CASE REPORT |
https://doi.org/10.5005/jp-journals-10005-2786 |
Palatogingival Groove: The Known–unknown Devourer
1,2,4–6Department of Pediatric and Preventive Dentistry, RUHS College of Dental Science, Rajasthan University of Health Sciences (RUHS), Jaipur, Rajasthan, India
3Department of Pedodontics and Preventive Dentistry, Government Dental College and Hospital, Jaipur, Rajasthan, India
Corresponding Author: Sumedha Gupta, Department of Pediatric and Preventive Dentistry, RUHS College of Dental Science, Rajasthan University of Health Sciences (RUHS), Jaipur, Rajasthan, India, Phone: +91 9529034226, e-mail: sumedhagupta.gupta@gmail.com
ABSTRACT
Aim: This case report aims to describe the management of a maxillary lateral incisor with a palatogingival groove (PGG) associated with a complex lesion.
Background: The PGG is a rare developmental anomaly that involves the lingual surface of the maxillary incisors and extends for varying distances and depths on the root surface. This anomaly is usually inconspicuous and funnel-shaped, which forms a niche where bacterial plaque and calculus can accumulate to levels significant for pathological changes resulting in endodontic and periodontal lesions. These grooves are easily overlooked as etiologic factors, as they are concealed by the periodontal tissues.
Case description: This paper describes the successful management of a rare case of maxillary lateral incisor with an accessory root, two canals, and a complex or type III PGG with a endodontic–periodontic lesion using a multidisciplinary approach.
Conclusion: Recognizing PGG as the initiator of pathology is critical for the successful treatment and favorable prognosis of the affected tooth.
Clinical significance: This case report highlights the importance of three-dimensional (3D) imaging using cone beam computed tomography (CBCT) that can provide accurate and sensitive information to assess and plan the treatment of the teeth with PGG. It also emphasizes that with the development of newer materials and diagnostic tools, clinicians need a detailed understanding of the characteristics, treatment, and prognosis of PGG to successfully manage the condition.
How to cite this article: Gupta S, Tandon S, Rathore AS, et al. Palatogingival Groove: The Known–unknown Devourer. Int J Clin Pediatr Dent 2024;17(S-1):S95–S99.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.
Keywords: Biodentine, Case report, Cone beam computed tomography, Palatogingival groove, Perio–endo lesion, Platelet-rich fibrin.
BACKGROUND
The palatogingival groove (PGG), also known as the palato-radicular groove or radicular lingual groove, is a developmental anomaly primarily found on the lingual aspect of maxillary incisor teeth.1,2 Its occurrence rate ranges from 2.8 to 8.5%, commonly observed in maxillary lateral incisors and less frequently in central incisors.2,3 The exact cause of this groove remains debated, with theories suggesting it could be due to an infolding of the enamel organ and Hertwig’s epithelial root sheath during tooth development or an aborted additional root formation attempt.4,6 However, more recently, it has been related to the concept of “alteration of genetic mechanisms.”7
This anatomical aberration poses clinical challenges as it serves as a pathway for bacterial infiltration into the periodontal ligament (PDL), leading to progressive periodontal inflammation. In some cases, the groove may also allow communication between the periodontium and pulp, often through accessory canals, facilitating bacterial travel in both directions and potentially resulting in necrosis of the pulp tissue.8
The prognosis of teeth harboring a PGG varies based on factors, such as its location, accessibility, severity of associated periodontal disease, and the groove’s characteristics (e.g., length and depth).9 Combined endodontic–periodontic treatment approach is usually required for its successful management.
This recent case report highlights the effective management of a complex lesion associated with a maxillary lateral incisor exhibiting a PGG, utilizing cone beam computed tomography (CBCT) to aid in treatment planning and employing a combination of endodontic and periodontic interventions for successful outcomes.
CASE DESCRIPTION
A 13-year-old male patient presented with complaints of pain, tooth mobility, and sporadic pus discharge from the upper left front tooth area, persisting for the past 2–3 months. The pain was described as dull and erratic. There was no history of trauma to the affected tooth, and the patient had not sought treatment for the current issue.
Upon intraoral examination, a sinus opening was noted on the labial vestibule associated with the maxillary left lateral incisor (Fig. 1A). There were no signs of discoloration, carious involvement, or fracture of the concerned tooth. It was tender on percussion with grade I mobility. A periodontal assessment revealed a deep pocket of approximately 8 mm in the midpalatal aspect of the upper left lateral incisor, which was associated with a deep palato-radicular groove (Figs 1B and C). On pulp vitality testing, tooth 22 showed no response, while the adjacent teeth 21 and 23 showed a positive response.
Figs 1A to D: Preoperative images. (A) Sinus opening on the labial vestibule in relation to the maxillary left lateral incisor; (B) Maxillary palatal view demonstrating PGG in the left maxillary lateral incisor; (C) Probing depth of 8 mm on the midpalatal aspect of the maxillary left lateral incisor; (D) Intraoral periapical radiograph (IOPA)
An intraoral periapical radiograph (IOPA) discovered a huge diffuse periapical rarefaction in relation to tooth 22. Additionally, a vertical radiolucent line parallel to the main canal along the root’s length raised suspicion of a vertical root fracture. An accessory root’s presence was also ambiguous (Fig. 1D). To clarify these findings and visualize the complex anatomy, a CBCT scan was recommended. CBCT imaging established the existence of a deep PGG, an additional root with an accessory canal, and a significant periapical lesion with discontinuity of the buccal and palatal cortical plates in relation to tooth 22 (Figs 2A to E).
Figs 2A to E: Preoperative CBCT images. (A to C) Axial views showing PGG, accessory root with an accessory canal, and large periapical lesion, respectively; (D) Sagittal view demonstrating discontinuity of buccal and lingual cortical plates; (E) 3D view from palatal aspect showing the complete extent of PGG
Based on these findings, a diagnosis of a combined endodontic–periodontic lesion in relation to tooth 22 with type III PGG was made. With the patient’s consent, a combined endodontic–periodontic treatment approach was planned.
Under local anesthesia (2% xylocaine with 1:80,000 epinephrine) and rubber dam isolation, two separate access openings were created—one for the main canal and another for the accessory canal, as guided by CBCT imaging (Fig. 3A). After determining the working length, the canals were instrumented using K-files (Fig. 3B). Following thorough biomechanical preparation and irrigation using 3% sodium hypochlorite and normal saline, calcium hydroxide was positioned as an intracanal medicament, and the access cavities were temporarily closed for 3 weeks.
Figs 3A to C: (A) Access opening under rubber dam isolation; (B) Working length estimation IOPA; (C) Postobturation IOPA
At the subsequent appointment, with the patient asymptomatic and the sinus opening healed, both canals were obturated using gutta percha (GP) points and a bioceramic sealer via lateral condensation technique (Fig. 3C). Glass ionomer cement (GIC) was used to seal the access cavity.
After 1-week, periodontal flap surgery was accomplished to address both the periodontal pocket and PGG concurrently. Approximately, 10 mL of blood was drawn from the patient’s antecubital vein for preparation of platelet-rich fibrin (PRF), which was centrifuged. Following thorough disinfection with betadine and administration of local anesthesia (2% xylocaine with 1:80,000 epinephrine), a full-thickness mucoperiosteal flap was raised on the palatal aspect of the upper left lateral incisor. Upon reflection, a progressive bony defect was found on the palatal aspect of the affected incisor (Fig. 4A). After the removal of granulomatous tissue, the PGG was outlined to the apex. Following scaling, root planning, and saucerization of the groove with a long-tapered diamond bur, it was sealed with Biodentine™ (Septodont, Saint-Maur-des-Fossés, France) (Fig. 4B). PRF membranes were positioned over the bony defect, and the flap was repositioned and secured with interrupted sutures (Figs 4C and D). Postoperative instructions were provided, including a prescription for a 0.12% chlorhexidine gluconate rinse, and the patient was prescribed antibiotics (ornidazole + ofloxacin) and analgesics (ibuprofen) for 5 days.
Figs 4A to D: (A) Advanced bony defect found on reflection of full thickness palatal mucoperiosteal flap; (B) PGG sealed with Biodentine; (C) PRF membrane placed over the bony defect; (D) Postsuturing
The patient was scheduled for follow-up appointments at 1 week, 1, 2, 3, 6, and 12 months, postoperatively. At these visits, the concerned tooth was examined both clinically and radiographically to assess the endodontic and periodontal status. At the 3-month follow-up, the pocket probing depth decreased from 8 to 4.0 mm, and it persisted at 3 mm at the 6-month follow-up (Fig. 5A). No bleeding upon probing or exudate was observed, and tooth mobility decreased to within physiological limits. The 12-month follow-up radiograph demonstrated significant bone regeneration in the osseous defect (Fig. 5B).
Figs 5A and B: (A) Probing depth reduced to 3 mm on 6 months follow-up; (B) 12-month follow-up radiograph
DISCUSSION
A thorough evaluation of preoperative radiographs is crucial when dealing with cases exhibiting complex anatomical variations and rare canal configurations. In the current case, the root anatomy appeared indistinct in the preoperative radiographs, indicating potential anatomical and morphological anomalies. Consequently, the utilization of CBCT proved invaluable, providing detailed insights into the depth and apical extent of the groove, its communication pathways, the location of accessory roots and canals, and the extent of bone loss.
The treatment strategy for teeth affected by PGG revolves around three key principles—(1) comprehensive elimination of microbial contamination, (2) thorough and permanent sealing of the groove communicating with the pulp and periodontium, and (3) promoting periodontal regeneration and complete healing.10 Initial assessment involves determining pulp involvement. If the tooth remains vital and lacks direct communication between the groove and pulp, preserving pulp vitality while treating the groove separately is advised.11 However, in cases where chronic involvement of the periodontium renders the tooth nonvital, endodontic treatment becomes necessary, as in this case.
Various materials have been employed for sealing PGG, including GIC, amalgam, composite resin, and calcium silicate-based types of cement like mineral trioxide aggregate and Biodentine. Biodentine, recognized as a “dentin replacement and repair material,” boasts bioactive properties conducive to promoting hard tissue regeneration. It facilitates hydroxyapatite crystal formation at the dentin material interface, improving sealing ability, with additional benefits including easy handling, a short setting time, compatibility with moisture, enhanced mechanical properties, and biocompatibility. Studies have demonstrated its support for PDL fibroblast adhesion and its utility as a root repair material, making it a preferred choice for PGG repair in this instance.12,13
While some literature suggests successful outcomes with intentional replantation for extensive groove area cases, this option was not pursued in this case due to the presence of an accessory root.14 For attachment apparatus regeneration, PRF membrane placement over the bony defect was opted for, as it releases growth factors conducive to wound healing and new bone formation. This approach offers simplicity, minimal cost, reduced need for specialized grafting materials, and negligible risk of disease transmission or graft rejection, given its autologous nature.15
Clinical Significance
In the past, a tooth diagnosed with a PGG presenting a complex lesion was often considered to have a poor prognosis, leading to recommendations for immediate extraction. However, advancements in materials, diagnostic tools, and a deeper understanding of the characteristics and treatment approaches have resulted in numerous recent cases demonstrating successful outcomes in managing teeth with PGG. Recognizing the presence of this anomaly is crucial for clinicians, as it enables accurate diagnosis and effective management strategies to be implemented, ultimately improving treatment outcomes.
ORCID
Sumedha Gupta https://orcid.org/0000-0003-3254-7150
Rinku Mathur https://orcid.org/0000-0002-8687-3632
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