- Email: [email protected]
Suction drainage in the postsurgical treatment of jaw cysts
J Oral Maxillolac Surg 51:630·633.1993
Suction Drainage in the Postsurgical Treatment of Jaw Cysts ERIK HJ0RTING-HANSEN, DDS, DROOONT,* S0REN SCHOU, DDS, PHD,t AND NILS WORSAAE, DDS:f: Intraoral or extraoral closed suction drainage was used following the surgical enucleation of 42 jaw cysts. Primary healing was observed in 38 (90%) of the patients and complete osseous regeneration was achieved in 17 of 30 patients. In the remaining patients, a slight loss in width and height of the involved area occurred. No functional disturbances were caused by these bony reductions.
and final healing was not discussed. Later sporadic reports have appeared recommending the use ofthe vacuum drainage system in the treatment of cysts, osteomyelitis, and various types of mandibular osteotomies.v'? The aim of the present study was to analyze a large series of jaw cysts in which the vacuum drainage system had been applied as part of the surgical treatment to determine the frequency ofcomplications and the possible influence on the osseous regeneration.
Textbooks on oral and maxillofacial surgery usually suggest two treatment modalities, for the treatment of odontogenic cysts': enucleation and marsupialization. Enucleation is generally preferred because all pathologic tissue is removed and the primary closure eliminates the inconvenience ofa large, slowly healing cavity in the mouth that is characteristic of the marsupialization procedure. However, it is often mentioned that there is a great risk for breakdown of the blood clot because of liquefaction and failure of organization when large cysts are treated by enucleation. Exudation from the wound surfaces also may cause an increase in tension, so dehiscence of the suture line may occur followed by invasion of microorganisms from the oral cavity causing infection ofthe coagulum. Attempts to overcome these problems have been made either by filling the cystic cavity with different types of bone transplant or implant materials' or by application of a pressure bandage. Rud 3 and Heidsieck4 introduced the vacuum drainage system in the treatment of large cysts with good results. However, only the immediate postoperative findings were described,
Material and Methods Forty-two patients, 24 men and 18 women, were operated for jaw cysts during the period from 1978 to 1988 and suction drainage according to the method of Mandal'? was applied as part of the treatment. The age of the patients varied from 16 to 80 years, with a median age of 58 years. Thirty-six (86%) of the lesions were located in the mandible and six in the maxilla (Fig 1). The majority of the mandibular lesions involved the body as well as the ramus. The cysts were located in edentulous areas of the jaws in 21 of the cases and in relation to teeth in 21 cases. The size of the cysts was expressed as area in square centimeters, multiplying the largest distance distalproximal and craniocaudal. Calculations were based on panoramic orthopantomoradiographs that were available in 35 patients. The smallest cyst measured 5.20 crrr'; the largest was 46.0 cm 2 with a median of 22.41 em? and a 95% confidence interval on the median from 16.96 to 27.36 crn''. Whenever possible, the suction drain 13 (Steritex AS, Denmark) was placed intraorally via a small independent stab incision approximately 2 cm away from the major incision line, fixed to the mucous membrane with a suture, and exited from the oral cavity via the commissure; otherwise, the drains were exited through
Received from the Departments of Ora! and Maxillofacial Surgery, Un iversity Hospital (Rigshospitalet) and the School of Dentistry, Health Science Faculty, University of Copenhagen, Copenhagen, Denmark. • Professor and Chairman, Departments of Oral and Maxillofacial Surgery, the University Hospital and the School of Dentistry, Health Science Faculty, University of Copenhagen, Copenhagen, Denmark. t Jun ior Resident, Departments of Oral and Maxillofacial Surgery, the University Hospital and the School of Dentistry , University of Copenhagen, Denmark . Formerly, Associate Director; presently, Cochairman, Department of Oral and Maxillofacial Surgery, Aalborg County Hospital, Aalborg, Denmark. Address correspondence and reprint requests to Dr Hjorting-Hansen: Norre Aile 20, DK-2200 Copenhagen N, Denmark.
*
© 1993 American Association of Oral and Maxillofacial Surgeons 0278.2391/93/5106-0004$3.00/0
630
631
H10RTING·HANSEN, SCHOU, AND WORSAAE
~
»:»
~
~
~ ~
YJ
Y Y
y
y
y
~
~
~
~
~
y
~
~
~
y
~
~
\r!1 y
~
y
FIGURE I.
«.»
y
».»
Diagrams of the extent of 31 of the mandibular cysts. The drawings are based on panoramic radiographs.
the skin. The vacuum was created by compression of a plastic bottle with a content of 150 mL. The drain was 2 mm in diameter with -a distance of 10 mm between each hole. Results Primary healing with complete closure ofthe incision line occurred in 38 patients (90%). In two patients, a minor dehiscence appeared that closed after a few weeks following irrigation of the cavity. Suppuration developed in two cases necessitating further drainage; however, healing occurred after 2 months. There was no correlation between the size of the cyst or the way ofpassing the drains and the occurrence ofdehiscence/ secondary infection; however, in two of the cases with complications, the cysts were related to the teeth. The amount of fluid evacuated by the drain varied from 12 to 325 mL, with a median of 117 mL. The drain was kept in place for an average of 3.6 days, varying from 48 hours to 6 days. In general, the drain
was removed when less than 10 mL of fluid was evacuated in 24 hours. The drain bottle was emptied every 12 hours. The vacuum was kept constant, and attempts were made to ensure that there was a closed suction system during the entire period of drainage. Histologic examination of the surgical specimens revealed odontogenic cystic tissue in 52% (22) and odontogenic keratocyst tissue in 38% (16). In one case, the cyst was lined by respiratory epithelium and one had the histologiccharacteristics ofan aneurysmal bone cyst. In two cases, this information was missing. Postoperatively, the patients were followed at yearly intervals. The longest observation period was nearly 12 years, the shortest 10 months, with a median of 4 years 8 months and a 95% confidence interval on the median from 2 years I month to 6 years I month. Radiographs as well as clinical examinations were done to evaluate healing. In 30 patients, the radiographs allowed an evaluation of the healing. Complete osseous regeneration was noted in 17 cases (57%). Although resorption and the intimate relationship of vital teeth
632
SUCTION DRAINAGE IN JA \V CYSTS
to the cyst wall were seen during enucleation of the cyst postoperatively, complete healing occurred and normal periodontal structures were found radiographically and the involved teeth remained vital. In eight patients, there was a complete osseous regeneration but there was a loss in height of the alveolar process compared with the preoperative condition and to the contralateral side of the mandible; in five of these cases, the reduction was mainly located in the ramus region. Healing with connective tissue scar formation was noted in three mandibular and two maxillary cases. The edentulous patients were able to wear their dentures I week postoperatively and in only a few cases was relining of the denture necessary. Recurrence ofa keratocyst was found in four patients.
Discussion This study clearly demonstrates that suction drainage is beneficial in the treatment oflarge jaw cysts. Primary healing was secured in more than 90% ofthe 42 lesions. Minor complications with dehiscence only occurred in four cases; of these, two were cysts in relation to teeth. The prerequisite for successful use of the closed vacuum drainage system is a completely watertight suture line. In this study, mattress sutures together with a continuous suture were used; however, difficulty in obtaining a watertight closure may occur around the necks of the teeth. Whenever possible, therefore, incisions along the marginal gingiva should be avoided. A loss of bone expressed as reduction in the diameter of the healed alveolar process was found in eight cases. A similar observation has been made by Zoller and Kristen, 12 who found a slight depression of the mucous membrane over the osseous window at the time of removal of the drain. In this series, this reduction did not result in any functional disturbances with respect to the possibility of wearing dentures. The reduction can probably be avoided by filling the cavity with a bone graft after enucleation of the cyst; however, this necessitates a secondary intervention. Granules of porous hydroxylapatite also may be used. Whenever possible, a mucoperiosteal-osteal flap2 should be used. In this way, a thin layer of cortical bone adherent to the periosteum may be preserved, reduction in the width and height of the alveolar process is avoided, and the risk of healing with connective tissue sear formation is markedly reduced. The close approximation of vital teeth to cysts has been one of the indications for using marsupialization for large lesions. In this study, it was clearly demonstrated that even teeth with signs of resorption may retain their vitality after careful enucleation ofthe cyst. The surgeon should avoid curetting the bone in intimate relation to teeth. However, this may slightly increase the risk of recurrence if the lesion is a keratocyst.
Ascending infections along the drain , especially when it is kept for more than 24 hours, has often been reported in the orthopedic literature. Based on a study of 120 consecutive cases of total hip replacement, Willett et al!" found an increasing frequency of infection due to spread of skin organisms when the drain was kept for more than 24 hours. In this study, the drain was left an average of 3.6 days; this did not result in secondary infections, independent of whether the drain was passed intraorally or extraorally. Controlled studies of bilateral interventions such as bilateral total hip replacement and bilateral angioplasties where a suction drain was placed on one side and not on the other l 5, 16 did not show any advantage of suction drainage. We do not feel that it would be ethical to carry out a similar study with regard to jaw cysts. The good results obtained in this study, along with the clinical experience of oral and maxillofacial surgeons with regard to dehiscence along suture lines and breakdown of the blood clot and secondary infection when large cysts have been enucleated, leads us to recommend the application of the suction drainage system in the treatment of these lesions. The advantage of evacuation ofthe fluid in such cavities is further stressed by the findings ofAlexander et al, 17 who demonstrated a progressive loss of opsonic activity in fluids collected from dead spaces. The closed drainage system also has been applied with good results in head and neck sepsis7, I8, I9 or along with elective osteotomies of the mandible," In our department, the system is similarly applied for infectious types of lesions, both on an ambulatory basis as well as in inpatients. However, a limited study of 10 patients in whom bilateral sagittal osteotomies ofthe mandible with suction drainage on one side and not on the other were performed did not show any difference in terms of swelling or pain between the two sides.
References I. Laskin DM (ed): Oral and Maxillofacial Surgery, vol 2. St Louis, MO, Mosby, 1985, pp 427-490 2. Hjorting-Hansen E: Studies on Implantation ofAnorganic Bone in Cystic Jaw Lesions. Munksgaard, Copenhagen, Denmark, 1970 3. Rud J: Sugedreenering i oral kirurgi, Tandkegebladet 71:1120, 1967 4. Heidsick C: Saugdrainage bei Unterkieferzysten im aufsteigenden Ast. Dtsch Zahn Mund Kieferheilk 50:295, 1968 5. Schmelzle R, RoHrs J: Die intraorale Redon-Drainage bei Osteotomie in aufsteigenden Unterkieferast. Fortschr Kiefer Gesichtschir 18:148, 1974 6. Moore JW, Upton GL, Frederickson GC: Intraoral suction drain for reduction of postoperative edema. J Oral Surg 33:462, 1975 7. Witkowski M, Mazaraki A: Clinical evaluation of the usefulness of suction drainage in surgical procedures on the face and neck. Czech Stomato1 29:249, 1976 8. Hjorting-Hansen E: Suction draina ge in the treatment of odontogenic lesions. VII International Conference on Oral Surgery, Dublin, Ireland, June 1980
633
HJ0RTING-HANSEN, SCHOU, AND WORSAAE
9. Pfister W, Sprossig M, Wachtel D, et al; Bakteriologische und klinische Untersuchungen am Unterdruckdrainagen nach unterschiedlichen operativen Eingriffe im Kiefer-Gesichtsbcreich. Dtsch Zahn Mund Kieferheilk 69:491, 1981 10. Muller W, Zinner R, Wachtel D, et al: Klinische und bakteriologische Untersuchungen zur Einschiitzung der Behandlungsergebnisse infektios-entztindlicher Prozessen in Gesichts-HalsBereich durch Unterdruck Drainage. Deutsche Zahn Mund Kieferheilk 69:353, 1981 I I. Flynn TR, Hoekstra GW, Lawrence FR: The use of drains in oral and maxillofacial surgery: A review and a new approach. J Oral Maxillofac Surg 41:508, 1983 12. Zoller J, Kristen K: Der primate Wundverschluss grosser Zysten mit Hilfe der enoralen Saugdrainage, Zahniirztl Prax 37:298, 1986 13. Mandal AC: Sugednenering og prirnrer sarheling. Nord Med 71: 108,1964 14. Willett KM, Simmons CD, Bentley G: The effectof suction drains
15.
16.
17.
18.
19.
after total hip replacement. J Bone Joint Surg [B] 70:607, 1988 Healy DA, Keyser J III, Holcomb GW III, et al: Prophylactic closed suction drainage of femoral wounds in patients undergoing vascular reconstruction. J Vase Surg 10:166, 1989 Beer KJ, Lombardi AV Jr, Mallory FH, et al: The efficacy of suction drains after routine total joint arthroplasty. J Bone Joint Surg [A] 73:584, 1991 Alexander J\V, Korelitz J, Alexander NS: Prevention of wound infections. A case for closed suction drainage to remove wound fluids deficient in opsonic proteins. Am J Surg 132:59, 1976 Reuther J: Indikation und Technik der Saugspiildrainage zur Behandlung von kronischen Knocheninfektionen. Zahnatl Welt Riindschaii 88:899,.1979 Peckitt NS, Fields MJ, Gregory MC: A closed suction drainage system for head and neck sepsis. J Oral Maxillofac Surg 48: 758, 1990
Suction Drainage in the Postsurgical Treatment of Jaw Cysts ERIK HJ0RTING-HANSEN, DDS, DROOONT,* S0REN SCHOU, DDS, PHD,t AND NILS WORSAAE, DDS:f: Intraoral or extraoral closed suction drainage was used following the surgical enucleation of 42 jaw cysts. Primary healing was observed in 38 (90%) of the patients and complete osseous regeneration was achieved in 17 of 30 patients. In the remaining patients, a slight loss in width and height of the involved area occurred. No functional disturbances were caused by these bony reductions.
and final healing was not discussed. Later sporadic reports have appeared recommending the use ofthe vacuum drainage system in the treatment of cysts, osteomyelitis, and various types of mandibular osteotomies.v'? The aim of the present study was to analyze a large series of jaw cysts in which the vacuum drainage system had been applied as part of the surgical treatment to determine the frequency ofcomplications and the possible influence on the osseous regeneration.
Textbooks on oral and maxillofacial surgery usually suggest two treatment modalities, for the treatment of odontogenic cysts': enucleation and marsupialization. Enucleation is generally preferred because all pathologic tissue is removed and the primary closure eliminates the inconvenience ofa large, slowly healing cavity in the mouth that is characteristic of the marsupialization procedure. However, it is often mentioned that there is a great risk for breakdown of the blood clot because of liquefaction and failure of organization when large cysts are treated by enucleation. Exudation from the wound surfaces also may cause an increase in tension, so dehiscence of the suture line may occur followed by invasion of microorganisms from the oral cavity causing infection ofthe coagulum. Attempts to overcome these problems have been made either by filling the cystic cavity with different types of bone transplant or implant materials' or by application of a pressure bandage. Rud 3 and Heidsieck4 introduced the vacuum drainage system in the treatment of large cysts with good results. However, only the immediate postoperative findings were described,
Material and Methods Forty-two patients, 24 men and 18 women, were operated for jaw cysts during the period from 1978 to 1988 and suction drainage according to the method of Mandal'? was applied as part of the treatment. The age of the patients varied from 16 to 80 years, with a median age of 58 years. Thirty-six (86%) of the lesions were located in the mandible and six in the maxilla (Fig 1). The majority of the mandibular lesions involved the body as well as the ramus. The cysts were located in edentulous areas of the jaws in 21 of the cases and in relation to teeth in 21 cases. The size of the cysts was expressed as area in square centimeters, multiplying the largest distance distalproximal and craniocaudal. Calculations were based on panoramic orthopantomoradiographs that were available in 35 patients. The smallest cyst measured 5.20 crrr'; the largest was 46.0 cm 2 with a median of 22.41 em? and a 95% confidence interval on the median from 16.96 to 27.36 crn''. Whenever possible, the suction drain 13 (Steritex AS, Denmark) was placed intraorally via a small independent stab incision approximately 2 cm away from the major incision line, fixed to the mucous membrane with a suture, and exited from the oral cavity via the commissure; otherwise, the drains were exited through
Received from the Departments of Ora! and Maxillofacial Surgery, Un iversity Hospital (Rigshospitalet) and the School of Dentistry, Health Science Faculty, University of Copenhagen, Copenhagen, Denmark. • Professor and Chairman, Departments of Oral and Maxillofacial Surgery, the University Hospital and the School of Dentistry, Health Science Faculty, University of Copenhagen, Copenhagen, Denmark. t Jun ior Resident, Departments of Oral and Maxillofacial Surgery, the University Hospital and the School of Dentistry , University of Copenhagen, Denmark . Formerly, Associate Director; presently, Cochairman, Department of Oral and Maxillofacial Surgery, Aalborg County Hospital, Aalborg, Denmark. Address correspondence and reprint requests to Dr Hjorting-Hansen: Norre Aile 20, DK-2200 Copenhagen N, Denmark.
*
© 1993 American Association of Oral and Maxillofacial Surgeons 0278.2391/93/5106-0004$3.00/0
630
631
H10RTING·HANSEN, SCHOU, AND WORSAAE
~
»:»
~
~
~ ~
YJ
Y Y
y
y
y
~
~
~
~
~
y
~
~
~
y
~
~
\r!1 y
~
y
FIGURE I.
«.»
y
».»
Diagrams of the extent of 31 of the mandibular cysts. The drawings are based on panoramic radiographs.
the skin. The vacuum was created by compression of a plastic bottle with a content of 150 mL. The drain was 2 mm in diameter with -a distance of 10 mm between each hole. Results Primary healing with complete closure ofthe incision line occurred in 38 patients (90%). In two patients, a minor dehiscence appeared that closed after a few weeks following irrigation of the cavity. Suppuration developed in two cases necessitating further drainage; however, healing occurred after 2 months. There was no correlation between the size of the cyst or the way ofpassing the drains and the occurrence ofdehiscence/ secondary infection; however, in two of the cases with complications, the cysts were related to the teeth. The amount of fluid evacuated by the drain varied from 12 to 325 mL, with a median of 117 mL. The drain was kept in place for an average of 3.6 days, varying from 48 hours to 6 days. In general, the drain
was removed when less than 10 mL of fluid was evacuated in 24 hours. The drain bottle was emptied every 12 hours. The vacuum was kept constant, and attempts were made to ensure that there was a closed suction system during the entire period of drainage. Histologic examination of the surgical specimens revealed odontogenic cystic tissue in 52% (22) and odontogenic keratocyst tissue in 38% (16). In one case, the cyst was lined by respiratory epithelium and one had the histologiccharacteristics ofan aneurysmal bone cyst. In two cases, this information was missing. Postoperatively, the patients were followed at yearly intervals. The longest observation period was nearly 12 years, the shortest 10 months, with a median of 4 years 8 months and a 95% confidence interval on the median from 2 years I month to 6 years I month. Radiographs as well as clinical examinations were done to evaluate healing. In 30 patients, the radiographs allowed an evaluation of the healing. Complete osseous regeneration was noted in 17 cases (57%). Although resorption and the intimate relationship of vital teeth
632
SUCTION DRAINAGE IN JA \V CYSTS
to the cyst wall were seen during enucleation of the cyst postoperatively, complete healing occurred and normal periodontal structures were found radiographically and the involved teeth remained vital. In eight patients, there was a complete osseous regeneration but there was a loss in height of the alveolar process compared with the preoperative condition and to the contralateral side of the mandible; in five of these cases, the reduction was mainly located in the ramus region. Healing with connective tissue scar formation was noted in three mandibular and two maxillary cases. The edentulous patients were able to wear their dentures I week postoperatively and in only a few cases was relining of the denture necessary. Recurrence ofa keratocyst was found in four patients.
Discussion This study clearly demonstrates that suction drainage is beneficial in the treatment oflarge jaw cysts. Primary healing was secured in more than 90% ofthe 42 lesions. Minor complications with dehiscence only occurred in four cases; of these, two were cysts in relation to teeth. The prerequisite for successful use of the closed vacuum drainage system is a completely watertight suture line. In this study, mattress sutures together with a continuous suture were used; however, difficulty in obtaining a watertight closure may occur around the necks of the teeth. Whenever possible, therefore, incisions along the marginal gingiva should be avoided. A loss of bone expressed as reduction in the diameter of the healed alveolar process was found in eight cases. A similar observation has been made by Zoller and Kristen, 12 who found a slight depression of the mucous membrane over the osseous window at the time of removal of the drain. In this series, this reduction did not result in any functional disturbances with respect to the possibility of wearing dentures. The reduction can probably be avoided by filling the cavity with a bone graft after enucleation of the cyst; however, this necessitates a secondary intervention. Granules of porous hydroxylapatite also may be used. Whenever possible, a mucoperiosteal-osteal flap2 should be used. In this way, a thin layer of cortical bone adherent to the periosteum may be preserved, reduction in the width and height of the alveolar process is avoided, and the risk of healing with connective tissue sear formation is markedly reduced. The close approximation of vital teeth to cysts has been one of the indications for using marsupialization for large lesions. In this study, it was clearly demonstrated that even teeth with signs of resorption may retain their vitality after careful enucleation ofthe cyst. The surgeon should avoid curetting the bone in intimate relation to teeth. However, this may slightly increase the risk of recurrence if the lesion is a keratocyst.
Ascending infections along the drain , especially when it is kept for more than 24 hours, has often been reported in the orthopedic literature. Based on a study of 120 consecutive cases of total hip replacement, Willett et al!" found an increasing frequency of infection due to spread of skin organisms when the drain was kept for more than 24 hours. In this study, the drain was left an average of 3.6 days; this did not result in secondary infections, independent of whether the drain was passed intraorally or extraorally. Controlled studies of bilateral interventions such as bilateral total hip replacement and bilateral angioplasties where a suction drain was placed on one side and not on the other l 5, 16 did not show any advantage of suction drainage. We do not feel that it would be ethical to carry out a similar study with regard to jaw cysts. The good results obtained in this study, along with the clinical experience of oral and maxillofacial surgeons with regard to dehiscence along suture lines and breakdown of the blood clot and secondary infection when large cysts have been enucleated, leads us to recommend the application of the suction drainage system in the treatment of these lesions. The advantage of evacuation ofthe fluid in such cavities is further stressed by the findings ofAlexander et al, 17 who demonstrated a progressive loss of opsonic activity in fluids collected from dead spaces. The closed drainage system also has been applied with good results in head and neck sepsis7, I8, I9 or along with elective osteotomies of the mandible," In our department, the system is similarly applied for infectious types of lesions, both on an ambulatory basis as well as in inpatients. However, a limited study of 10 patients in whom bilateral sagittal osteotomies ofthe mandible with suction drainage on one side and not on the other were performed did not show any difference in terms of swelling or pain between the two sides.
References I. Laskin DM (ed): Oral and Maxillofacial Surgery, vol 2. St Louis, MO, Mosby, 1985, pp 427-490 2. Hjorting-Hansen E: Studies on Implantation ofAnorganic Bone in Cystic Jaw Lesions. Munksgaard, Copenhagen, Denmark, 1970 3. Rud J: Sugedreenering i oral kirurgi, Tandkegebladet 71:1120, 1967 4. Heidsick C: Saugdrainage bei Unterkieferzysten im aufsteigenden Ast. Dtsch Zahn Mund Kieferheilk 50:295, 1968 5. Schmelzle R, RoHrs J: Die intraorale Redon-Drainage bei Osteotomie in aufsteigenden Unterkieferast. Fortschr Kiefer Gesichtschir 18:148, 1974 6. Moore JW, Upton GL, Frederickson GC: Intraoral suction drain for reduction of postoperative edema. J Oral Surg 33:462, 1975 7. Witkowski M, Mazaraki A: Clinical evaluation of the usefulness of suction drainage in surgical procedures on the face and neck. Czech Stomato1 29:249, 1976 8. Hjorting-Hansen E: Suction draina ge in the treatment of odontogenic lesions. VII International Conference on Oral Surgery, Dublin, Ireland, June 1980
633
HJ0RTING-HANSEN, SCHOU, AND WORSAAE
9. Pfister W, Sprossig M, Wachtel D, et al; Bakteriologische und klinische Untersuchungen am Unterdruckdrainagen nach unterschiedlichen operativen Eingriffe im Kiefer-Gesichtsbcreich. Dtsch Zahn Mund Kieferheilk 69:491, 1981 10. Muller W, Zinner R, Wachtel D, et al: Klinische und bakteriologische Untersuchungen zur Einschiitzung der Behandlungsergebnisse infektios-entztindlicher Prozessen in Gesichts-HalsBereich durch Unterdruck Drainage. Deutsche Zahn Mund Kieferheilk 69:353, 1981 I I. Flynn TR, Hoekstra GW, Lawrence FR: The use of drains in oral and maxillofacial surgery: A review and a new approach. J Oral Maxillofac Surg 41:508, 1983 12. Zoller J, Kristen K: Der primate Wundverschluss grosser Zysten mit Hilfe der enoralen Saugdrainage, Zahniirztl Prax 37:298, 1986 13. Mandal AC: Sugednenering og prirnrer sarheling. Nord Med 71: 108,1964 14. Willett KM, Simmons CD, Bentley G: The effectof suction drains
15.
16.
17.
18.
19.
after total hip replacement. J Bone Joint Surg [B] 70:607, 1988 Healy DA, Keyser J III, Holcomb GW III, et al: Prophylactic closed suction drainage of femoral wounds in patients undergoing vascular reconstruction. J Vase Surg 10:166, 1989 Beer KJ, Lombardi AV Jr, Mallory FH, et al: The efficacy of suction drains after routine total joint arthroplasty. J Bone Joint Surg [A] 73:584, 1991 Alexander J\V, Korelitz J, Alexander NS: Prevention of wound infections. A case for closed suction drainage to remove wound fluids deficient in opsonic proteins. Am J Surg 132:59, 1976 Reuther J: Indikation und Technik der Saugspiildrainage zur Behandlung von kronischen Knocheninfektionen. Zahnatl Welt Riindschaii 88:899,.1979 Peckitt NS, Fields MJ, Gregory MC: A closed suction drainage system for head and neck sepsis. J Oral Maxillofac Surg 48: 758, 1990