PMC10155105_01
A) Sinus tract tracing and working length measuring of the left maxillary central incisor; B) Obturation of the root canal with cold ceramic; C) Recall radiograph after 9 months showed bone regeneration and normal PDL
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F1
Sinus tract tracing revealed the communication of the lesion with the oral cavity through a defect on the buccal aspect of the left maxillary central incisor (Figure 1A).  The pulp chamber was temporarily restored with Cavit (Figure 1B). Moreover, the normal appearance of the apical periodontal ligament increased the thickness of the root canal walls, and the formation of a cementum-like tissue near the apical end of the root was observed radiographically (Figure 1C).
PMC10155105_02
A) Radiograph of endodontically treated right maxillary lateral incisor with a large periapical lesion; B) Root canal obturation with cold ceramic; C) Recall radiograph after 7 months exhibited periapical bone formation
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F2
Radiographic examination demonstrated resorption of the palatal aspect of the alveolar bone and a large periapical cystic lesion with persistent exudate (Figure 2A).  The quality of the final obturation was less than ideal due to the diffusion of cold ceramic particles in the periapical space (Figure 2B).
PMC10155105_03
A) Left maxillary lateral incisor with a large periapical lesion; B) Unsuccessful cold ceramic obturation with extensive penetration of the material into the periapical area; C) Placement of calcium hydroxide into the root canal following cold ceramic removal; D) Satisfactory cold ceramic obturation; E) Recall radiograph after one year suggesting insufficient bone regeneration; F) Recall radiograph after four years showed bone regeneration
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F3
The working length was then determined with H-file #25 (Mani, Tochigi, Japan) and the root canal was prepared up to F3 file under copious irrigation with normal saline (Figure 3A). Radiographic evaluation showed that the coronal portion of the root canal was solely filled with cold ceramic and the majority of the material was pushed into the periapical area (Figure 3B). Therefore, the cold ceramic was removed via ultrasonic file and calcium hydroxide was put into the root canal (Figure 3B). During the next appointment, the last effort was made to obturate the root canal with cold ceramic although persistent exudation was still present (Figure 3D). Recall radiograph after one year was not satisfactory in terms of healing of the periapical lesion (Figure 3E), although the patient had no relevant symptoms; therefore, surgical endodontic intervention was not undertaken. Radiograph at 4-year follow-up (Figure 3F) demonstrated adequate healing of the periapical lesion and bone regeneration along with the induction of apical closure.