Vacuum sealing drainage combined with continuous irrigation for the treatment of oral and maxillofacial abscesses—a retrospective study (2025)

Objective

The conventional treatment for oral and maxillofacial abscesses involves incision and drainage. However, postoperative dressing changes often cause pain and other discomfort to patients. Therefore, we explored the use of vacuum sealing drainage (VSD) technology for treating oral and maxillofacial abscesses. In this retrospective study, we evaluated the efficacy and value of VSD combined with continuous irrigation using physiological saline to treat oral and maxillofacial abscesses.

Materials and methods

Data from 115 patients with oral and maxillofacial abscesses were collected. Patients were divided into two groups based on the treatment strategy: 68 received traditional treatment (Group 1) and 47 were treated with the VSD device (Group 2). The treatment period, incision length and numerical rating scale (NRS) score were compared between the two groups. Postoperative complications were also recorded.

Results

All patients were successfully treated and discharged. Group 2 had a longer treatment duration (10.00 ± 5.87 days) than Group 1 (8.07 ± 3.47 days; p < 0.05) but demonstrated shorter incision lengths (3.04 ± 0.31cm vs. 3.57 ± 0.44cm; p < 0.01) and lower NRS scores on postoperative day 1 (1.83 ± 0.70 vs. 2.96 ± 0.83; p < 0.01). Complications included two allergic reactions to adhesive material in Group 2 and higher reoperation rates (Group 2: 4 cases; Group 1: 1 case).

Conclusion

VSD treatment for localized oral and maxillofacial abscesses is comfortable for patients and can reduce the length of surgical incisions. However, the therapeutic effect for maxillofacial multispace infection is still controversial.

Oral and maxillofacial infection is a common oral disease that can develop into an abscess if not treated promptly, and further distribution may lead to periostitis and cellulitis of the surrounding tissues and eventually spread to facial spaces, resulting in acute respiratory distress and difficulties in swallowing [1]. Oral space abscesses may spread further, leading to serious complications. The most severe and life-threatening complications of orofacial infections are cervicofacial necrotizing fasciitis, Ludwig angina, descending necrotizing mediastinitis, cavernous sinus thrombosis, and brain abscess. Despite their rarity, these complications still present with remarkable morbidity and mortality [2]. Therefore, for oral and maxillofacial abscesses, active treatment is necessary.

The traditional treatment method is abscess incision and rinsing combined with antibiotic treatment. The treatment process of rinsing dressings often causes great pain and psychological trauma in patients, especially to individuals with pain sensitivity, such as children, who also have greater resistance to rinsing. In addition, traditional treatment methods require long drainage incisions on the face to achieve adequate drainage, which may affect aesthetics.

Is there a better way to reduce the number of dressing changes and the pain of the treatment? The vacuum sealing drainage (VSD) technique attracted our attention. VSD was first described in 1993 by Fleischmann, who first reported the use of subatmospheric pressure for an extended period to promote debridement and healing following the successful use of this technique in 15 patients with open fractures [3]. Researchers reported that VSD was used for the treatment of soft tissue injuries and infections in the same year [4]. Professor Fleischmann used vacuum sealing as a carrier system for controlled local drug administration to treat acute infections of bone and soft tissues, chronic osteomyelitis, and chronic wounds and achieved good results [5]. We modified the VSD device to combine VSD with continuous irrigation and used it for the treatment of oral and maxillofacial abscesses over the last decade. We found that the current research on VSD treatment for the treatment of oral and maxillofacial infections has focused mainly on multispace infections [6,7,8,9,10], while there have been few reports on the treatment of general abscesses. In this retrospective study, we compared traditional treatments with VSD in our study centre and evaluated the efficacy and value of VSD technology combined with continuous irrigation in the treatment of oral and maxillofacial abscesses.

We conducted a retrospective analysis of all cases of oral and maxillofacial abscesses treated at the Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Wenzhou Medical University, between 2019 and 2023. Diagnosis was confirmed through comprehensive physical examination and imaging studies. The study protocol adhered to the ethical principles of the Helsinki Declaration (1975, revised 1983) and received approval from the Ethics Committee of the School And Stomatology, Wenzhou Medical University (Approval No. 2019005). Written informed consent was obtained from all participants or their legal guardians.Patients were stratified into two treatment groups based on therapeutic intervention: the conventional treatment group (Group 1) and the vacuum-assisted closure (VSD) group (Group 2), utilizing the Kulavac VSD device (BioAlpha, Inc., Korea). Notably, our modified VSD protocol incorporated an additional flushing tube for continuous negative pressure irrigation (Fig.1C).

In Group 1 (conventional treatment), standard incision and drainage procedures were performed with placement of a surgical drainage tube following abscess formation. Postoperative care included daily irrigation (1–2 times) until complete resolution of purulent discharge, accompanied by systemic antibiotic therapy adjusted according to antimicrobial susceptibility testing. Clinical parameters, including pain indices, complications, and treatment outcomes, were meticulously documented through medical record review.

Group 2 (VSD treatment) received advanced wound management through the modified VSD system. Following abscess incision, the VSD device was installed with continuous irrigation using 3000 mL of physiological saline over 24h, maintained at a negative pressure of 0.04–0.05MPa (Fig.2). Systemic antibiotics were administered concurrently. A distinctive feature of our protocol was the utilization of a single incision for multispace infections, with the VSD device effectively connecting multiple spaces. Device removal criteria included resolution of patient discomfort, clearance of drainage fluid, and normalization of inflammatory markers (e.g., CRP, WBC count). Post-removal observation continued for 24h prior to discharge. Cases unresponsive to VSD therapy were managed through conventional incision and drainage protocols.

Both groups underwent daily clinical evaluation documenting disease progression, hospitalization duration, systemic disease associations, infectious etiology, and pain indices. Pain assessment was performed using the Numerical Rating Scale (NRS), an 11-point scale ranging from 0 (no pain) to 10 (worst imaginable pain), categorized as no pain (0), mild pain [1,2,3], moderate pain [4,5,6], and severe pain [7,8,9,10]. NRS measurements were standardized: Group 1 assessments were conducted 30min post-irrigation on postoperative day 1, while Group 2 evaluations were performed at noon on postoperative day 1. Data were recorded as integers ranging from 0 to 10.

Incision lengths were primarily recorded intraoperatively, with supplementary measurements taken during the initial dressing change in cases where intraoperative measurement was not feasible. All clinical data, including changes in patient condition, pain indices, and related complications, were recorded daily to ensure comprehensive documentation of treatment outcomes.

The inclusion criteria for this study were as follows: (1) The patients were confirmed to have an oral and maxillofacial abscess and needed an incision and drainage operation. (2) The patients underwent incision and drainage. (3) There were complete case data. Exclusion criteria: (1) Patients with osteomyelitis of the jaw. (2) The medical records were incomplete.

Considering that patients often experienced a certain period of disease progression before hospitalization, we recorded not only the patients’ hospital stay but also the patients’ postoperative treatment duration and preoperative duration according to the chief complaint. We used the patient’s symptoms of pain, redness, or swelling as the starting point of the disease to determine the preoperative course of the patient. The disappearance of clinical symptoms was regarded as the cure criterion. Each patient was judged by the doctor to be healthy and allowed to be discharged at the end of the treatment process.

Patient data were systematically recorded, including:1. General information: age, sex, source of infection. 2.Treatment Details: Treatment modality, length of hospital stay, surgical incision length. 3.Outcome Measures: Pain indices (assessed using the Numerical Rating Scale, NRS), complications, and adverse reactions during treatment.

Continuous variables (age, preoperative course, postoperative course, length of inpatient treatment, NRS scores and incision length) in this study are reported as the mean ± standard deviation. Categorical variables are presented as proportions. Different variables were compared between the traditional group and the VSD group. Independent-sample t tests were used for measurement data, such as incision length. The Χ² test was used for enumeration data, such as the number of complications and adverse reactions. The level of statistical significance was defined as P < 0.05. All analyses were performed using SPSS Statistics, version 17 (SPSS Inc., Chicago, IL, USA).

General information

Our department admitted 145 patients for oral and maxillofacial abscesses, 115 of whom were included in the study. Twenty patients were excluded from the study, mainly because they refused to undergo surgery or had incomplete data; ten children were too young to be assessed with NRS and were not included in this study. Among the 115 patients, 63 (54.78%) were male, and 52 (45.22%) were female. The patients’ ages ranged from 5 to 86 years (mean: 45.51 ± 23.97 years). Sixty-six patients had odontogenic cases, 35 patients had glandular cases, and the remaining 14 cases resulted from trauma, iatrogenic causation, or other sources.

The 115 patients were divided into two groups: 68 patients received traditional treatment (Group 1), and 47 patients were treated with VSD (Group 2). The main source of infection in both groups was odontogenic, followed by glandular, and there was no significant difference between the two groups. The clinical data were recorded (Table1). Most patients were administered intravenous antibiotics before admission. There were no deaths among the patients. All patients’ other symptoms, including swallowing pain, were alleviated at different stages after surgery, but due to a lack of adequate records, no corresponding statistical analysis was performed in this study.

Duration of treatment

As shown in Table2,the preoperative course of the two groups was 7.34 ± 3.73 days (Group 1) and 8.68 ± 5.29 days (Group 2). There was no significant difference between the two groups. The postoperative course of the traditional group was 8.07 ± 3.47 days, which was significantly shorter than that of Group 2 (10.00 ± 5.87 days) (P < 0.05). Similarly, the total length of hospital stay for patients in the VSD group was also longer than that for patients in the traditional treatment group (P < 0.01). To address the potential impact of multispace infections on the results, we reanalysed the data after excluding seven patients with multispace infections (3 patients in Group 1 and 4 patients in Group 2). The postoperative duration in the traditional treatment group was 7.63 ± 3.10 days, which was significantly shorter than that in Group 2 (9.10 ± 2.72 days) (P < 0.05).

Numerical rating scale

A total of 115 patients were included (68 in Group 1 and 47 in Group 2). The NRS score of the patients in Group 1 before surgery was 5.69 ± 1.25, and the postoperative NRS score decreased significantly to 2.96 ± 0.83. The NRS score of Group 2 decreased from 5.36 ± 1.07 to 1.83 ± 0.70. Compared with that of Group 1, the NRS score was not significantly different before surgery but was significantly lower after surgery (P < 0.01) (Table3). After excluding patients with multispace infection, the postoperative NRS score in Group 1 (2.97 ± 0.83) was significantly greater than that in Group 2 (1.82 ± 0.69) (P < 0.01).

Location and length of the incision

In terms of incision length, patients who had undergone multiple surgeries after VSD treatment were not included but are mentioned in the description of postoperative complications. Sixty-seven patients in Group 1 and 43 patients in Group 2 were included. The average length of the incision was 3.57 ± 0.44cm in Group 1, which was significantly longer than that in Group 2 (3.04 ± 0.31cm) (P < 0.01). The incisions in the two groups of patients were mainly located in the masseteric-buccal region, followed by the submandibular region.Since the VSD group all adopted the extraoral incision, and there are many differences between intraoral and extraoral incisions, we compared the incision length of the 42 patients who underwent extraoral incision in Group 1 with that of Group 2.The average length of the incision was 3.55 ± 0.47cm in group 1, which was significantly longer than that in group 2 (P < 0.01)(Table4).

Complications or adverse reactions

In Group 1, one patient underwent secondary surgery because of poor drainage due to the spread of the infection. In Group 2, 4 patients underwent reoperation, one patient underwent four surgeries, and three patient underwent extensive incision drainage after removal of the VSD due to poor treatment. All patients were diagnosed with deep neck infections (DNIs), and the patients still progressed rapidly after VSD treatment; one of them developed a mediastinal infection and was then transferred to the intensive care unit for treatment. All of these patients were converted to conventional treatment and were eventually cured. None of the patients died from the infection (Table5).

In addition, two patients(4.26%) in the VSD group developed an allergic reaction to the VSD binding material, which manifested as the appearance of a rash. Three patients experienced air leakage from their VSD devices, and no postoperative bleeding occurred in either group of patients.

In 1997, a series of basic animal studies using a new subatmospheric pressure technique to expedite wound healing were presented by Michael J. Morykwas [11]. The study proved that the controlled application of subatmospheric pressure to wounds resulted in an increase in local functional blood perfusion, an accelerated rate of granulation tissue formation, and a decrease in tissue bacteraemia levels. With the widespread application of VSD in general surgery and hand surgery [12, 13], some scholars [14,15,16] have introduced VSD to oral and maxillofacial surgery, mainly focusing on treatment after maxillofacial reconstruction. Studies [17,18,19,20] have shown that the mechanism by which VSD promotes wound healing and exerts an anti-infection effect may be that the removal of interstitial fluid decreases localized oedema and increases blood flow, which in turn decreases tissue bacterial levels. Furthermore, negative pressure can reduce local oedema, dilate arterioles, and increase local oxygen partial pressure. Continuous negative pressure suction can promote the expression of a variety of repair signals and wound-healing genes and increase the number of various growth factors and enzymes at the wound surface and surroundings [21], thus promoting epithelial regeneration. Clinically, the vacuum sealing technique is thought to be an effective option for the management of infected wounds [22, 23]. Therefore, in this study, a combination of controlled subatmospheric pressure and continuous irrigation with normal saline was attempted for the treatment of oral and maxillofacial abscesses, and good results were achieved.

Pain is a major complication in patients with maxillofacial abscesses. In our study, the NRS score of the VSD group decreased significantly more than that of the traditional group. Studies [24,25,26] have shown that the mechanical pressure of the abscess and the stimulation of inflammatory mediators trigger pain in patients. Incision and drainage effectively reduced the tension of the abscess, and continuous negative pressure suction effectively maintained a low-pressure state to avoid the subsequent accumulation of exudate and pressure stimulation of peripheral nerves. Continuous negative pressure irrigation favoured the clearance of inflammatory mediators [27]. It has been noted that compared with conventional dressing changes, VSD can remove necrotic material from trauma faster, improve trauma hypoxia, accelerate trauma granulation tissue growth, and reduce the trauma infection rate [28]. We added continuous saline flushing to accelerate the removal of necrotic material. Although both traditional treatment methods and VSD technology can effectively reduce the pain caused by infection after resection and drainage, VSD negative pressure irrigation technology can more effectively reduce the pain of patients during treatment than traditional methods. While the mechanical stimulation of the wound caused by conventional dressing changes is also an important source of pain, the VSD device does not require additional dressing changes, thereby improving patient comfort during treatment.

Maxillofacial scarring is an aesthetic consideration, and numerous studies have shown that surgical scarring can have significant negative effects on patients [29,30,31,32]. In our study, VSD technology also effectively shortened the surgical incision, which is consistent with the findings of Yu’s study [7] and is beneficial for reducing scarring. Moreover, the literature provides a moderate level of evidence for the beneficial effects of incisional negative pressure wound therapy on scar quality [33]. This may be because high levels of inflammation can exacerbate scar formation [34], and negative pressure drainage combined with continuous irrigation can reduce the accumulation of inflammatory substances. However, due to the lack of postoperative follow-up data, the postoperative scar condition of patients was not fully evaluated in this study. Therefore, more comprehensive research is needed in the future.In addition, in recent years, several scholars have attempted to use needle aspiration (NA) for the treatment of neck abscesses, and it is considered to be a treatment method for patients which results in less scarring [35, 36]. However, abscess formation is an ongoing process, and single needle aspiration may not completely remove pus. In Shi’s research, patients required 3.07 sessions on average [35]. However, further studies are needed to determine the efficacy of NA in the treatment of oral and maxillofacial abscesses.

Due to the special anatomical structure of the oral and maxillofacial region, oral abscesses easily expand and develop and may cause serious complications, including asphyxiation, mediastinal infection, sepsis, and septic shock [37]. For localized oral and maxillofacial abscesses, good results were obtained in all patients. However, patients with multispace infections did not fare as well. In the conventional group, 4 patients with multispace infection underwent extensive incisions, one patient underwent a second operation because of poor drainage, and the others achieved good results. However, in the VSD group, 2 of 3 patients underwent two or more operations. This finding is not consistent with previous reports [7, 38], in which patients in the VSD group had better treatment outcomes than those in the conventional treatment group. This discrepancy may be due to our overemphasis on small incisions and the difficulty of achieving adequate drainage with a single VSD device for multispace infections. In addition, the pathogenic bacteria of multispace infections are mostly anaerobic, and the closed environment of VSD seems to not be conducive to the control of anaerobic bacteria. Qian’s [39] research showed that the VSD group required more surgical operations and had longer scars than did the Penrose drain group, which was similar to our results, and in the treatment of multispace deep fascial infection, they considered irrigation-assisted vacuum drainage to be a better treatment method than the traditional drainage method. All of the above studies showed that VSD can shorten the length of hospital stay, which is not consistent with our results, but this inconsistency may be due to the different study subjects. For localized oral and maxillofacial abscesses, compared with VSD, traditional methods seem to more easily observe the drainage of the wound and achieve a curative effect earlier, resulting in a shorter hospital stay.

In our research, we found that VSD bonding materials may cause skin irritation in some patients and that patients present allergy symptoms such as rash and itching; however, these symptoms did not cause serious consequences, and the patients were cured after removal of the VSD. At the same time, creased anatomical parts, such as the neck, may cause air leakage due to poor bonding, but this does not cause adverse consequences after timely treatment.

There are several limitations to this study. First, this study inevitably contains biases caused by individual differences, such as the different severities of infections and the overall health of different individuals, which could not be effectively reflected in this investigation. Second, because the evaluation of healing of an infection depends on the subjective judgement of the doctor, and since VSD inevitably interferes with the physician’s assessment, it may affect some research results. Using more objective indicators to evaluate the effect of treatment may yield more accurate results.

VSD:

Vacuum sealing drainage

NRS:

Numerical rating scale

DNI:

Deep neck infections

NA:

Needle aspiration

Authors and Affiliations

1. Department of Oral and Maxillofacial Surgery, School & Hospital of Stomatology, Wenzhou Medical University, 373 West College Road, Wenzhou, 325000, Zhejiang, China

   Sunqiang Hu,Jin Xiao,Xin Nie&Chi Wang

Contributions

Hu: Data Collection/Analysis/ Statistics/Interpretation. Drafting article. Approval of article. XN: Data Analysis/Interpretation. Critical Revision of article.Approval of article. JX: Data Analysis/Interpretation.CW: Concept/Design, Statistics. Drafting article. Approval of article.

Corresponding author

Correspondence to Chi Wang.

Ethics approval and consent to participate

The ethical committee of the School and Stomatology Wenzhou Medical University approved this study (No. WYKQ2019005). We certify that the study was performed in accordance with the 1964 Declaration of Helsinki and later amendments. Informed consent was obtained from all subjects and/or their legal guardian(s).

Consent for publication

Written informed consent for publication was obtained from all participants.

Competing interests

The authors declare no competing interests.

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