CASE REPORT

PALATAL LINGUAL GROOVE RECOGNITION AND TREATMENT

AUTHORS: Dr. Pooja Kakkar; Professor, Dr. Anant Singh; Post Graduate, Department of Conservative Dentistry and Endodontics, Sardar
Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, India
Address Of Correspondence: Dr. Pooja Kakkar, Professor and Head Department of Conservative Dentistry and Endodontics, Sardar Patel Post
Graduate Institute of Dental and Medical Sciences, Rai Bareilly Road, Lucknow-226025 India Cell:+919235597565 poojakakkar11@yahoo.com

ABSTRACT : Radicular Lingual Groove is a developmental anomaly that has a predilection for maxillary lateral incisors. The clinical
significance of this condition is that it acts as a retentive area for plaque which is difficult to keep clean. The result is an endodontal
periodontal lesion. This case report presents the diagnosis and treatment options to treat the defect.
KEY WORDS Radicular Lingual groove , Lateral incisor, Endo perio lesion

INTRODUCTION: modalities has been discussed.

Radicular lingual groove (RLG) is a developmental
anomaly mainly found on the palatal surface of maxillary lateral
incisors and to some extent on the labial surface of maxillary
central incisors.1This groove has also been termed as radicular
groove, cingulo- radicular distolingual groove, palato- gingival
groove and vertical developmental groove.2 The anomaly might
be unilateral or bilateral.3 Presence of RLG has also been
observed in maxillary second molars.4 It is an enamel or
cementum lined groove that usually initiates at the level of the
cingulum extending along the root to varying lengths.5
The etiology of the groove is not fully understood. One school of
thought suggest that this defect is a mild form of dens invaginatus
but there is only an infolding of epithelium resulting in a groove
rather than an invagination that results in a circular opening.
Others believe that radicular groove formation may represent an
aborted attempt to form an additional root.6 The presence of RLG
does not always indicate the development of pathology. In most
cases the epithelial attachment remains intact across the groove
and the periodontium remains healthy. Once the attachment is
breached due to endodontic involvement, a self containing
periodontal pocket forms along the length of the groove.
Inflammation can progress from an apical lesion coronally along
the groove, causing a primary endodontic and secondary
periodontic lesion. The epithelial attachment may also be
breached by gingival irritation secondary to microbial plaque
retention creating a periodontal defect. The inflammation can
spread to the pulp through defects in the groove to involve the
root apex.7
This anomaly can pose dilemmas for diagnosis and clinical
management. The RGL might escape detection until patient
presents with advanced pulpal pathosis with secondary
periodontal involvement. The clinical significance of this funnel
shaped defect lies in the fact that it makes the tooth a susceptible
niche for bacterial plaque accumulation and subsequent
inflammation. Prognosis of teeth affected by this anomaly
depends upon the depth and extension of the groove. Shallow
grooves may be corrected by odontoplasty in conjunction with
periodontal treatment. Grooves that are more advanced,
prognosis may be poor due to pulpal or periodontal breakdown.
This article presents a case of a lateral incisor anatomically
complicated with a RLG. The rationale behind the treatment
Journal of Dental Sciences & Oral Rehabilitation : Jan-March 2012
CASE REPORT
A 40 year old female patient presented in the outpatient
department with a complaint of pain, pus discharge from upper
anterior region and bad mouth odour. History revealed that pain
was mild and intermittent. Clinical examination showed the
gingiva on the labial aspect was inflamed and edematous and
bleeding on probing and pus discharge from the palatal gingival
sulcus area. Soft tissue examination revealed a draining sinus
tract on the labial alveolar mucosa associated with maxillary
left lateral incisor (Fig 2A). Mobility of tooth was within
physiological limits. Oral hygiene was fair. Medical history was
non contributory. Hard tissue examination revealed the tooth #
22 to have an intact crown without caries or fracture. A radicular
lingual groove on the distopalatal aspect of the tooth starting
from the cingulum area of the crown into the gingival sulcus
creating a 8mm pocket with purulent exudates (Fig 2 B). Facially
the gingival sulcus had normal probing depth. Since bilateral
occurance of RLG is possible, tooth # 12 was also examined but
no evidence of the same was found after sulcular probing and
radiography. Radiographically, there was a large localized lateral
bony defect encircling the root apex of the affected tooth (Fig
1A).
Thermal and electric vitality tests gave a negative response
confirming the diagnosis of nonvital pulp. The sinus tract and
periodontal pocket revealed the communication with the apical
area confirming the diagnosis of chronic suppurative apical
periodontitis. The bony lesion appeared to be a combined endo-
perio lesion.
Treatment plan comprised of oral prophylaxis followed by
primary endodontic management and periodontal pocket
elimination and groove repair. Under rubber dam isolation, the
standard access cavity was prepared followed by cleaning and
shaping using and crown down technique upto an apical file size
50. Root canal was debrided using copious irrigation with 3%
Sodium Hypochlorite and final rinse with saline before closing.
Calcium hydroxide dressing was placed between appointments.
One week later obturation was completed by cold lateral
condensation an AH Plus as sealer (Fig 1B). Access was sealed
with composite. Two weeks later, after the sinus tract had healed
the palatal pocket could still be probed (8 mm). Periodontal flap
surgery for pocket elimination was scheduled. A full thickness
53
mucoperiosteal flap was reflected on the palatal aspect and the
RGL was isolated to its most apical extent (Fig 2D). Granulation
tissue was curetted from the apical defect and surrounding area
to leave soft tissue more conductive to regeneration (Fig 2C).
Thorough scaling and root planing was performed over the
groove the bacteria that might have colonized there. The groove
was saucerised, i.e a small round diamond bur was used to
hollow out the defect to its depth (Fig 2E). A chemical
conditioning of the groove was performed by using 10%
polyacrylic acid and GIC type II was applied over the defect (Fig A B C
2F). The surrounding area was kept isolated from blood and Fig re 1.A.Diagnostic radiograph B.Obturation radiograph C. Radiograph
tissue fluids during setting of the cement by using local taken after 6 months showing healed periapical lesion
hemostatic gelatin sponge. After the cement had hardened the
apical defect was filled with bone graft (Fig 2G). The flap was
readapted and stabilized with sling sutures and wound site was
covered with non eugenol periodontal dressing. The patient was
given post surgery precautions and maintenance protocol
instructions which included non steroidal anti inflammatory
drug, ibuprofen 400mg three times daily for three days and 0.2%
chlorhexidine mouth rinse twice daily for two weeks. One week
following surgery the dressings and sutures were removed. A B
Healing after surgery was uneventful. The patient was put on
periodic recall after 1,3,6,12 months post operatively during
which radiographs were taken for evaluation of the endodontic
and periodontal status. During this period, the probing depth
gradually reduced to about 3mm (Fig 2H). Radiographically,
there was complete disappearance of radiolucency around the
lateral incisor suggesting bone fill of the previously existing
osseous defect (Fig 1C).
DISCUSSION
Radicular lingual groove is a rare developmental anomaly with a
prevalence of 2.8-8.5%.8 Successful treatment of RLG depends
on the ability to eradicate inflammatory irritants by eliminating
the groove. RLG acts as a “plaque trap” facilitating the
development of a combined endodontic periodontal lesion
because there might be a communication between the pulp canal
system and the periodontium through the accessory canals. This
might even lead to being diagnosed as a primary endodontal
lesion. The diagnosis might further be complicated because the
picture might point towards a periodontal abscess, and
radiographically the RLG might appear like a vertical root
fracture or an extra root canal.9 Prognosis of teeth affected by this
anomaly depends of the location, depth and extension of the
groove and the extent of periodontal destruction. Teeth with
mobility within normal limits and shallow grooves can be
corrected by odontoplasty in conjunction with periodontal
treatment including curettage of granulation tissue. However
when the groove is more advanced with associated extensive
periodontal destruction, the management becomes complex.
Successful treatment of this particular type of RLG depends on
the ability to eradicate inflammatory irritants by eliminating the
Figure 2. A.Pre-operative photograph B. Pre -operative photograph
groove and encouraging the patient to keep good hygiene. palatal view C. Showing defect after curettage D. Showing after palatal
In the past combined endodontic-periodontal lesions of this sort flap reflection E.Saucerization of groove F. Glass ionomer filled in the
were often untreatable by any means other than extraction. saucerized groove G. Bone graft placed in the defect H. Post operative
Treatment options that have been performed are curettage of the photogarph showing normal sulcus depth
affected tissues,10 burring out the groove with a round bur
Journal of Dental Sciences & Oral Rehabilitation : Jan-March 2012 54
 11 11
(saucerization), sealing the groove with a variety of materials, 7. Simon JH, Glick DH, Frank Al. The relationship of
root canal therapy as a primary or secondary endodontic lesion,2 endodontic periodontic lesions. J Periodontal
surgical procedures including guided tissue regeneration therapy 1972;43(4);202-208
and intentional replantation.12 Odontoplasty was carried out by 8. Everett FG, Kramer GM. The disto-lingual groove in the
saucerization of the groove along its entire length to eliminate maxillary lateral incisor; a periodontal hazard. J Periodontol
bacterial plaque and calculus and to prevent bacterial 1972;43:352–61.
recolonisation. Materials that have been suggested to fill the 9. Robison SF, Cooley RL. Palatogingival groove lesions:
groove in the past are Silver amalgam,13 Composite,14 Glass recognition and treatment. Gen Dent 1988;36:340–2.
Ionomer Cement (GIC),15 Dense hydroxy apatite alloplast,16 10. Schafer E, Cankay R, Ott K. Malformations in maxillary
emdogain17 to name a few. In this case GIC type II was used to incisors: case report of radicular palatal groove. Endod Dent
seal the defect. GIC has advantages of antibacterial effect, Traumatol 2000;16:132–7.
chemical adhesion to the tooth structure adequate sealing ability 11. Zucchelli G, Mele M, Checchi L. The papilla amplification
and promoting epithelial and connective tissue attachment.15 flap for the treatment of a localized periodontal defect
Regeneration of periodontal attachment and bone and associated with a palatal groove. J Periodontol 2006;
consequently improvement of the clinical conditions was 77:1788–96.
observed by reduction in pocket depth from 8mm to 3mm. 12. Attam K.Tiwary S. Talwar S. Et al. Palatogingival groove;
Cleaning and sealing of coronal portion of the groove to prevent Endodontic Periodontal management – Case report. J Endod
bacterial colonization. Conditioning of the groove removes the 2010;36;1717;1540-6
surface debris, increases the wettability and increases bond
13. Friedman S, Goultschin J. The radicular palatal groove; a
strength of GIC cement18, Since there was an advanced bony
therapeutic modality. Endodon Den Traumatol 1988;4;282-
defect that surrounded the root, a synthetic alloplast
6
hydroxyapatite bone graft (RTR bone graft, Septodont) was
14. Cortellini P, Pini PG, Tonetti MS. Periodontal regeneration
placed to promote bone regeneration. Healing was uneventful. A
of human infrabony defects: I—clinical measures. J
one year post operative follow up revealed increased
Periodontol 1993;64:254–60.
radiodensity at the apex. The patient was asymptomatic and a
3mm non bleeding sulcus was present on the lingual aspect. 15. Maldonado A, Swartz ML, Phillips RW. An in vitro study of
certain properties of a glass ionomer cement. J Am Dent
CONCLUSION
Assoc 1978;96:785–91.
Radicular lingual grooves are most often missed out during oral
16. Jeng JH, Lu HK, Hou LT. Treatment of an osseous lesion
examination. Such deep grooves can predispose to pulpal
associated with a severe palato-radicular groove: a case
necrosis and treatment failure due to lack of awareness by the
report. J Periodontol 992;63:708–12.defects: I—clinical
clinician. This case reported the successful management a
measures. J Periodonto1993;64:254–60.
primary pulpal and secondary periodontal lesion complicated by
17. Khalid Al-Hezaimi et al, Oral Surg Oral Med Oral Pathol
the presence of a RLG. A multidisciplinary approach from
Oral Radiol Endod 2009;107:82-85
diagnosis to treatment can help salvage an otherwise hopeless
tooth. 18. Powis DR, Folleras T, Marsen SA, Wilson AP. Improved
adhesion to glass ionomer cement to dentin and enamel.
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