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Aim: This study aimed to evaluate whether utilizing additional cone beam computed tomography (CBCT) imaging has any effect on quality of life and healing outcome following periapical surgery compared with periapical radiographs (PR). Methodology: The study was registered in ClinicalTrials.gov (NCT04333940). In this parallel group randomized controlled trial, 52 patients (88 teeth) with persistent apical periodontitis and periapical radiographic evidence of periapical lesion were randomly assigned to either PR or CBCT group. The primary predictor was the type of the imaging method (PR only or with additional CBCT). The primary outcome was patient's quality of life during the first week after periapical surgery and the secondary outcomes were duration of surgery and healing outcome at 12‐month follow‐up. Participants of both groups received periapical surgery based on the pre‐surgical plan provided by the radiographic imaging methods. Quality of life (QoL) was assessed using Modified Shugars questionnaire. Radiographic analysis for healing was conducted using Molven's criteria and modified PENN 3D criteria. The categorical data between groups were analysed using the Chi‐square test, whilst intragroup comparisons were analysed using the McNemar test. The average scores for each component of QoL (oral functions, general functions, pain, swelling and other symptoms), combined QoL scores (overall average of values of 13 variables) and analgesic usage on each day were calculated and analysed. Results: At 12 months of follow‐up, fifty patients were evaluated. Participants in PR group reported significantly more swelling on first three days compared with CBCT group. The analgesic use was higher in the PR group on 2nd and 3rd day (Mann–Whitney U test with Bonferroni correction; p <.007). A significant difference in the limitation of general functions was observed at the second day (p <.07) with the higher values in the PR group. The combined QoL score between the two groups was found to be non‐significant. However, none of the patients experienced intraoperative complications or neurovascular exposure. The mean surgical time was lesser in the CBCT group (p <.05). Radiographic healing revealed a success rate of 96.2% for the PR group and 95.8% for the CBCT group with no significant difference between the groups. Conclusion: Participants in the CBCT group experienced substantially less early postoperative swelling and limitation in general functions, in comparison with the PR group. However, preoperative CBCT had no effect on other QoL parameters and intraoperative complications in medium‐risk patients. Furthermore, CBCT did not exhibit any added advantage over periapical radiography in terms of assessing healing outcome following endodontic microsurgery. CBCT offered surgically relevant anatomic information for pre‐surgical planning and ensured the treatment rendition with a significantly reduced operative time. [ABSTRACT FROM AUTHOR]