Trephination for acute pain management

By Henry BM, Fraser JG

Date: 06/2004
Journal: JOE

Purpose: to aid the clinician in diagnosing an acute apical abscess and implementing the treatment necessary to rapidly resolve the patient’s problem.


•Trepanation (trephination), defined as cutting a circular piece of cranial bone to relieve pressure by cutting a hole through cortical bone into the cancellous spaces to relieve a build up of pressure due to infection or inflammation.

•Trephination is indicated for the relief of severe pain of periapical origin, to establish drainage from an acute apical abscess, or to limit the spread of an existing cellulitis.

•Patients who require a trephination procedure are usually experiencing an acute apical abscess or an acute exacerbation of a chronic apical abscess. •Apical trephination as described by Gutmann and Harrison may provide sufficient drainage through the tooth to resolve the problem. 

•One of the limitations with this approach is the size of the apical hole, which is generally recommended as a size #20 or #25 file. However, Pus is often very viscous and the amount of effective drainage that can be obtained through the apex is questionable.

Surgical trephination technique

•Diagnosis, identification of anatomical landmarks, profound anesthesia, incision, retraction of tissue, trephination, apical curettage, and wound closure. Figures

•A horizontal incision should be made roughly in the middle to apical 1⁄3 of the root. Figure

•Once drainage has been achieved, the surgical site can be irrigated and closed. Using an H-shaped piece of rubber dam as a drain sutured into the incision with the drain extending into the apical area is advocated. Figure

Clinical significance:  

Removal of the causative factor (bacteria in the RCS) is the main factor in pain relieve. It could be attempted by Orthograde access and drainage, unless a swelling is present (where I&D is proposed)