Teeth exhibiting internal root resorption or those with persistent large periapical lesions after non-surgical endodontic treatment are generally considered to have an unfavorable prognosis. Extraction of teeth with unfavorable prognosis, followed by dental implant placement, has become an acceptable treatment option. However, dental implants are not indicated for young people with growing jaws. Consequently, it is recommended that clinicians prioritize the preservation of natural dentition in younger patients and defer implant therapy until skeletal growth has ceased. In cases where tooth preservation is attempted despite severe periradicular defects, a surgical approach is often required to manage associated symptoms. However, modern periradicular surgery frequently leads to unaesthetic complications such as conspicuous scar formation or gingival recession. The introduction of novel combinatory surgery, including guided tissue regeneration (GTR), de epithelialized free gingival graft (DFGG), and coronally advanced flap (CAF) optimizes the clinical outcomes, addressing both the functional and aesthetic needs of the patient.