## 4 Discussion  
Hyaluronic acid is a biomaterial with complex biological properties that has been investigated for its potential in postoperative wound healing and recovery. Hyaluronic acid (HA) possesses both pro-inflammatory and anti-inflammatory properties. It interacts with the TSG-6 protein, activated by TNF-\(\alpha\), to regulate inflammatory cell activity and stabilize the granulation tissue [20]. While hyaluronic acid promotes inflammation through IL-1, it simultaneously limits it via TSG-6, supporting the maintenance of granulation tissue and suggesting its potential utility in postoperative healing [23; 24]. This dual functionality allows HA to promote inflammation via interleukin-1 (IL-1) while concurrently mitigating excessive inflammatory responses through TSG-6, thereby supporting a balanced inflammatory environment conducive to tissue healing [25]. In the early postoperative period following impacted mandibular third molar surgery, HA administered in spray form has been shown to enhance patient comfort by reducing swelling and trismus, although it does not significantly alleviate pain. These observations are consistent with studies indicating that HA provides some wound healing benefits, though its clinical effects post-surgery tend to be modest [26; 27]. However, our study found that HA did not significantly alleviate pain compared to the control treatment, a result consistent with mixed outcomes reported in the literature [28]. The results of our prospective, double-masked, randomized controlled trial revealed a nuanced picture of HA's clinical utility. Although there were no significant differences between the HA and the control groups overall, the HA group demonstrated a statistically significant improvement in trismus on day 7 (\(p\) = 0.002). This finding aligns with some studies that report limited or transient benefits of HA, indicating that the therapeutic window for HA's effectiveness may be narrow [13; 18; 19; 29]. Regarding swelling and pain outcomes, we found no significant differences between the HA and the control groups during the early postoperative days. Although some studies suggest that topical or injectable HA can reduce edema and pain by modulating the inflammatory response, our data did not show a meaningful advantage over conventional care [26]. One possible explanation is that the effective management of early postoperative pain with NSAIDs and other analgesics may have obscured any additional analgesic benefits of HA [1]. Moreover, the study's statistical power may have been insufficient to detect subtle differences, raising the possibility of type II errors. [PERSON] et al. found lower VAS scores for the HA group (39.2 \(\pm\) 17.4) compared to controls (45.8 \(\pm\) 15.6) on day 1, suggesting that HA may modulate early inflammation, although our study did not show a similar pain reduction [20]. Likewise, [PERSON] et al. reported significantly lower VAS pain scores (\(p\) = 0.001) for sockets treated with 0.8% HA but observed no meaningful differences in swelling or trismus, underscoring HA's potential analgesic effect [21]. [PERSON] et al. similarly noted modest improvements in swelling and trismus, mirroring our day 7 trismus findings; yet, swelling reduction remained insignificant [22]. These mixed results highlight the need for further research to clarify HA's clinical benefits. Primary closure is generally preferred to protect bone and soft tissue after third molar extraction. However, some studies suggest that secondary healing may reduce postoperative swelling and pain [30]. The outcomes can be influenced by the surgical technique, the wound closure method, and the use of biomaterials such as HA. Therefore, future research should systematically compare these factors to determine the most effective approaches. Hyaluronic acid also has bacteriostatic properties at high concentrations, effectively targeting bacteria like _Aggregatibacter actinomycetemcomitants_ and _Prevotella oris_, which are common in gingival lesions and periodontal wounds [31].