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ABSTRACT

This article is a case report of the successful interdisciplinary management of a maxillary lateral incisor with a deep palato-gingival groove. The tooth presented with severe periodontal destruction owing to the deep extension of the groove up to the root apex. The groove was meticulously diagnosed and treated by endodontic and subsequent periodontal surgery leading to complete resolution of the pathological process.

Keywords: Interdisciplinary management, Maxillary lateral incisor, Palatogingival groove, Mineral trioxide aggregate, Radicular groove.

How to cite this article: Narmatha VJ, Thakur S, Shetty S, Bali PK. The Complex Radicular Groove: Interdisciplinary Management with Mineral Trioxide Aggregate and Bone Substitute. J Contemp Dent Pract 2014;15(6):792-796.

Source of support: Nil

Conflict of interest: None

INTRODUCTION

Morphological defects in dental structure like, e.g. dens invaginatus, talon cusp, and the palatogingival groove remain an enigma to the endodontists worldwide. To combat these developmental anomalies all we need is right diagnosis, right treatment plan and the right management.

Palatogingival groove is a developmental anomaly that starts near the cingulum of the tooth and runs down

CASE REPORT10.5005/jp-journals-10024-1620

The Complex Radicular Groove: Interdisciplinary Management with Mineral Trioxide Aggregate and Bone Substitute1VJ Narmatha, 2Sophia Thakur, 3Sheetal Shetty, 4Praveen Kumar Bali

1,4Senior Lecturer, 2Professor, 3Assistant Professor1Department of Conservative Dentistry and Endodontics Army College of Dental Sciences, Secunderabad, Andhra Pradesh, India2Department of Conservative Dentistry and Endodontics, Bapuji Dental College and Hospital, Davangere, Karnataka, India3Department of Conservative Dentistry, Faculty of Dentistry Melaka Manipal Medical College, Manipal, Karnataka, India4Department of Pedodontics, College of Dental Sciences Davangere, Karnataka, India

Corresponding Author: VJ Narmatha, Senior Lecturer Department of Conservative Dentistry and Endodontics, Army College of Dental Sciences, Secunderabad, Andhra Pradesh India, Phone: 8331996080, e-mail: narmatha910@gmail.com

the cementoenamel junction in apical direction, termi-nating at various depths along the root.1 This anomaly predominantly is encountered in maxillary lateral inci-sors along the palatal surface with a prevalence rate of 2.8 to 8.5%.2,3

The significance of this funnel-shaped defect lies in the fact that it makes the tooth a susceptible niche for bac-terial plaque accumulation and subsequent inflammation. Complicated by the palatal occurrence and patient’s inability to keep the area clean, periodontal breakdown is inevitable.4

Lee et al5 reported an association between palato-gingival groove and apical periodontitis.

The prognosis of teeth with palatogingival groove is compromised when there is severe periodontal destruc-tion as well as a periapical inflammatory lesion. The success of any treatment modality in such cases depend on the depth of the groove, the groove’s extension, and the relation of the groove to the root canal.1,3,6

The anatomical complexity of the radicular groove demands a keen and insightful method of diagnosis and a multifaceted treatment approach by the clinician. Given the great clinical importance of the palatogingival groove and its sporadic occurrence, the objective of this paper is to present a report of a case of palatogingival groove and the interdisciplinary management of the same using contemporary techniques.

CASE REPORT

A 27-year-old patient reported to the Outpatient Depart-ment of Conservative Dentistry and Endodontics, Bapuji Dental College and Hospital. On clinical examination, the left maxillary lateral incisor (#22) had a discolored intact crown without caries or fracture. The tooth was tender on percussion and pulp sensibility tests showed a nega-tive response on comparison to the adjacent teeth. The mobility of the tooth was within physiological limits. On periodontal examination, there was a 9 mm pocket depth and purulent exudate associated with a palatogingival groove on the palatal aspect of the tooth (Fig. 1).

Intraoral periapical radiograph revealed the presence of a well circumscribed periapical radiolucency indicating

JCDP

The Complex Radicular Groove: Interdisciplinary Management with Mineral Trioxide Aggregate and Bone Substitute

The Journal of Contemporary Dental Practice, November-December 2014;15(6):792-796 793

JCDP

chronic apical periodontitis. A patent root canal was seen with another parapulpal radiolucent line (Fig. 2), which is a typical radiographic representation of the palatog-ingival groove.

Hence a diagnosis of endodontic periodontal lesion with palatogingival groove presenting with pulpal necrosis and chronic apical periodontitis was inferred. Following this, an interdisciplinary treatment plan was devised for the patient.

TREATMENT PROTOCOL

Endodontic Phase

The tooth was isolated with rubber dam. Access cavity preparation was done followed by working length determination which was confirmed with a radiograph. Subsequently, the cleaning and shaping procedures were undertaken using the conventional step back technique with an apical preparation up to size 60 K. (Mani Inc, Ulsunomiya, Japan). Copious irrigation between instru-mentation was done using 1% sodium hypochlorite with alternate irrigation with 17% ethylenediamine tetraacetic acid. Calcium hydroxide intracanal medicament was placed in the interappointment period. The tooth was

obturated with gutta-percha and zinc oxide eugenol based sealer using lateral condensation technique (Fig. 3).

Radiographic assessment after obturation showed a thin radiopaque line extending from the midroot level to the apical third indicating an obturated lateral canal (Fig. 3).

Periodontal Phase

During the periodontal phase of the therapy, a full thick-ness mucoperiosteal flap was raised from the palatal aspect, and the palatogingival groove was identified to its complete apical extent. Thorough scaling and root planing were performed to eliminate the calculus and microorganisms. Curettage of the granulation tissue was done (with Gracey curette number 1, 2 and 5, 6; (Hu-Friedy Manufacturing Co, Chicago, IL) to make the perio- dontium more conducive to regeneration. Preparation of the groove was done to receive the sealing material, mineral trioxide aggregate (ProRoot MTA, Dentsply, Tulsa Dental) (Fig. 4). The cement was mixed with saline to obtain a packable consistency. This mix was applied into the radicular part of the defect. A chemical condition-ing of the coronal part of the groove was done using 10% polyacrylic acid, and glass ionomer cement type II (Fuji II, GC Corporation, Tokyo, Japan) was applied into the def-ect. After both the cements had hardened, the localized bony cavity was filled with bone graft (Spongious bone substitute; Geistlich Pharma AG, Wolhusen, Switzerland) (Fig. 5). The flap was approximated and supported with single interrupted sutures. The postoperative radiograph showed a radiopaque line adjacent to the radiopacity of the gutta-percha indicating a satisfactory seal with ProRoot MTA. Patient was instructed on postsurgical precautions and maintenance therapy, which included chlorhexidine rinse (0.12% solution) twice a day for 5 weeks. During this period he was recalled once a week for professional tooth cleaning.

Fig. 1: Discolored maxillary left lateral incisor with 9 mm Pocket depth on periodontal examination

Fig. 2: Preoperative intraoral periapical radiograph of maxillary left lateral incisor showing typical parapulpal radiolucent line

Fig. 3: Completion of root canal therapy of maxillary left lateral incisor

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Fig. 4: Surgical procedure — flap reflection, identification of groove extent and cavity preparation

Fig. 5: Restoration of the coronal portion of the groove with glass ionomer cement, radicular portion with mineral trioxide aggregate and placement of bone graft

Fig. 6: Follow-up after 1 year showing clinical reduction in pocket depth and intraoral periapical radiograph showing complete resolution of periapical lesion

Follow-up

Follow-up was done for period of 1 year during which there was a significant clinical attachment gain of 6 mm and disappearance of the periapical radiolucency in the intraoral periapical radiograph (Fig. 6).

DISCUSSION

Various authors have proposed different opinions regard-ing the formation of the palatogingival groove. Some authors proposed that this anatomical anomaly is a mild form of dens invaginatus,3,5 whereas others consider that

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it is the incomplete attempt of a tooth to form another root.7 Ennes and Lara et al suggested that an alteration of genetic mechanisms could be responsible for the groove occurrence.8

The funnel-like shape of the palatogingival groove promotes the accumulation of plaque and calculus, making thorough cleaning by the patient, or even by the dentist, nearly impossible.9-11 Periodontal disease may hence ensue jeopardizing the pulpal heath depending on the grooves depth and communication through apical foramen, accessory and lateral canals.12

The rationale behind the chosen treatment modality was the following: (1) complete elimination or partial sau-cerization of the radicular portion of the groove to remove bacterial plaque and calculus and to avert recolonization of microorganisms; (2) cleaning and appropriate sealing of the coronal and radicular portion of the groove with glass ionomer cement and mineral trioxide aggregate respectively (3) regeneration of periodontal attachment and bone and consequently improvement of the clinical conditions (reduction in pocket depth).

The prognosis of teeth affected by this anomaly depends on the location, depth, and extension of the groove and the extent of periodontal destruction.4,13,14 Successful treatment of this particular type of palatogingival groove depends on the ability to eradicate inflammatory irritants by eliminating the groove and encouraging the patient to keep good hygiene.

Materials, such as composite, amalgam and glass ionomer cement, have been used to fill the palatogin-gival groove.15,16 In the present case, mineral trioxide aggregate was chosen to seal the radicular portion of the groove, because of its proven biocompatibility, excellent sealing ability, hard tissue inductive and conductive properties.17,18 Glass ionomer cement was used to seal the coronal part of the groove due to its advantages of having chemical adhesion to the tooth structure, antibacterial property, adequate seal ability and promoting epithelial and connective tissue attachment.19-21

Bone fill is a desirable result of periodontal regenera-tion procedures. Several reports indicate that bone fill is enhanced by the addition of a graft material.22,23 Hence, in the present case a bone substitute was used to fill the defect and enhance healing of lesion.

CONCLUSION

The following conclusions can be drawn:• Effective diagnosis of the palatogingival groove is

critical.• Complex interdisciplinary approach can have hope

for teeth with extremely poor prognosis.

• Mineral trioxide aggregate can be a beneficial and effec- tive restorative option for teeth with palatogingival grooves.

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