Oral and Maxillofacial Surgery, Facultad de Estomatologa, Universidad Autnoma de San
Luis, Potos, San Luis Potos, Mexico.
Associate Professor, Department of Oral and Maxillofacial Surgery, Facultad de Estomatologa, Universidad Autnoma de San
Luis, Potos, San Luis Potos, Mexico.

#Associate Professor, Clinical Epidemiology Postgraduate Program, Facultad de Medicina, Universidad Autnoma de San Luis
Potos, Mxico.
**Associate Professor, Department of Oral and Maxillofacial Surgery, Facultad de Estomatologa, Universidad Autnoma de San
Luis, Potos, San Luis Potos, Mexico.
Address correspondence and reprint requests to Dr PozosGuilln: Facultad de Estomatologa, Universidad Autnoma de San
Luis Potos, Av Dr Manuel Nava #2, Zona Universitaria, CP 78290,
San Luis Potos, SLP Mexico; e-mail: apozos@uaslp.mx
2010 American Association of Oral and Maxillofacial Surgeons

0278-2391/10/6802-0014$36.00/0
doi:10.1016/j.joms.2009.07.037

319

320
began in 1971 when Mester applied it to accelerate the
healing of chronic ulcers.7 Since then, it has been used
for the treatment of a wide variety of disorders including
carpal tunnel syndrome, rheumatoid arthritis, osteoarthritis, tendinopathy, ankle sprains, epicondylitis, lumbalia, and nonhealing ulcers, among others.8
Laser therapy is still experimental; however, good
results have been reported in the treatment of dentin
hypersensitivity,9 temporomandibular joint disorders,10 paresthesia of the inferior alveolar nerve after
third molar surgery11 and sagittal split osteotomy,12 trigeminal neuralgia, herpes labialis,13 aphthous ulcers,
alveolitis,14 and mucositis after chemotherapy or radiotherapy,15 among others. The Food and Drug Administration has approved its use only in carpal tunnel syndrome and mild chronic neck and shoulder pain of
musculoskeletal origin.5 Recent in vitro and in vivo studies of photoactivated disinfection of root canals have
demonstrated the effectiveness of this therapy.13
In animal models, it has been shown to promote
osteoblastic activity and bone regeneration around
osseointegrated implants, evidenced by a larger number of viable osteocytes in the implant interfaces.16
Lasers have also been reported to accelerate bone consolidation after mandibular distraction osteogenesis.8
Further, they have been favorably used in vivo in the
treatment of bisphosphonate-associated necrosis of the
jaws17 and to decrease pain and swellingpossibly to
accelerate postextraction bone regeneration.5
In vivo and in vitro studies have demonstrated their
possible utility in regenerating the periodontal ligament after subgingival curettage, as demonstrated by
the proliferation of fibroblasts. In vitro studies have
also suggested the destruction of bacteria in periodontal pockets.18 According to Brugnera et al,14 the cells
have an improved response threshold to laser stimuli
with doses from 4 to 6 J/cm2 (optical window).
Contraindications to laser therapy depend on its possible bio-stimulation effect and its possible effects on
benign and malignant cells of a specific area. Absolute
contraindications are danger of eye and thyroid gland
irradiation; patients with a malignant neoplasm, cardiac
pacemaker, or epilepsy; and pregnancy. Relative contraindications are local infection, blood disease, photosensitive skin or use of drugs that cause photosensitivity,
and chance of irradiating the gonads.16,19
The aim of this study was to evaluate the effectiveness of the therapeutic laser in the control of pain,
swelling, and trismus associated with surgical removal
of impacted lower third molars.

Patients and Methods

PATIENTS

Thirty patients older than 18 years were recruited

into the study from the Department of Maxillofacial

THERAPEUTIC LASER AFTER SURGERY

Surgery at San Luis Potos University. A double-blind,

randomized, controlled clinical trial was conducted in
accordance with the Declaration of Helsinki, and the
ethics committee of the Faculty of Dentistry approved
the study design. All subjects were informed of the
risks of oral surgery and experimental treatment, and
they signed an institutionally approved consent form.
The 30 patients meeting the inclusion criteria had
the following characteristics: male or female gender,
18 to 30 years of age, healthy, impacted lower third
molar(s), and surgical difficulty grades II to IV. Exclusion criteria included contraindications to laser therapy, systemic illness, local infection, tobacco use, oral
contraceptives use, pregnancy, and lactation.
STUDY DESIGN

This investigation was a double-blind, randomized,

controlled clinical trial conducted in patients after
extraction of an impacted mandibular third molar.
Patients were assigned sequential numbers in the order of enrollment and received their allocated treatment according to a computer-generated randomization schedule prepared before start of the study.
Patients were randomized into 2 treatment groups,
each with 15 patientsan experimental group (laser)
and a control group (nonlaser)and were told to
avoid any analgesics 12 hours before the procedure.
The experimental group received laser therapy, and
the control group only routine management. After
surgery, the laser was applied intraorally, using a
punctal technique, at 1 cm from the involved area.
Extraoral laser was then instituted 24, 48, and 72
hours postsurgically, using a zonal technique and irradiating 6 points distributed 3 cm apart along 2
imaginary lines, one extending from the tragus to the
outer corner of the mouth and the other from the
earlobe to soft tissue pogonion (Fig 1). A therapeutic
laser with an 810-nm wavelength diode (Quantum IR
810; Laser Systems, Queretaro, Mexico) and a power
output of 100 mW in continuous mode and administering 4 J/cm2 was applied at each point. Dexamethasone 4 mg intramuscularly was administered to all
patients 1 hour before surgery. Postoperatively, they
received amoxicillin 750 mg orally every 12 hours for
5 days, acetaminophen 500 mg orally every 6 hours
for 3 days, andin case of intense pain ketorolac 30
mg as rescue medication.
All surgical procedures were carried out by the
same surgeon; evaluation was done by an independent investigator. In each procedure, 1 partial or full
bony impacted mandibular third molar was extracted
under local anesthesia consisting of a nerve block of
the inferior alveolar and buccal nerves with 2 1.8-mL
capsules of 4% articaine containing 1:100,000 epinephrine (Medicaine; Septodont, Saint Maur des Fosses, France). A mucoperiosteal flap was created by

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AMARILLAS-ESCOBAR ET AL

mouth opening, preoperatively and at 24, 48, and 72

hours and on the seventh day. Distances between the
tragus and outer corner of the mouth, tragus and soft
tissue pogonion, angle of the mandible and lateral
corner of the eye, anda fourth measurement we
proposeangle of the mandible and outer corner of
the mouth were registered. Intraoperative and postoperative complications were registered.
STATISTICAL ANALYSES

For statistical analysis and comparison among groups

for continuous variables, the Wilcoxon test was used,
and for categorical variables Fisher exact test was employed. A P value less than .05 was considered statistically significant.

Results

FIGURE 1. Points irradiated with zonal technique.

Amarillas-Escobar et al. Therapeutic Laser After Surgery. J Oral
Maxillofac Surg 2010.

making an incision distal to the lower second molar

along the anterior edge of the mandibular ramus. This
flap was used to close the surgical wound. Suturing
was done with 4-0 silk. The difficulty of the extraction
procedure was evaluated based on a modified scale of
Prant: grade I, extraction with forceps only; grade II,
extraction by osteotomy; grade III, extraction by osteotomy and coronal section; and grade IV, complex
extraction. In all cases, duration of the operation
(from incision to final suture) was recorded.
ASSESSMENTS

A horizontal, 10-cm visual analog scale was used to

assess pain at 6, 24, 48, and 72 hours, ranging from 0
(without pain) to 10 (very intense pain). The level of
facial swelling was evaluated by the method used by
stn et al20 and trismus, by measuring the maximum

Demographic characteristics of the sample were

similar between the 2 treatment groups for age and
gender. Variables describing the difficulty of the surgical procedure such as duration of operation and
surgical difficulty were also similar between groups
(Table 1).
Intensity of pain was lower in the laser group than
in the nonlaser group in all evaluations, but without
statistically significant differences (P .05). In each
study group, 4 patients used rescue medication; however, the time for the rescue medication after surgery
showed significant statistical differences (P .05,
Wilcoxon test; Table 2).
The laser group presented less swelling than the
nonlaser group in all evaluations, but without significant statistical differences (P .05; Fig 2).
The extent of oral opening was greater in the laser
group than in the nonlaser group in all evaluations,
but without significant statistical differences (P .05;
Fig 3).

Discussion
Controversies over bio-stimulation of tissue induced by laser therapy still exist. A lack of uniform

Table 1. SUMMARY OF DEMOGRAPHIC AND SURGICAL VARIABLES

Group

Sample Size

Laser
Nonlaser
P value

15
15

Median Age
(Range)

Female/Male

Surgical Difficulty:
Grades I/II/III*

Duration of
Surgery (Range)

21.6 (19-23)
21.5 (18-27)
.46

12/3
7/8
.06

0/4/11
1/7/7
.26

7.4 (5-10)
7.3 (5-11)
.86

*Grade I, extraction with forceps only; grade II, extraction by osteotomy; grade III, extraction by osteotomy and coronal
section; grade IV, complex extraction.
Duration of operation in minutes.
Amarillas-Escobar et al. Therapeutic Laser After Surgery. J Oral Maxillofac Surg 2010.

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THERAPEUTIC LASER AFTER SURGERY

Table 2. INTENSITY OF PAIN AND TIME OF RESCUE MEDICATION

Median VAS (mm)

Rescue Medication

Group

3h

6h

24 h

48 h

7d

Frequency

Median Time (h) (range)

Laser
Nonlaser
P value

17.9
22.0
.05

17.4
19.0
.05

2.3
4.6
.05

3.9
4.4
.05

1.2
2.8
.05

4
4
.05

11.7 (4-17)
4.2 (3-5)
.05

Abbreviation: VAS, visual analog scale.

Amarillas-Escobar et al. Therapeutic Laser After Surgery. J Oral Maxillofac Surg 2010.

reporting of physical and biological variables such as

type of laser, output power (continuous or pulsed),
frequency of pulse, wavelength, time and mode of
application, distance of source from irradiated tissue, and histologic tissue differences and absorption characteristics make standardization of results
difficult.
All references to the use of laser therapy in the
postoperative management of third molar surgery employ different methodologies and, in some, explanations as to selection of their respective radiation parameters are not given. Carrillo et al21 divided patients
having extraction of lower third molars into 3 groups:
those receiving laser radiation helium-neon 633 nm
with 10-J/cm2 energy density, those receiving ibuprofen, and a control group. There were no differences in
pain and swelling levels between the laser and placebo groups in the first 4 hours, but the laser and
ibuprofen groups showed significant reduction of trismus on the seventh day compared with the placebo
group. Taube et al22 evaluated the local effect of soft
laser therapy (helium-neon 8 mW, 50 Hz) on postoperative pain, after removal of both lower third molars
with similar impaction characteristics, applying it for
2 minutes at one of the surgical sites. No statistically

significant differences in pain level occurred between

the 2 sides.
Wahl and Bastnier23 applied a laser helium-neon
after surgery and at 24, 48, and 72 hours. They reported reduction of pain in the experimental group in
all evaluations, but without statistically significant differences. Information on the quantity of energy applied was not given. Roynesdal et al24 carried out
extraction of both lower third molars similarly impacted in 2 separate operations, irradiating unilaterally with a 6-J semiconductor laser at 830 nm, 40 mW,
and found pain reductionand decreases in swelling
and trismusat 9 hours, without statistically significant differences. Fernando et al25 carried out extraction of both lower third molars similarly impacted,
using a laser semiconductor at 830 nm, 30 mW, with
application intraorally at 4 J, at each surgical site in
the experimental group. They reported pain and
swelling levels at 24 and 72 hours and on the seventh
day, in addition to wound healing. There were no
differences between groups in pain and swelling levels at 72 hours, or in wound healing. Neckel and
Kukizl26 studied 2 groups that underwent extraction
of a lower third molar, applying 11 J/cm2 of energy
with a laser diode at 810 nm intraorally at the surgical

stn et
FIGURE 2. Swelling as measured by the method used by U
al.20 Data are expressed as medians.

FIGURE 3. Comparison of oral opening laser and nonlaser

groups. Data are expressed as medians.

Amarillas-Escobar et al. Therapeutic Laser After Surgery. J Oral

Maxillofac Surg 2010.

Amarillas-Escobar et al. Therapeutic Laser After Surgery. J Oral

Maxillofac Surg 2010.

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AMARILLAS-ESCOBAR ET AL

site. They recorded the number of days and levels of

postoperative pain. Statistical evaluation revealed significant differences, ie, lower pain levels and duration
in the experimental group compared with the control
group.
Markovic et al2 evaluated postoperative pain in 3
groups: the first group received laser gallium:aluminum:arsenic 637 nm, 50 mW, at the surgical site, 4
J/cm2 for 10 minutes; the second group received
diclofenac 100 mg 1 hour preoperatively; and the
third was the control group. All patients had 1 of their
lower third molars extracted, and a single evaluation
found statistical differences in the reduction of pain in
the laser group compared with the diclofenac and
control groups. Based on the same extraction protocol, these investigators then used 4 groups to compare the effectiveness of laser against dexamethasone.
Group 1 received 4 J/cm2 of laser (gallium:aluminum:
arsenic, 637 nm, 50 mW) at the surgical site; group 2,
the same laser dose plus an injection of dexamethasone 4 mg in the internal pterygoid muscle; group 3,
the same laser dose plus dexamethasone 4 mg intramuscularly and 4 mg intraorally 6 hours postoperatively; and group 4 was the control group. A single
evaluation the following day found a significant reduction of swelling in all groups that received laser therapy compared with the control group; the group
receiving laser and local dexamethasone exhibited
even better results.4
The methodologies and results of these diverse
studies are too varied to define the ideal parameters
for use of the therapeutic laser or to evaluate its
clinical effectiveness. In this study, several daily doses
of therapeutic laser were applied intra- and extraorallysomething not done in previous studies
with the intention of finding out if the accumulative
effect was favorable. Although the results indicate
that the proposed method reduces pain, swelling, and
trismus, the differences were not statistically significant compared with a control group.
We estimated a post hoc (and a posteriori) sample
size calculation considering data obtained in this
study using a method for sample size calculation to a
repeated measurements approach in clinical trials.
Trismus results were considered with 5 time points
(0, 6, 24, 48, and 72 hours), 0.05 and 1-P .2,
using a correlation of 0.6025 and variance of 82.39.
According to this, 13 individuals are needed in each
group. So, in concordance with previous works, the
nondifferent results between groups are not explained
by sample size. In contrast, the use of therapeutic laser
after surgical removal of impacted lower third molars
did not result in a significant decrease in postoperative
pain, edema, and trismus compared with the control
group. However, in patients who required rescue medication, the time to medication request was significantly

shorter for the control group. A possible reason to explain the lack of response to treatment can be the high
technical difficulty of the surgical approach; most patients included in this study required extraction by osteotomy and coronal section.
Acknowledgment
We thank Norman Wahl for his assistance in editing this report.

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