From Hopeless to Regenerated: Successful Preservation of a Tooth with Massive PeriapicalLesion in an Adolescent

Abstract

Background: Periapical lesions in adolescents present a particular therapeutic challenge due to
age-related anatomical and physiological characteristics, including greater susceptibility to dental
trauma, higher caries risk, wide apical foramen and thin dentinal walls. At the same time, high
regenerative capacity offers the possibility of successful treatment even in cases with an initially
very poor prognosis.
Case Presentation: This report presents a 14-year-old patient with a massive periapical lesion
and an iatrogenic root canal perforation of tooth 12. Cone-beam computed tomography (CBCT)
imaging revealed an extensive osseous defect with complete perforation of the palatal cortical
plate and marked destruction of the vestibular bone. Management included sealing the
perforation with MTA under an operative microscope and endodontic treatment followed by
apicoectomy with bone graft augmentation and placement of a PRF membrane. After the
surgery, the tooth was stabilized with a wire-composite splint until physiologic stability was
restored. A four-month follow-up CBCT scan showed complete repair of the osseous defect,
homogeneous graft integration, re-established cortical continuity, and preservation of a normal
periodontal ligament space. Clinically, stable function and satisfactory esthetics were achieved.
Conclusion: This case demonstrates that even large periapical lesions complicated by iatrogenic
perforation with an initially unfavorable prognosis can be successfully managed through a
combination of advanced endodontic therapy and surgical intervention. A multidisciplinary
approach, precise diagnostics, and the use of bioactive materials enabled preservation of the
natural tooth and complete recovery of periapical structures in an adolescent patient.