Apical osteotomy is a surgical procedure that is performed in the treatment of cysts and granulomas of the incisors and premolars, where there has already been conducted endodontic treatment and the tooth canal is filled properly. The operation is aimed at removal of the granuloma or the cyst, present in the root apex. After the removal of this soft tissue, the empty space in the bone is filled by the naturally growing bone and the tooth is completely cured.

Before a decision is made for apical osteotomy, an X-ray image of the root is taken to check the quality of the filling of the canal and the changes in the periodontium (the size of the granuloma or cyst).
Apical osteotomy is a microsurgical operation that lasts about two hours. Firstly an anesthetic is used to induce insensitivity to pain in required area. Then a small incision of the mucous membrane in the area of the root apex is done and the supporting bone is exposed. Using special bone cutters, a small window is formed in it while removing the surface layer of bone until the root apex and the granuloma/cyst are reached. Using special instrument called curette, the granuloma is cleaned and apex of the root is cut. Then the root filling in the area of the cut is examined, in case it is required to be filled further.
In the newly formed bone cavity, a bone void filler is placed and covered with a mucous membrane which is sutured from above. In most cases there is complete recovery, but in rare cases there may be relapses (granuloma forms again – if it is not cleaned well).

Hemisection is applied in most cases for teeth with multiple roots. This is due to the fact that their roots are close to critical structures, such as maxillary sinus in the upper jaw and the groove of the nerve of the lower lip and the tongue. Proximity to such important structures makes apical osteotomy extremely difficult and an uncertain method with greater risk of damage to these structures. Therefore, the method of hemisection is suitable for these teeth. This method is very useful because in multi-rooted teeth, the granuloma or cyst usually covers only one root, while the others are not affected. It is a fact that the multi-rooted teeth remain functionally stable if one of their roots is subtracted. This is exactly what hemisection is. The procedure involves removal of the diseased root and the respective part of the tooth crown. This is done under anesthesia. The remaining root or roots serve for shaping a tooth stump with specific shape and size, on which a dental crown is built and the tooth becomes functional again and indistinguishable from the rest. Hemisection applies in cases, where there are many curves and impassable root canals where proper processing and filling are impossible.

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