Endodontic management of maxillary lateral incisor with palato-gingival groove - an innocuous culprit of endo-perio lesion.

Dr. Rafeza Sultana

MS-Resident, Phase-B

Dept. of Conservative Dentistry & Endodontics

BSMMU

Abstract:

Morphological defects occurring in dental structures can be sometime predisposing factor for the onset of inflamatory processes in the periodontal &/ pulpal tissue. Palato-gingival groove is one such defect, most frequently found on the palatal surface of the maxillary laterals. Recognition of such a defect is critical & important, especially because of its diagnostic complexity & further consequences.  This case repot is to describe the clinical management of tooth with palato-gingival groove (PGG) in a right maxillary lateral incisor with endo-perio lesion leading to dentoaiveolar abscess & sinus tact.

Keyword: Palato-gingival groove, Endo-perio lesion.

Introduction:

The region where the maxillary lateral incisors are located is considered to be an area of embryological hazard (J Dijalma et al, 1991). A great number of minor & major malformations occur in this area. For instance cleft palate, globule-maxillary cyst, missing or supernumerary tooth, dense in dente & peg lateral incisors. Another anomaly occurring in that region is PGG (Everetti FG et al, 1972).

The etiology of groove formation is not fully understood. But it is thought that the formation of PGG is by infolding of the enamel organ & the Hertwing’s root sheath (Walker & Jons, 1983) & has been speculated to an aborted formation of additional root (Keruzoudis et al, 2003).

The PPG has the similarity to dens  invaginatus, however it differs from dens invaginatus in such way that PGG occurs due to an infolding of the epithelium (resulting in a groove), rather than an invagination (resulting in a circular opening) (TG Ground 1988).

The anomaly has a variety of name, the PPG, the radicular lingual groove, the palato-radicular groove, the facial-radicular groove, the disto-lingual groove (Cacflia MS et al, 1998).

The PPG is the funnel shaped appearance which forms a niche for bacterial plaque & calculus accumulation making it difficult for the patients as well as professionals.

These grooves can be classified in to mild, moderate & complex based on its depth and extent. Mild one terminates at the CEJ whereas moderate grooves continue apically along the root surface. The complex forms are deeply grooved defects that separate an accessory root from the main root trunk (Goon WW et al, 1991).

                           

   Mild                                    Moderate                       Complex

                  Fig: Different types of palato-gingival groove.

Deferent studies have revealed a prevalence rate for palatal groove of about 2.8% to 8.5%, the most prevalent being the maxillary lateral incisor (D Rachana et al, 2007). In lateral incisors 43% of the grooves on the root extended less than 5mm. 47% between 6-10mm and only 10% more than 10mm (Kogan 1986).

Case report:

A 30 year old female patient came to the dept. of conservative Dentistry & Endodontics, BSMMU with the complaint of occasional episodes of swelling of gum & purulent discharge in relation to upper right lateral incisor. Her medical history was non contributory. There was no history of trauma, caries nor any discoloration of tooth. Intra-oral examination showed localized swelling & an intraoral draining sinus pointing on the labial gingiva at the apex of right lateral incisor. The palatal surface of lateral incisor showed fossa with mild calculus embedded in it. Periodontal examination revealed mild bleeding on probing & a narrow periodontal pocket (<5mm) alongside the groove & other aspects were revealed normal. There was no mobility associated with it. To locate the origin of the sinus, a gutta percha cone (no#25) was inserted in to its course & a radiograph was taken. The GP cone pointed towards the apex of the offending tooth. Radiograph also showed periapical radiolucency (about 3mm). On vitality test the tooth was found to be non vital. The findings were suggestive of primary pulpal lesion (Type-1 endo- perio lesion).

So, the case was diagnosed as type-I endo-perio lesion due to palato-gingival groove (Mild type).

Treatment plan comprised with of oral prophylaxis followed by primary endodontic management provided three dimensional obturation & repair of PGG with glass ionomer cement (Type-II).

The consent of the patient was taken. After mouth preparation, a straight line access cavity was done. The necrotic pulp remnants were removed & washed out by 2.5% NaOcl & normal saline. Working length (WL) measuring radiograph was taken & the WL was established as 20mm. Then the canal was prepared up to no #50 K file along with copious irrigation with NaOcl & normal saline. The canal was dried with paper point & Ca(0H)₂ paste was placed as an intracanal medicament for one week. The access was tightly sealed with ZOE cement. At the next visit the canal was found dry. Then the canal was irrigated with normal saline and dried with paper point. Before obturation a master point was inserted in to the canal & felt the tug back. Then the tooth was obturated with ZOE sealer & GP cone by lateral condensation technique and final restoration was made with GIC. The post-operative radiograph was taken at the same visit for obturation evaluation. The PPG was repaired with GIC as well. The patient was advised for follow up at 3, 6 & 12 months intervals.

   

Fig: exploration of sinus tract

  

Fig: Detection of PGG

Fig: Shallow periodontal pocket alongside the grioove

Fig: Pre-operative x-ray

Fig: Sinus trakcking x-ray

Fig: WL-measurring x-ray

Fig: Obturation x-ray

Discussion:

Palato-gingival groove is a developmental anomaly that has the predilection for the maxillary lateral incisor. The PGG presents of variable extent & depth that may or may not involve a communication between pulp cavity & periodontal tissue. These grooves are deep initially after root formation & become shallow with age due to deposition of dentin (Anderregg CR, 1993). The PPG is one of the important entities & could manifest either as true endodontic lesion, periodontal disease or may appear as a combined endo-perio lesion.

For anatomical region, the PGG is an ideal plaque trap for promoting periodontal break down & pulp necrosis. Reasons for the occurrence of combined lesion are existence of communication between the pulp chamber and the periodontium. Friedman & Goultschin have suggested pulpal necrosis followed by apical periodontitis is often earliest manifestation of PPG.

Clinician should be aware of the incidence & method for treating PPG. Rrarely the PGG can be seen on radiographic examination in the form of a parallel radiolucent vertical line (RW Lee 1968) or in other cases not following the root canal (DS August 1978).

The PGG requires early diagnosis and treatment as it may result in radicular & pulpual pathosis. This fissure like channel is a locus of plaque & calculus accumulation, which acts as a secondary local etiologic factor encouraging the development of periodontitis (Kozlovsky A 1988). 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 (Robinson SF 1988).

The pulp is also affected by bacteria which are situated in the radicular groove. Bacteria and their products may enter in to the pulp through the accessory foramen and lateral canals situated along the floor or side walls of the groove. Another groove of the bacterial invasion into the pulp is via the exposed dentinal tubules on the side of the groove where surface resorption as a result of inflamatory process (N P Kerezoudis 2003).

Treatment may vary from case to case. Early diagnosis of the case is very much important for preventive measure. Teeth with deep palatal groove should be treated with fissure sealant before plaque and food impaction & breakdown of the periodontal structures (M Hulsmann 1997).

Although several modalities have been suggested for the treatment of this condition. There is general consensus that these are predictable failures. Many treatment regimen have been suggested such as conventional root canal treatment, combined root canal therapy followed by saucerization of the defect with flowable composite, intentional replantation and guided tissue regeneration according to severity.

In the last decades, with extensive knowledge of guided tissue regeneration, mechanical barrier have been used to halt the epithelium down growth along the root surface, allowing periodontal ligament, cementum and bone to regenerate along periodontally diseased roots. Calcium sulphate, collagen methyl cellulose acetate, enamel matrix protein etc have used as mechanical barrier to allow periodontal regeneration (S Andreana 1998).

The prognosis of a tooth with PPG mainly depends on location of the groove, severity of the periodontal problem, accessibility of the defect & the type of groove ie shallow or deep, long or short.

In this case report, patient presented with true endodontic involvement (type-1 endo-perio lesion), as an earlier manifestation of PGG. So non surgical endodontic treatment was done provided three dimensional obturation & the groove was repaired with GIC & advised for periodic follow up.

GI cement was used because of its antibacterial activity & the property of chemical adhesion to the tooth structure. Clinical & histological studies have been shown that there is an apical & CT adherence to the GI cement during the healing process.

Conclution:

Palato-gingival groove is an enigma & it is considered as a silent killer that can pose dilemmas for diagnosis & clinical management. The PGG might escape detection until patient presents with advanced pulpal pathosis with secondary periodontal involvement. So the evaluation of clinical signs & appropriate diagnostic tests are of paramount important to prevent incorrect diagnosis & treatment. Endodontists must be capable of performing advanced periodontal regeneration techniques during endo-surgery for the successful treatment of those lesions.

References:

Anderegg CR, Meitzer DG (1993) Treatment of the palato- gingival groove with guided tissue regeneration. Report of 10 cases. J Periodontol 64:72-4

Andreana S A (1998) Combined approach of treatment for developmental groove associated periodontal defect. A case report J periodontal 69: 601-7

August DS (1978) The radicular ligual groove: an overlooked differential diagnosis J Am Dent Assoc 90: 1037-9

Cecflia MS, Lara VS, Moraes IG, Paolo S, Brazil (1998) The palato-gingival groove a cause of failure in root canal treatment. Oral Surg Oral Med Oral pathol Oral radiol Endod 85:94-8).

D. Rachana, Prasannalatha Nadig, Gururaj Nadig (2007) The palata groove: Application of computed tomography in its detection – A case report. Journal of conservative dentistry 10: 83-43(6): 353-361.

Everatt FG, Kermer GM (1972) The disto-lingual groove in the maxillary lateral incisor. J Endod 1991: 17:244-8.

Goon WW, Carpenter WM, Braces NM, Ahlfeld RJ, Complex facial radicular groove in a maxillary lateral incisor. J Endod 1991; 17:244-8.

Jesus Dijalma Pecora, Manoel Damia O Sousaneto Et AI (1991) Invitro Study Of redicular Grooves In Maxillary Incisors. Braz Dent J 2(1):69-73.

Kogan S (1986) The prevalence, location and conformation of palato radicular grooves in maxillary incisors. J Peridontol 57:231.

Kozlovsky A, Tal H, Yechezkiely N, mozes O (1988) Facial radicular grooves in a maxillary central incisor – A case report. J Periodontol September 59(9):615-617.

Lee RW, Lee EC, Poon RY (1968) Palato gingival grooves in maxillary incisors: a possible predisposing factoto localized periodontal disease. Brit dent J 2:14-8

M hulsmann (1997) Dens invaginatus: aetiology, classification, prevalence, diagnosis and treatment considerations. Int Endod J 79-90.

N.P. Kerezoudis, G.J. Siskos & V. Tsatsas (2003) Bilateral buccal radicular groove in maxillary incisors: case report. Int Endo Jour 36:898-906.

Robinson SF, Cooley RI (1988) Palato-gingival groove lesions: recognition and treatment. Gen Dent 36:340-342.

Tom G. Gound, Glenn I. Mze (1998) treatment options For The Redicular Lingual Groove A Review & Discussion. Pract Periodont Aesthetic Dent 10(3):369-375.