Surgical management of large periapical lesion- A case series

Endodontic therapy usually achieves high success rates, yet persistent large periapical lesions may require surgical management. This report presents two cases of radicular cysts with cortical perforations treated surgically after failed nonsurgical root canal treatment. In the first case, a 55-year-old woman exhibited a large mandibular anterior lesion causing swelling and tenderness, while the second involved a 40-year-old woman with a palatal lesion extending across the midline. Both cases underwent chemo-mechanical root canal preparation, intracanal medicaments, and obturation using mineral trioxide aggregate (MTA). Persistent symptoms prompted periradicular surgery with apicoectomy, cyst enucleation, and adjunctive use of platelet-rich fibrin (PRF) to promote healing. Follow-up CBCT showed satisfactory bone regeneration and symptom resolution after 10 to 12 months. These cases underscore the importance of surgical intervention combined with regenerative materials for managing large, complex periapical lesions when nonsurgical approaches fail. PRF and MTA enhance biological healing and improve clinical outcomes in endodontic microsurgery.