Indian Journal of Dental ResearchIndian Journal of Dental ResearchIndian Journal of Dental Research
HOME | ABOUT US | EDITORIAL BOARD | AHEAD OF PRINT | CURRENT ISSUE | ARCHIVES | INSTRUCTIONS | SUBSCRIBE | ADVERTISE | CONTACT
Indian Journal of Dental Research   Login   |  Users online: 578

Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size         

 


 
Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 3  |  Page : 415-418
Successful management of pulpo-periodontal lesion in maxillary lateral incisor with palatogingival groove using CBCT scan


Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India

Click here for correspondence address and email

Date of Submission08-Jun-2011
Date of Decision02-Sep-2011
Date of Acceptance20-Jan-2012
Date of Web Publication11-Oct-2012
 

   Abstract 

Palatogingival groove is a rare developmental anomaly involving the lingual surface of the maxillary incisor and resulting in severe endodontic and periodontal lesions. This case report describes a multidisciplinary approach for the combined management of the endodontic and periodontal problems for successful rehabilitation of the involved tooth. Cone-beam computed tomography (CBCT) helped in correct diagnosis of the lesion and hence enabled effective treatment.

Keywords: CBCT, glass-ionomer cement, palatogingival groove, thermoplasticized gutta-percha

How to cite this article:
Rajput A, Talwar S, Chaudhary S, Khetarpal A. Successful management of pulpo-periodontal lesion in maxillary lateral incisor with palatogingival groove using CBCT scan. Indian J Dent Res 2012;23:415-8

How to cite this URL:
Rajput A, Talwar S, Chaudhary S, Khetarpal A. Successful management of pulpo-periodontal lesion in maxillary lateral incisor with palatogingival groove using CBCT scan. Indian J Dent Res [serial online] 2012 [cited 2019 Oct 14];23:415-8. Available from: http://www.ijdr.in/text.asp?2012/23/3/415/102243
Palatogingival groove is a rare developmental anomaly of maxillary central and lateral incisors and is associated with periodontal pockets and bone loss, which may lead to pulpal necrosis. Its prevalence is 2.8%-8.5%, [1],[2] the occurrence varying in different populations and subpopulations. It is most commonly seen in the maxillary lateral incisors and less frequently in the central incisors.

The etiopathogenesis of palatogingival groove has not been fully elucidated. The palatal groove is thought to represent an infolding of the enamel organ and Hertwig's root sheath, leading to an external defect adjacent to the gingival crevice. [3] However, more recently, the etiopathogenesis has been related to the recent concept of alteration of genetic mechanisms. [4] The groove provides the site or pathway for bacteria to penetrate into the periodontal ligament area, resulting in a periodontal pocket along the length of the groove. [5] Necrosis of the adjacent pulp tissue can develop because of the presence of irritants in an area that is separated from pulp tissue by only a thin layer of enamel and dentine or cementum. [6]

Careful clinical and radiographic examination is necessary for correct diagnosis and treatment planning in such cases. Because of the two-dimensional limitations of radiographs, they are not sufficient to understand the complex anatomy of root canal system in such an anomaly. This has given palatogingival groove a reputation for being difficult to diagnose. However, with the advent of cone-beam computed tomography (CBCT), early diagnosis and timely treatment has become possible.

This case report describes the successful endodontic and periodontal management of palatogingival groove present in a maxillary lateral incisor with the use of CBCT. A combined treatment approach involving both endodontic therapy and periodontal surgical management resulted in adequate periodontal healing and resolution of the associated periradicular radiolucency.


   Case Report Top


A 20-year-old patient reported with the chief complaint of pain, discoloration, and mobility in relation to tooth 12 for the last 3-4 months. Periodontal examination revealed an around 10-mm pocket associated with a deep palatoradicular groove in relation to the maxillary right lateral incisor on its lingual surface [Figure 1]. The tooth was discolored gray-black and revealed a negative response to an electronic pulp tester (Parkell Electronics Division, New York, USA), confirming the diagnosis of a nonvital pulp. There was neither caries nor any history of trauma in relation to the concerned tooth. Thus, it appeared likely that pulp necrosis had occurred secondary to the deep periodontal defect occurring as a result of the palatoradicular groove. An intraoral periapical radiograph revealed a periapical lesion with a bony defect [Figure 2]. Since bilateral occurrence of the palatoradicular groove is possible, tooth 22 was also examined, but no evidence of a palatoradicular groove was found after sulcular probing and radiography.
Figure 1: Preoperative photograph showing presence of periodontal pocket associated with palatogingival groove

Click here to view
Figure 2: Preoperative radiograph of maxillary left lateral incisor showing the palatogingival groove with periapical radiolucency

Click here to view


Gutta-percha tracing into the periodontal pocket revealed direct communication of the periodontal pocket with the periapical area, thus confirming that the problem was primarily periodontal and secondarily endodontic in nature. Extension of the groove along the root was not clear either clinically or on radiography; on angulated x-ray views it simulated a two-rooted lateral incisor. To clarify these doubts and to establish a definitive diagnosis, we decided to refer the patient for a three-dimensional CBCT of tooth 12. CBCT demonstrated the complex anatomy of tooth 12 and showed that the groove extended till the root apex, in this manner bifurcating the root into two halves, with each having a different apex in the axial planes [Figure 3]. The pulp chamber was found to be in intimate association with the groove. CBCT revealed the presence of a 'C' shaped sheet of pulp tissue surrounding the bifurcation coronally, extending from mesial to distal along the palatal aspect of the tooth.
Figure 3: CBCT axial section demonstrating the complex anatomy of 12 with invagination extending from mesial to distal along the palatal aspect of 12

Click here to view


After taking the patient's consent, combined a combined endodontic-periodontal treatment approach was planned. Access opening was done in the usual manner except that the width of the opening was slightly increased to enable access to the bifurcation area and thus both the apices. Working length was taken [Figure 4] and the canals were cleaned and shaped using K-files, 3% sodium hypochlorite, 2% chlorhexidine, and normal saline, after which calcium hydroxide (UltraCal XS™, Ultradent Products, Inc., South Jordan, UT) was packed in both the canals for 1 week. The access opening was sealed with intermediate restorative material (IRM) (Dentsply Caulk, Milford, DE) and the tooth was reduced out of occlusion. Thermoplasticized gutta-percha (Thermafill Plus™) was used to obturate both the canals, and the access cavity was finally sealed in with glass-ionomer cement (Fuji II™; GC Corporation, Tokyo, Japan) [Figure 5].
Figure 4: Initial working length radiograph

Click here to view
Figure 5: Periapical radiograph of the completed endodontic treatment

Click here to view


The patient was reviewed after 1 week, when periodontal flap surgery was performed to eliminate the pocket and groove simultaneously. A full-thickness mucoperiosteal flap was reflected on the palatal aspect of the maxillary right lateral incisor. On reflection, an advanced circumferential bony defect was found, which surrounded the palatal, mesial, and distal aspect of lateral incisor. Granulomatous tissue was removed from the bony defect and the palatoradicular groove was traced to the apex. Following root-planing, the groove was conditioned with 10% polyacrylic acid, isolated with cotton pledgets, and sealed with light-cured glass-ionomer cement (Fuji I™; GC Corporation) [Figure 6]. Hydroxyapatite graft material (Perio Bone G ® ; Top Notch-Health Care Products, Aluva, Kerala, India) was mixed with saline and placed into the deep bony defect. The flap was readapted and stabilized with sling sutures and the wound site covered with non-eugenol periodontal dressing (Coe- Pak™; GC Inc., Alsip, IL, USA). Postoperative instructions were given and a 0.12% chlorhexidine gluconate rinse was prescribed. The patient was prescribed antibiotics (ornidazole + ofloxacin) and analgesics (ibuprofen) for 5 days. The dressings and sutures were removed 10 days after surgery so as to stabilize the graft material.
Figure 6: (a) Surgical photograph showing the presence of palatogingival groove (b) Surgical photograph showing the groove restored with GIC

Click here to view


The patient was recalled after 1 week and then in the first, second, third, sixth, twelfth, and eighteenth month postoperatively for follow-up. During these visits radiographs were taken for evaluation of the endodontic and periodontal status. Discoloration was masked with direct composite veneer. After 2 months, the pocket probing depth had reduced from 10 mm to 4.0 mm and between the sixth month and the eighteenth month it remained at 3.5 mm. There was no exudate or bleeding on probing. Mobility was reduced to within physiological limits. The 18-month follow-up radiograph [Figure 7] demonstrated excellent bone fill of the osseous defect.
Figure 7: Periapical radiograph demonstrating excellent periradicular healing

Click here to view



   Discussion Top


The complex anatomy of palatogingival groove calls for detailed knowledge of the dental root's internal morphology for successful planning of endodontic therapy. Periapical radiographs provide 2-D images of anatomic structures, and the superimposition of adjacent tissues may obscure the true nature of palatogingival groove and the extent of periodontal damage. CBCT is an x-ray imaging approach that provides high-resolution 3-D images. It is especially useful in endodontics for identification of anatomic features and variations of the root canal system. In this particular case, the use of CBCT proved to be of great advantage as it demonstrated the dimensions of groove, its communicating nature, the site of bifurcation, the volume of bone loss and, thus, the approximate amount of graft required for filling the defect. [7]

Due to the abnormal anatomical configuration, the palatogingival groove poses technical difficulties in its clinical management. When no visible communication exists between the groove and the pulp cavity, treating the groove as a separate entity and preserving the vitality of the pulp is a recommended treatment approach. Endodontic treatment was done in this case as the tooth had become nonvital due to the chronic long-standing involvement of the periodontium because of the presence of communicating channels between the groove and the pulp chamber, which facilitated bacterial penetration, causing the pulp tissue to undergo inflammation, degenerative changes, and eventual pulp necrosis.

The groove was associated with severe periodontal breakdown and extensive periapical lesion, necessitating surgical intervention. The periapical pathosis in this case was primarily due to the infected periodontium. However, it was not known how long the root canal had been infected prior to the patient developing symptoms. Mechanical debridement of the primary root canal was difficult, but the combination of chemo-mechanical instrumentation and the use of calcium hydroxide were found to be an effective method for eliminating bacteria. The use of a warm gutta-percha technique helped to obturate the root canal system, as it was possible to compact the softened material into the major irregularities within the root canal system. [8]

The problem encountered in the management of a tooth that presents with a palatal groove relates to the inability to adequately treat the tooth periodontium and resolve the associated localized periodontal defect. It is important to note that it is the ability to adequately treat the associated periodontal defect that ultimately determines the prognosis of these teeth. This case report describes successful management of a maxillary lateral incisor with a deep palatal groove and associated periodontal and pulpal involvement using a combined endodontic and periodontic treatment approach. With this management approach there was improvement in periodontal ligament attachment and periradicular healing as assessed on the 18-month follow-up radiograph.


   Conclusion Top


CBCT meets a much needed diagnostic imaging need in dentistry. With a collaborative management of the complex root canal system and the significant developmental anomaly in this case, periodontal ligament attachment and periradicular healing were evident both clinically and radiographically on follow-up.

 
   References Top

1.Everett FG, Kramer GM. The disto-lingual groove in the maxillary lateral incisor; a periodontal hazard. J Periodontal 1972;43:352-61.  Back to cited text no. 1
[PUBMED]    
2.Withers JA, Brunsvold MA, Killoy WJ, Rahe AJ. The relationship of palatogingival grooves to localized periodontal disease. J Periodontol 1981;52:41-4.  Back to cited text no. 2
[PUBMED]    
3.Hans MK, Srinivas RS, Shetty SB. Management of lateral incisor with palatal radicular groove. Indian J Dent Res 2010;21:306-8.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Ennes JP, Lara VS. Comparative morphological analysis of the root developmental groove with the palato-gingival groove. Oral Dis 2004;10:378-82.  Back to cited text no. 4
[PUBMED]    
5.Attam,K, Tiwary R, Talwar, S, Lamba AK. Palatogingival Groove: Endodontic-Periodontal Management-Case Report. J Endod 2010;36:1717-20.  Back to cited text no. 5
    
6.Ballal NV, Jothi V, Bhat KS, Bhat KM. Salvaging a tooth with a deep palatogingival groove: an endo-perio treatment - a case report. Int Endod J 2007;40:808-17.  Back to cited text no. 6
[PUBMED]    
7.Gandhi A, Kathuria A, Gandhi T. Endodontic-periodontal management of two rooted maxillary lateral incisor associated with complex radicular lingual groove by using spiral computed tomography as a diagnostic aid: a case report. Int Endod J 2011;44:574-82.  Back to cited text no. 7
[PUBMED]    
8.Budd CS, Weller RN, Kulild JC. A comparison of thermoplasticized injectable gutta-percha obturation techniques. J Endod 1991;17:260-4.  Back to cited text no. 8
[PUBMED]    

Top
Correspondence Address:
Ambica Khetarpal
Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.102243

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

This article has been cited by
1 Diagnostic Applications of Cone-Beam CT for Periodontal Diseases
Yousef A. AlJehani
International Journal of Dentistry. 2014; 2014: 1
[Pubmed] | [DOI]



 

Top
 
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


    Abstract
   Case Report
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed5688    
    Printed113    
    Emailed11    
    PDF Downloaded299    
    Comments [Add]    
    Cited by others 1    

Recommend this journal