CASE REPORT

Palato-gingival groove (PGG) - An enigma

ARUN A. I, SHILPA BHANDI II, SUBHASH T S III
speculated to be an aborted formation of an additional root.3 In 1958, Oehlers described for the first time a radicular invagination of an upper lateral incisor in a Chinese female. At this time, the idiom groove was not in common in the dental literature. Later Lee et al formulated the term groove when presenting a case report concerning palatal grooves in maxillary laterals.4 The anomaly generally has a funnel-like shape, which forms a niche where bacterial plaque and calculus accumulate; this makes it difficult, and sometimes impossible, for the patient or even the professional to clean properly. Inflammation thus develops in the periodontal tissue adjacent to the groove.5 Palatal grooves can vary in depth and complexity. Mild ones terminate at the CEJ whereas moderate grooves continue apically along the root surface. The most complex forms are deeply invaginated defects that separate an accessory root from the main root trunk. 6 The clinical significance if PGG is related to the incidence of localized periodontitis with or without pulpal pathosis, depending on the depth, extent and complexity of the groove. 7 This paper reports two cases of PGG successfully treated with two different treatment modalities. A) Bilateral PGG resolved using flowable composite. B) Unilateral PGG treated by intentional reimplantation.

ABSTRACT
Aim: To treat the palatogingival groove, an endo-perio entity with conservative and surgical endodontic approach. Objective: Potential use of flowable composite and root canal therapy along with intentional reimplantation in the treatment of palatogingival groove in maxillary lateral incisors. Case description: Two cases with unilateral and bilateral PGG have been reported. The study demonstrates the use of flowable composite in resolving the bilateral PGG and RCT followed by intentional reimplantation in treating the unilateral PGG. Conclusion: The cases reported utilize conservative and surgical endodontic approach for an endo perio lesion. The results demonstrate how these techniques may optimally help to maintain a tooth whose location in the arch is very critical. Key words: palato gingival groove, endo perio lesions, intentional reimplantation,

Introduction
The area of the maxillary lateral incisor is an area of embryological hazard. A great number of major and minor malformations occur in this area, for instance cleft palate, the globulo-maxillary cyst and missing or supernumerary and peg shaped lateral incisors. The dens in dente are also found more frequently in this area than anywhere else in the dentition. Another mild anomaly or variant occurring in this region is the palatogingival groove.1 As a developmental anomaly, PGG is not a rare condition, mostly occurring on the palatal aspect of maxillary lateral incisors.2

Case reports
A female patient of age 28 reported to Department of Conservative Dentistry and Endodontics, Bapuji Dental College and Hospital, Davangere. Her chief complaint was sensitivity with respect to 12, 22 (upper right and left front tooth region). Careful examination showed a notch at the junction of marginal gingiva w.r.t. 12 and 22 and 4mm pocket with the same(Figure 1.1). Severe bleeding on probing with grade I mobility was present.

The formation is by infolding of the enamel organ and the Hertwigs epithelial root sheath and has been speculated to be an aborted formation of an additional IJCD NOVEMBER, 2010 1(2) root.3 In 1958, Oehlers described for the first time a radicular

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Fig 1.1: Bilateral Palatogingival Groove

Fig 1.2: Sulcular incisions were given and flap raised

Fig 1.3: Saucerization of the groove done

Fig1.4: Etching and bonding done

Fig1.5: Groove resolved by restoring with flowable

Fig1.6: Sutures placed

composite On manual probing with Williams graduated periodontal probe the tooth indicated concavity crossing CEJ extending to the root in the form of a groove. Thermal and electrical pulp testing showed normal response. Thus the endodontic treatment was not indicated. The treatment consisted of reflection of a full thickness periosteal flap palatally using sulcular incision under local anesthesia (Figure 1.2); the grooves were noticed extending just beyond CEJ around 4mm deep. The saucerization of grooves was done by high speed diamond point with continuous stream of water (Figure 1.3). Then the grooves were Fig1.7: Sutures removed after 2 weeks resolved using FILTEK FLOW flowable composite resin (3M/ESPE, St. Paul, MN, USA) with prior etching and bonding using XENO III (DENTSPLY, USA) (Figures 1.4, 1.5,). Next flap was repositioned and sutures were placed IJCD NOVEMBER, 2010(Figure 1(2) 1.6). Patient was recalled after two 2010 Int. Journal of Contemporary Dentistry weeks for suture removal and evaluation (Figure1.7). And at the end of fifth month of surgery soft tissue evaluation was done. The result showed there was

CASE REPORT
(Figure 1.6). Patient was recalled after two weeks for suture removal and evaluation (Figure1.7). And at the end of fifth month of surgery soft tissue evaluation was done. The result showed there was reduction in the pocket depth with pulp vitality being normal again. 2) A male patient of age 36 years reported to Dept of Conservative Dentistry and Endodontics, Bapuji Dental College and Hospital, Davangere. The chief complaint was severe pain and mobility with respect to 12. On careful examination grade II mobility was present with a pocket depth of 7mm on palatal aspect and a groove was noticed extending onto the root surface from CEJ. (Figure 2.1) The patient was explained about the treatment options of extraction and dental implant or extraction and reimplantation. Patient agreed for latter option. According to the treatment plan the tooth was extracted under local anesthesia and observed that there was presence of deep palato gingival groove extending from CEJ till the apex. (Figure 2.2 & 2.3) The groove was treated using ultrasonic tips and was restored with FILTEK FLOW flowable composite resin (3M/ESPE, St. Paul, MN, USA) with prior etching and bonding using XENO III (DENTSPLY, USA) (Figure 2.4) . And root canal treatment was carried out extra orally, and tooth was obturated (Figure 2.5). The whole procedure was carried out within a time span of 10 min 30 seconds. Tooth was repositioned back into the socket and x-ray was taken to evaluate the position of the tooth. Finally composite splinting was done (Figure 2.6). Patient was recalled after 2 weeks for evaluation. The composite splint was removed after a month. The healing was satisfactory. Tooth mobility was normal. There was reduction in pocket depth. Patient was recalled after 6 months and the clinical examination revealed no response to percussion, palpation and mobility was within normal limits.

Fig 2.2: Tooth 12 extracted

Fig 2.3: Groove extending upto the apex

Fig 2.4: Groove resolved by restoring with flowable

composite

Fig2.1: Palatogingival groove noticed with

Fig2.5: Tooth Obturated

respect to 12

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radiolucent vertical line12 or in other cases not following the root canal.13 Although several modalities have been suggested for the treatment of this condition, there is general consensus that these are usually predictable failures, and that extraction is the most frequent solution.14 One treatment modality that has been discussed more than the others has been the attempted elimination of the groove by way of its saucerization or flattening.4 This involves the grinding of the root surface, sometimes quite extensively, and results in loss of tooth substance and exposure of cut dentin. One limitation of this technique is its impracticality in deep grooves that communicate with the root canal, and as concluded by Meister, this treatment only can be successful if there is not a continuous opening along the length of the radicular lingual groove between the pulp canal and the periodontal tissues. In the last decades, with extensive knowledge of guided tissue regeneration, mechanical barriers have been used to halt epithelium downgrowth along the root surface, allowing periodontal ligament, cementum and bone to regenerate along periodontally diseased roots. Also calcium sulfate has been used as mechanical barrier to allow periodontal regeneration.15 In the cases reported here, the palatogingival groove which is an endo-perio lesion is being treated with conservative and endodontic approach without any periodontic intervention. In the first case the bilateral PGG is resolved by filling it with flowable composite. A full thickness periosteal flap was reflected palatally using sulcular incision under local anesthesia; around 4mm deep grooves were noticed extending just beyond CEJ. The saucerization of grooves was done and the grooves were resolved using flowable composite resin. The flap was repositioned and sutures were placed and patient was recalled after two weeks for suture removal and evaluation. The evaluations done after five months showed satisfactory results. In the second case reported the treatment modality required was a surgical endodontic one. Due to the severity of the case, showing severe pain, grade II mobility, and a pocket depth of 7mm, the treatment of choice with patients consent was intentional replantation. The tooth was extracted under local anesthesia and the groove was resolved using flowable composite resin. Root canal treatment was carried out extra orally, and tooth was obturated. The whole procedure was carried out within a time span of 10 min 30 seconds. Tooth was repositioned back into the socket and x-ray was taken to evaluate the position of the tooth. Finally composite splinting was done and the patient was recalled after 2 weeks for evaluation. The case was again evaluated after a month and the composite splint was removed. Patient was recalled after 6 months and the clinical examination revealed no response to percussion,

Fig 2.6: Wire and Composite Splinting done.

Discussion
The PGG is a developmental anomaly of variable extent and depth that may or may not involve a communication between the pulp cavity and the periodontal tissue. The anomaly has a variety of names: the palatogingival groove, the radicular lingual groove, the radicular groove, the palatoradicular groove, the facial radicular groove, the developmental groove, and the disto lingual groove.5 Kogan reported a prevalence of 4.6% in both central and lateral incisors. 54% of the grooves terminated on the root surface. In lateral incisors 43% of the grooves on the root extended less than 5mm. 47% between 6-10mm and only 10% more than 10mm. 8 Gher and Vernino stated that depth and extent of the groove is an important factor in the prognosis of the tooth. Grooves are deepest immediately after the root formation and become shallower with age. This is due to the increased cementum deposition. 9 Scanning electron microscopy of teeth with radicular palatal grooves has found that the deepest part of the groove is usually in the cervical region (Gao et al. 1989). In severe cases, the histological findings are more distinctive. Dysplastic radicular dentin with numerous clefts are often encountered along the length of the defect, while in deeply invaginated cases, there may be a groove with entrapped enamel within a blind cul-de-sac1 This fissure like channel is a locus of plaque and calculus accumulation, which acts as a secondary local etiologic factor encouraging the development of periodontitis.10 A patient with PGG may have the symptoms of a periodontal or acute dento alveolar abscess or may show no symptoms at all. Frequently a lesion related to a groove is characterized by recurrent symptomatic episodes. 11 Only rarely can the PGG be seen on radiographic examination in the form of a parallel the treatment of this condition, there is general

IJCD NOVEMBER, 2010 1(2) 7 Although several modalities have been suggested for 2010 Int. Journal of Contemporary Dentistry

CASE REPORT
palpation and mobility was within normal limits. The cases reported here presented effective management of an endo-perio entity with only conservative and endodontic approach, which also successfully resulted in the regain of lost periodontal support. More importantly the position of these lateral incisors in their critical positions in the arch was maintained thus restoring the esthetics of the patient. 9. Gher M, Vernino A. Root morphology: Clinical significance in pathogenesis and treatment of periodontal diseases. J Am Dent Assoc 1980; 101: 627 10. Kozlovsky A, Tal H, Yechezkiely N, Mozes O. Facial radicular groove in a maxillary central incisor A case report. J Periodontol 1988 September; 59(9):615-617. 11. Robinson SF, Cooley RI. Palato-gingival groove lesions: recognition and treatment. Gen Dent 1988;36:340-342 12. Lee RW, Lee EC, Poon RY. Palato gingival grooves in maxillary incisors: a possible predisposing factorto localized periodontal disease. Brit Dent J 1968;2:14-8 13. August DS. The radicular lingual groove: an overlooked differential diagnosis. J Am Dent Assoc 1978;96:1037-9 14. Anderegg CR, Metzler DG. Treatment of the palato-gingival groove with guided tissue regeneration. Report of 10 cases. J Periodontol 1993;64:72-74. 15. Andreana S. A combined approach for treatment of developmental groove associated periodontal defect. A case report. J Periodontol 1998;69:601-607.
About the Authors: I ) Dr Arun A. MDS Senior Lecturer Dept Of Conservative And Endodontics Sri Siddhartha Dental College Tumkur.

Conclusion
Deep radicular grooves can predispose to pulp necrosis and the establishment of combined endodontic-periodontal lesions. Evaluation of clinical signs and appropriate diagnostic tests are of paramount importance in order to prevent incorrect diagnosis and treatment. Endodontists must be capable of performing advanced periodontal regeneration techniques during endodontic surgery for the successful treatment of these lesions.

References
1. Everett FG, Karmer GM. The disto-lingual groove in the maxillary lateral incisor; A periodontal hazard. J Peridontol 1972 June;43(6):353-361. 2. Hou GL, Tsai CC. Relationship between palatoradicular grooves and localized periodontitis. J Clin Periodontol 1993;20:678682. 3. Simon JH, Glick DH, Frank AL. Predictable endodontic and periodontic failures as a result of radicular anomalies. Oral Surg Oral Med Oral Pathol 1971;31:823-826. 4. Schafer E, Cankay R, Ott K. Malformations in maxillary incisors : case report of radicular palatal groove. Endod Dent Traumatol 2000;16:132-137. 5. Cecflia MS, Lara VS, Moraes IG, Paulo S, Brazil. The palato-gingival groove a cause of failure in root canal treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:94-8). 6. Goon WW, Carpenter WM, Braces NM, Ahlfeld RJ. Complex facial radicular groove in a maxillary lateral incisor. J Endod 1991; 17 : 2448. 7. Wei PC, Geivelis M, Chan CP, Ju YR. Successful treatment of pulpal-periodontal combined lesion in a birooted maxillary lateral incisor with concomitant palato-radicular groove. A case report. J Periodontal 1999;70:1540-1546. 8. Kogan S. The prevalence, location and comformation of palato radicular grooves in maxillary incisors. J Periodontol 1986;57:231.

Senior Lecturer Dept Of Conservative And Endodontics Bapuji Dental College And Hospital Davangere.

II) Dr Shilpa H. Bhandi MDS

Professor Dept Of Cons And Endo Bapuji Dental College And Hospital Davangere. Correspondence Address: Dr. ARUN A. Pragathi, #123, Near G D Naidu Hall, West Of Chord Road, Rajajinagar I Block. Bangalore

III)Dr Subhash T. S.

MDS

E-mail drarun243@gmail.com

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2010 Int. Journal of Contemporary Dentistry