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CASE REPORT

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MANAGEMENT OF PALATOGINGIVAL

GROOVE IN MAXILLARY INCISOR

- A CASE REPORT AND REVIEW

Dr. Aishwarya Durai, Dr. Kota Bala Chaithanya Prasad *

Department of periodontics, Chettinad Dental College and Research Institute. Chennai, Tamilnadu, India.

*Department of Pedodontics, Sri Venkateshwara Dental College, Chennai, Tamilnadu, India.Kanchipuram

603319.Tamil Nadu , India.

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ABSTRACT

Website: jidam.idamadras.com

Palatogingival grooves

(PGG) are developmental

malformations which predispose to endo-perio lesions.

Owing to their occurrence, funnel-shaped morphology

and vacillating extent on tooth root, they advocate plaque

and bacterial adherence to levels significant for the

development of pathology. Several treatment approaches

have been recognized in literature for the management of

PGG. In this report, a 32 year old patient reported with the

complaint of pain in maxillary left central incisor. Clinical

examination confirmed an endo- perio lesion in relation

to PGG. The aim of this case report is to provide treatment

strategies for PGG which includes eradication of microbes,

sealing the PGG to eliminate bacterial colonization and to

Address for correspondence:

regenerate the attachment apparatus. Combined endo - perio

approach will be successful in resolving the pathology with

Dr. Aishwarya Durai, MDS.,

complete healing clinically and radiographically. Prompt

Senior Lecturer,

diagnosis, prevention and management is required to

Chettinad Dental College and

prevent tooth loss due to complications arising secondary

Research Institute, Chennai,

to their presence.

Tamilnadu, India.

E-mail: dkm.aishwarya@gmail.com

KEYWORDS: Palatogingival groove, mineral tri-oxide

aggregate, platelet rich fibrin.

Received

: 26.9.2019

Accepted

: 11.11.2019

Published

: 27.12.2019

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JIDAM/Volume:6/Issue:4/Pages 144 - 149/October - December 2019

Aishwarya et al: Management of palatogingival groove in maxillary incisor

INTRODUCTION:

maxillary central incisor for past 2 months came

to the Out-patient Department Of Periodontics.

Palato-gingival groove(PGG) is defined as a

On Clinical examination, the left maxillary central

developmental anomaly of the root that when present

incisor (21), had an intact crown without caries or

is usually found on the lingual surface of the maxillary

fracture, with a positive response to percussion (Fig

incisor teeth(Lee KW et al,1968)¹.PGG originates

1). The tooth was grade II mobile with probing pocket

when the central fossa crosses the cingulum and

depth of 8mm in the mesio-palatal aspect of the tooth

extends to varying distance in an apical direction

with a concomitant finding of palatogingival groove

(Withers JA et al,1981).Diverse occurrence rates for

extending into the gingival sulcus

(Fig

2). Oral

PGG have been reported². Kongon et al, surveyed

hygiene was satisfactory. An IOPA of 21 revealed

3,168 extracted maxillary incisors and reported a

widening of PDL space in the mesial aspect of the

prevalence rate of 4.6% total, and 5.6% in maxillary

tooth extending upto the apical region. The patient

central inciors⁵.

was then referred to Department of Endodontics

Several etiologies have been claimed for this

for testing vitality of pulp, which showed delayed

developmental anomaly:

response. A diagnosis of Type -II Palatogingival

groove was made⁶. The patient was planned for a root

1. Consequence of an alteration in growth, such

canal therapy followed by periodontal management.

as an infolding of the inner enamel epithelium and

epithelial sheath of hertwig (Lee KW et al,1968¹).

2. Variant of dens invaginatus(Lee KW et al, 1968¹

and Withers JA et al,1981²). 3.Alteration of a genetic

mechanism and attempt to form another root^3,4. It

has been claimed that irritants and microorganisms

progress along the hollow, funnel-shaped PGG

surface, advancing to the periodontal breakdown and

root surface contamination resulting in retrogenic

Fig 1- Frontal view showing absence of caries or

pulp necrosis even though PGGs do not reach the

crown fracture in relation to 21

apex and are not very deep. The aim of this case

report was to provide a diagnostic and treatment

strategy for PGG which includes.

• Eradication of the microbes

• Sealing the radicular groove

to eliminate

bacterial colonization; and

• To regenerate the attachment apparatus.

CASE REPORT:

Fig 2- Probing pocket depth of 8mm noted pre-

operatively in relation to 21

DIAGNOSIS AND TREATMENT PLANNING:

ENDODONTIC MANAGEMENT:

A 32 year old male patient who had a dull

A Phase I therapy, oral prophylaxis was

intermittent pain at the palatal side of the left

performed. An endodontic access was performed

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Aishwarya et al: Management of palatogingival groove in maxillary incisor

after disinfecting the area with 2% Chlorhexidine

conditioning was done using 1% tetracycline (Fig

7) and Mineral Tri-oxide Aggregate (Steptodont,St.

digluconate (Calypso,Septodent, India) and isolating

Maur-des-Fossess,France) was applied into the

with rubber dam. A working length was determined

defect (Fig 8). The area was kept isolated from blood

using an electronic apex locator .The root canal was

and tissue fluids during the setting of the cement.

cleaned and shaped using crown down technique

Defect closure with Bone Graft and PRF membrane:

A 12ml sample of whole blood was drawn

along with rotary Ni-Ti ProTaper system along with

intravenously from the patients left ante-cubical vein

Glyde

(Dentsply Maillefer Company,USA). The

and centrifuged (REMI Model R-8c with 12x 15ml

tooth was copiously irrigated with

2.5% sodium

swing out head) under 3000 rpm for 10mins to obtain

hydrochloride, following which the access was

the PRF (Fig 10).The bony defect was filled with

De- mineralized freeze-dried bonegraft (Osseograft,

temporized using calcium hydroxide. The patient

Advanced Bio-Tech, India) (Fig 9). The compressed

was then recalled after

1 week, the tooth was

PRF membrane was the placed over the graft (Fig 11)

asymptomatic and hence it was obturated using

and flap was approximated using 3-0 BBS sutures

thermo-plasticized gutta percha obturating technique

(Fig 12). Immediate post operative radiograph was

taken to view the bone defect fill (Fig 13).

(Fig 3) with the appropriate master gutta-percha cone

and AH-Plus sealer (Denstsply Maillefer Company,

USA).

Fig 4- A full-thickness flap raised in relation to the

palatal aspect of 21.

Fig 3- Pre-operative IOPA showing radiolucency on

the mesial aspect of 21

PERIODONTAL MANAGEMENT:

Phase II/surgical therapy:

Patient was then recalled after 4 weeks for review and

periodontal therapy². On re-examination, decrease

Fig 5- PGG noted after flap elevation in relation to

in mobility was noted from grade II to grade I. the

the palatal aspect of 21.

patient was anaesthetized using local anaesthesia

(2% lignocaine with epinephrine

1:80000).An

envelope flap was raised from the buccal and palatal

aspect (Fig 4) involving one-two teeth on either side

and the PGG was isolated to its most apical extent

(Fig 5). A thorough scaling and root planing was

done over the groove and degranulation was done

using Gracey Curette Number 1/2 and 11/12 (Hu-

friedy Manifacturing Co,Chicago,IL) to leave the soft

tissue more conducive for regeneration (Fig 6). Root

Fig 6- Odontoplasty done using a round bur in

relation to 21 palatal aspect.

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JIDAM/Volume:6/Issue:4/Pages 144 - 149/October - December 2019

Aishwarya et al: Management of palatogingival groove in maxillary incisor

Fig 7- Root conditioning done using tetracycline in

Fig 11- PRF placed in relation to the palatal aspect

relation to the palatal aspect of 21.

of 21.

Fig 8- PGG sealed using MTA in relation to the

Fig 12- 3-0 BBS sutures placed in relation to 21,.

palatal aspect of 21.

22,23

Fig 9- Xenograft placed in the bone defect in relation

Fig 13-Immediate post-op IOPA in relation to 21.

to the palatal aspect of 21.

POST-SURGICAL INSTRUCTIONS:

Following surgery, the patient was placed on

amoxicillin 500 mg, thrice a day dosage for 5 day and

Ibuprofen to relieve discomfort. In addition 0.12%

Chlorhexidine gluconate rinse twice daily for two

weeks, half an hour after brushing was prescribed.

The patient was asymptomatic post-operatively and

sutures were removed after 7 days. The patient was

then recalled after 3 months and then 6 months; he

showed improvement clinically and radiographically.

Fig 10- PRF procured

Clinically there was a reduction in the pocket depth

with 3mm non- bleeding sulcus at the end of 6

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JIDAM/Volume:6/Issue:4/Pages 144 - 149/October - December 2019

Aishwarya et al: Management of palatogingival groove in maxillary incisor

months (Fig 14). There was a significant reduction in

property and was covered by a PRF membrane. The

radiolucency radiographically.

platelet rich fibrin membrane acts by releasing high-

concentration growth factors (such as transforming

growth factor type beta 1 (TGF-β1), platelet-derived

growth factor

(PDGF)-AB, vascular endothelium

growth factor (VEGF)) and glycoproteins (such as

thrombospondin-1) during at least

7days [Dohan

Ehren fest DM et al, 2009]⁸ into the wound site,

thereby stimulating healing and new bone formation

(Choukroun J et al 2006)¹⁰. The use of platelet rich

fibrin membrane is a simple cost effective method

and also reduces the need for specialized grafting

material. Because it is a completely autologous

Fig 14- 6 months post-operative view in relation to

product, the risk of disease transmission and graft

the palatal aspect of 21.

rejection is negated(Choukroun J et al 2006)¹⁰.

The post-operative view showed a reduction in PPD

DISCUSSION:

and symptomatic relief for the patient clinically

and radiographically reduction in the size of the

The PGG is a rare aberration on the maxillary

anterior teeth, with a prevalence rate of 5.6% in the

radiolucency at the end of 6 months.

maxillary central incisors. PGG apparently renders

a communication between the oral environment

CONCLUSION:

and pulp resulting in concomitant endodontic

and periodontal pathology⁹. Understanding the

PGG if left unattended may predispose the

anatomic complexities associated with the palato

maxillary incisors to attachment loss. This case

radicular groove is critical to the overall success

report involved a maxillary central incisor with a

of the treatment. In our case report the elimination

of the groove was done by sealing with MTA and

type II PGG associated with periodontal and pulpal

regeneration of the lost periodontal structures with

involvement. The treatment outcomes that have been

the use of bone graft (Xenograft) and PRF.

achieved in this case are clinical attachment gain

(8 mm), no increase in gingival recession, and the

ELIMINATION OF THE RADICULAR

GROOVE:

disappearance of the periapical radiolucency, thus

emphasizing the fact that complex interdisciplinary

Many materials have been used for

approach can have hope for teeth with poor prognosis.

eliminating the groove like Amalgam, Composite,

Glass inomer Cement and emdogain. MTA(Mineral

FINANCIAL SUPPORT AND

trioxide aggregate) is a bioactive, biocompatible,

SPONSORSHIP:

antibacterial material with good stability, and

excellent sealing ability. High success rate for MTA

Nil

also stimulates the production of cytokines in human

osteoblasts, allows good adherence of the cells to the

CONFLICTS OF INTEREST:

material, thereby playing an active role in dentin-

bridge formation⁷.

There are no conflicts of interest.

REGENERATION OF THE PERIODONTAL

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