Pathological lesions that develop in the jaws are very common, and odontogenic cysts result from the presence of remnants of epithelium from the development of teeth or inflammatory processes.[1] The lesions may be silent for extended periods but slowly lead to destruction of bone, swelling of the face, movement of the teeth, and pathological fractures in severe cases.[2] The most common types seen in clinical practice are radicular cysts, dentigerous cysts, and odontogenic keratocysts.[2] In a study by Mammadov et al. (2024), the authors analyzed 392 odontogenic cysts, with 57.9% being radicular cysts and 33.17% being dentigerous cysts.[3] It was found that the mandible was involved in 81.54% of cases, which makes it a significant part of odontogenic cystic lesions.[3] Surgical enucleation is still a well-accepted method for appropriate lesions; however, the osseous defect after enucleation poses challenges in terms of bone regeneration and wound healing.[4]

After enucleation of the cyst, the remaining bony cavity spontaneously closes with the formation of blood clots, recruitment of inflammatory cells, angiogenesis, and osteogenesis.[5] However, the regeneration rate depends on the defect size, the anatomical site, patient characteristics, and the condition of adjacent tissues.[4] Larger defects might take longer to heal and may affect the structural integrity in the healing process.[6] A postoperative infection is another major consideration that can lead to wound dehiscence, delayed healing, more pain, and more treatment needs. Gupta et al. (2025) stated that enucleation of maxillomandibular cystic lesions may require a longer time to achieve complete healing, especially if the defect is large.[7] Such obstacles have led to the exploration of some biological adjuncts that may help to increase tissue repair while reducing post-op complications.

Platelet-rich fibrin (PRF) is a second-generation platelet concentrate that is being investigated more and more in oral and maxillofacial surgery due to its relatively easy preparation, biocompatibility, and regenerative potential.[8] It is composed of a three-dimensional fibrin matrix with cells and growth factors, such as platelet-derived growth factor, transforming growth factor-β (TGF-β), and vascular endothelial growth factor (VEGF).[9] In bone and soft tissue healing, these biological components play a role in cellular proliferation, angiogenesis, collagen synthesis, and tissue remodeling.[10] The fibrin network also provides a scaffold that supports cellular migration and organization of the healing wound.[11] Moreover, its leukocytic nature and role in local immunity have also suggested a role in the protection of surgical wounds after operation, which has not yet been clearly demonstrated to improve clinical outcomes in terms of surgical-site infections.[12] PRF is thus a good alternative to improve tooth regeneration after the enucleation of an odontogenic cyst.[13]

Traditionally, enucleation allows for spontaneous bone regeneration, but maximizing postoperative healing is an important clinical goal, especially in cases with significant osseous defects and delayed healing. The biological use of PRF may represent a potential, cost-effective, and accessible adjunct that can enhance the healing environment without the need for synthetic graft materials. Its clinical utility, however, will have to be proven directly against the conventional approach. This is in part because promoting biological mechanisms doesn't necessarily denote measurable improvements in patient outcomes. A combined assessment of bone healing and the risk of postoperative infection could lead to a more complete understanding of the therapeutic effect of PRF and support its use in routine treatment of mandibular cysts. Therefore, the present study aimed to compare bone healing and the incidence of postoperative infection following enucleation of mandibular odontogenic cysts with and without adjunctive application of platelet-rich fibrin.

This comparative prospective clinical study aimed at comparing bone healing and postoperative infection after enucleation of mandibular odontogenic cysts using platelet-rich fibrin (PRF) versus non-PRF. The study was conducted at Abdullah Dental Care, Hayatabad Peshawar, Pakistan during 6 months period from 1^st October 2025 to 31^st March 2026. Patients who had undergone surgical enucleation of odontogenic cysts in the lower jaw (mandible) were assessed and then split into two groups based on whether or not they had received PRF. Group A consisted of patients undergoing conventional cyst enucleation, and Group B consisted of patients undergoing conventional enucleation without PRF application. Primary outcomes were achieved bone healing, secondary outcomes were postoperative surgical-site infection.

The sample size was estimated using the OpenEpi sample-size calculator for comparing two independent means, with a 95% confidence level, 80% statistical power, and a 1:1 allocation ratio. The calculation was made on the basis of the randomized controlled trial carried out by Shokry et al. (2025) that compared bone regeneration after jaw cyst enucleation with and without albumin-enhanced platelet-rich fibrin.[14] The investigators found the increase in the bone density of the intervention group to be 275.5 ± 158.0 grayscale values, whereas the control group had an increase of 188.2 ± 94.99 grayscale values.[14] These values were used in these calculations, and the minimum number of patients required per group was about 36 patients. To account for a possible 10% loss to follow-up, the sample size was set to 80 patients, with 40 patients in each group.

The patients were recruited by a non-probability consecutive sampling method from those who met the inclusion/exclusion criteria during the study period with mandibular odontogenic cysts. Eligible patients were assessed for eligibility and randomized to treatment groups (PRF or conventional treatment). The same clinical examination techniques, postoperative follow-up, and definitions of outcomes were used to assess both groups to allow comparison of bone healing and postoperative infection.

Patients aged 18–60 years, of either gender, with clinically and radiographically diagnosed mandibular odontogenic cysts requiring surgical enucleation were considered eligible for inclusion. Patients needed to have cysts that could be completely enucleated, good overall health to tolerate oral surgery as well as to attend follow-up appointments, and informed consent. Then, those patients whose cysts were confirmed with histopathology were invited for the final assessment. Patients with uncontrolled diabetes mellitus, immunodeficient status, recent (active) systemic infections, bleeding disorders, thrombocytopenia, and history of chemotherapy or radiotherapy in the maxillofacial region were excluded. Patients on anticoagulant therapy, patients with an acute infection at the operative site that requires immediate treatment, patients with recurrent cystic lesions who require more extensive reconstructive surgery, and patients with incomplete follow-up records were also excluded.

Eligibility, demographics, and clinical data were gathered using a structured data collection form after screening for eligibility, age, gender, medical history, cyst location, cyst size, clinical presentation, and relevant radiographic data. An intraoral and extraoral examination was undertaken and preoperative imaging reviewed to determine the extent of the lesions and the relationship with other adjacent anatomical structures. Routine pre-operative investigations were carried out in all patients as needed. Informed consent was obtained in writing prior to surgery. The surgery was done under local or general anesthesia depending on the size and complexity of the lesion. After mucoperiosteal flap elevation, there was adequate exposure of the bone, and the lining of the cyst was carefully stripped and completely excised from the surrounding bone. The excised tissue was sent for histopathological examination.

For Group A, platelet-rich fibrin was made by extracting the patient's own venous blood just prior to surgery. Blood was placed into sterile tubes with no anticoagulants and centrifuged following the standard PRF preparation procedure. The fibrin layer, which was separated from the layer of red blood cells, was transferred into the residual bony cavity after enucleation of the cyst. For Group B, the cavity was allowed to heal naturally by the blood clot without any regenerative material or PRF being used. This site was then closed with suitable sutures. All patients were given the same postoperative instructions and pain medication, oral hygiene, and antibiotic therapy as needed.

Patients were assessed postoperatively on days 3, 7, and 14 and at weeks 4, 8, and 12. Postoperative infection was evaluated clinically as the presence of purulent discharge, increasing swelling, persistent or worsening pain, wound dehiscence with inflammatory signs, or any other evidence of surgical-site infection. The clinical assessment of the presence or absence of infection was used to define the binary outcome and was documented. Bone healing was assessed using standard roentgenograms taken immediately after surgery and at the last follow-up, with the appropriate imaging approach and anatomic landmarks. The changes in the residual bony defect, radiographic bone fill, and evidence of the formation of trabecular bone were evaluated. If clinically available, changes in the volume of the defects were measured using cone-beam computed tomography to calculate the percentage of bone fill. Delayed healing, wound dehiscence, and requirement for further treatment were also documented as postoperative complications.

IBM SPSS Statistics (version 26.0) was used to enter and analyze data. The quantitative variables, such as age, cyst dimensions, baseline defect volume, and percentage of postoperative bone fill, were presented as mean and SD for normally distributed variables. Gender, cyst type, and postoperative infection and wound complications were shown as frequencies and percentages, as they were qualitative variables. The Shapiro–Wilk test was used to assess the normality of quantitative variables. The independent-samples t-test was applied to compare normally distributed continuous variables between the two groups. Changes in radiographic measurements within groups were evaluated using the paired-samples t-test.  Expected cell counts were small, and post-operation infection rates and other categorical outcomes were compared using the chi-square test and fisher's exact test. A p-value < 0.05 was considered statistically significant.

A total of 80 patients were included in the analysis, with 40 patients allocated to the platelet-rich fibrin (PRF) group and 40 to the conventional enucleation group. There were no differences in gender distribution or mean age between the two groups. The majority were aged 31–45 years, and males were slightly more common than females. Medical characteristics at baseline were also similar, with no significant differences between groups (Table 1).

The most common lesions were radicular cysts, dentigerous cysts, and odontogenic keratocysts. Most lesions were found in the back of the lower jaw, and the most common clinical sign was swelling. There were no statistically significant differences in the baseline characteristics of the cyst size, location, anesthesia type, or operation duration between groups (Table 2).

At 12 weeks, radiographic evaluations showed that the PRF group had significantly more bone regeneration than the control group. Patients treated with PRF had a significant decrease in residual defect volume and significantly more bone fill (p<0.01). In addition, favourable trabecular bone formation was more common after PRF application, and this reflected better radiographic healing than was seen with traditional enucleation (Table 3).

Post-operative infection was observed with a lower incidence in the PRF group compared to the control group (10.0% versus 27.5%), but this was not statistically significant (p=0.083). The majority of infections were detected in the early period (first 2 postoperative weeks). Patients receiving PRF had less purulent discharge, localized erythema, increased swelling, and persistent pain (Table 4), but these differences were not statistically significant.

The postoperative wound healing was significantly better in the PRF group, and the satisfactory healing rate was significantly higher by day 14 (p=0.005). The PRF group reported decreased rates of wound dehiscence, ongoing discomfort, and need for further postoperative treatment; however, these differences were not statistically significant (Table 5).

The mean value of bone fill was significantly higher in the PRF group in all three cyst categories (radicular cysts, dentigerous cysts, and odontogenic keratocysts) when evaluated in subgroups based on cyst type. PRF application was also an apparent reduction in the numbers of infected samples across all three categories of cyst. These results were descriptive, however, and were limited by the small number of subjects available in each subgroup (Table 6).

Table 1. Demographic and baseline clinical characteristics of study participants

Table 2. Clinical, radiographic, and surgical characteristics of mandibular odontogenic cysts

Table 3. Comparison of radiographic bone healing between the PRF and control groups

Table 4. Comparison of postoperative infection between the PRF and control groups

Table 5. Postoperative wound healing and complications

Table 6. Bone healing and infection according to odontogenic cyst type

In the present analysis, it was observed that enucleation of mandibular odontogenic cyst together with PRF yielded better bone regeneration than conventional cyst enucleation. Gupta et al. (2025) noted a significant improvement in bone healing on radiographs in maxillomandibular defects treated with injectable PRF and

hydroxyapatite.[7] Another 2023 randomized trial also showed that PRF application leads to better bone volume and trabecular thickness in third molar extraction sockets.[15] However, Shokry et al. (2025) found no significant difference in bone regeneration between albumin-enhanced PRF and conventional healing following jaw cyst enucleation. The results indicate that the regenerative results may be dependent on the PRF formulation, defect characteristics, and follow-up period.[14]

The findings by Njokanma et al. (2022) on no significant difference in radiographically assessed bone regeneration at the site of PRF placement in third molar sockets in the mandible were in contrast.[16] Likewise, Iftikhar et al. (2024) reported a decrease in the postoperative symptoms but without any significant gains in hard-tissue regeneration.[17] In a systematic review and meta-analysis, Hajibagheri et al. (2025) reported better soft-tissue healing but no significant effect on bone healing.[12] The differences highlight that PRF's regenerative benefits are not seen in all clinical procedures.

Postoperative infection was numerically less frequent in the PRF group, although the difference was not statistically significant. In a systematic review, Ribeiro et al. (2024) reported that the use of leukocyte-rich PRF after third molar surgery resulted in good postoperative healing and reduced incidence of complications, such as infection.[18] Likewise, Davarpanah et al. 2026 reported a decrease in alveolar osteitis after the application of PRF, which is a different condition from surgical-site infection.[19] Hence, the infection difference that was observed should be taken with a grain of salt, and it is not possible to conclude a preventive effect.

The PRF group had a higher frequency of satisfactory wound healing. The findings were similar to Shruthi et al. (2022), who found that PRF application resulted in decreased postoperative pain, swelling, and trismus.[20] In a similar study, Çiftçi Şişman et al. (2026) showed greater early soft-tissue healing and less postoperative pain with the application of injectable PRF after third molar surgery of the mandible.[21] Direct comparisons were limited, however, with the above studies performed over extraction sockets in contrast to odontogenic cyst defects.

Overall, the results indicate that there may be benefits for radiographic bone regeneration and early wound healing in PRF, and there is insufficient evidence on infection after surgery. When interpreting the available literature, differences in surgical procedures, methods of PRF preparation, defect dimensions, and follow-up periods should be taken into consideration. Longer-term, larger, prospective studies with standardized imaging and follow-up time are needed to determine the clinical efficacy of PRF after enucleation of odontogenic cysts in the mandible.

Based on these results, platelet-rich fibrin (PRF) may be beneficial as an adjunct after enucleation of the mandibular odontogenic cyst in terms of bone regeneration and early wound healing. Due to its autologous nature, low cost, and relatively simple preparation, it could be a viable alternative in routine oral and maxillofacial surgery. That being said, the decrease in postoperative infection was not statistically significant, and more clinical data are needed to endorse its routine use.

The study had several limitations: a single-center design, a small number of patients, and a 12-week follow-up period, which may not be long enough to assess complete bone regeneration. Non-probability consecutive sampling and non-randomized group allocation could introduce selection bias and confounding. The size, type, and healing response to the cysts themselves and to the individual may also affect the outcomes. In addition, the low number of postoperative infections did not allow for meaningful differences to be seen between groups.

The application of adjunctive PRF after the enucleation of the mandibular odontogenic cyst led to better bone fill and earlier wound healing than the traditional treatment. The PRF group had fewer postoperative infections, but this difference was not statistically significant. Randomized controlled trials with uniform protocols and extended follow-up periods are warranted to confirm PRF's effectiveness in improving mandibular regeneration and reducing infection risk.

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