Indian J Dent Adv 2012; 4(2) 838

Management ofPalatoradicular Groove

Harikumar V1, Ravichandra P V2, Rajani P3, Lakshmi Santoshi P4

ABSTRACT:

Palatoradicular groove is a developmental anomaly which has

been implicated as an initiating factor in localized gingivitis

and periodontitis. These grooves when further complicated by

pulp necrosis can present a diagnostic and treatment planning

challenge to the operator. This article describes the management

of bilateral maxillary lateral incisors with shallow and deep

palatoradicular grooves.

Key words: Palatoradicular groove, Palatogingival groove,

Radicular groove, Developmental anomalies, Endo- perio lesion.

C A S E R E P O R T

doi: ...........................

1Professor2Professor & HOD3&4Post Graduate StudentsDepartment of Conservative Dentistry and EndodonticsKamineni Institute Of Dental Sciences,Narketpally, Nalgonda Dist. A.P.

Article Info:

Received: April 10, 2012;Review Completed: May, 12, 2012;Accepted: June 7, 2012Published Online: August, 2012 (www. nacd. in)© NAD, 2012 - All rights reserved

Email for correspondence:harikumarvemisetty@gmail.com

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INTRODUCTION

Developmental infoldings may result in defects that can provide a pathway for pulpal pathology. Onesuch defect is palatoradicular groove which is seen in the central fossa of maxillary incisors that extendsapically on to the root.1 It can be defined as “a developmental groove in a root that, when present, is usuallyfound on the lingual aspect of maxillary incisor teeth”.2 These grooves are commonly seen on the palatalaspect of maxillary lateral incisors followed by maxillary central incisors and second molars. Many termshave been used to describe this defect: palatogingival groove,3,4 developmental radicular anomaly,5 disto-lingual groove,6 radicular lingual groove,7 radicular groove, and cingulo-radicular groove.

Lee et al. were the first to report an association between palatoradicular groove and localized periodontitis.They proposed that the palatal groove represents an infolding of the enamel organ and Hertwig’s epithelialroot sheath and parallels the pathogenesis of dens invaginatus. Unlike dens invaginatus, however, theinfolding that occurs in the palatal groove is usually less extensive and creates an external defect that is

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Indian J Dent Adv 2012; 4(2) 839

situated adjacent to the gingival crevice.3 Morerecently, in a morphological analysis of thesegrooves, Ennes and Lara8 suggested that the palatalgroove could be the result of an alteration of geneticmechanisms, rather than a dental germ folding. Theprevalence rate of this defect has been reported tobe 2.8% - 8.5%9.

The significance of this defect lies in the factthat it has the potential to provide a pathway forbacteria to penetrate into the periodontal ligamentarea. It acts as a nidus for plaque accumulation andsubsequent inflammation. Once a breach occurs inthe periodontal attachment and the groove isinvolved, a self-sustaining localized periodontalpocket can develop along the length of the groove.5

The groove might vary in depth along the root,and it might also communicate with the pulp cavityleading to pulpal necrosis, complicating theprognosis. But the main communication between thepulp and the periodontium in incisors with aradicular groove is probably the accessory canals,which might be anywhere along the groove.10 Thesegrooves often present a diagnostic and treatmentplanning dilemma. While frequently associated withperiodontal pockets and bone loss, pulpal necrosisof these teeth may precipitate a combinedendodontic-periodontic lesion associated withlocalized periodontitis.

Suggested treatment modalities were curettageof the affected tissues, elimination of the groove bygrinding and/ or by sealing with a variety of fillingmaterials11. If the groove extends beyond the middlethird of the root apex, surgical procedures arerequired, which include, among others, the use ofbarriers and/ or intraosseous grafts to correct thedefect12 Although, the defect is of periodontaletiology, restorative treatment alone and/orendodontic treatment is often required because ofsecondary pulpal involvement. If periodontalbreakdown continues, extraction of the affectedtooth should be considered13. This article presents acase report of bilateral palatoradicular groove inmaxillary lateral incisors and their management.

CASE REPORT

A 21-year-old male patient with good generalhealth presented to the department of Conservative

dentistry & Endodontics with the chief complaintof proclined tooth with pus discharge in left upperanterior quadrant. The patient was unaware of anyprevious trauma to the maxillary anterior regionand had no history of pain in that area. On clinicalexamination, bilateral, palatoradicular grooves weredetected on the palatal aspect of maxillary lateralincisors (Figure.1). Dental caries and inflamedgingiva was seen on the palatal aspect of rightlateral incisor (#12) and left lateral incisor (#22).Inright maxillary lateral incisor (# 12) mobility andprobing depth was within physiological limitswhereas in left lateral incisor (#22) a probing depthof 8mm was recorded on palatal aspect which wasconfirmed by radiograph (Figure 8 and 9) and thetooth was proclined (Figure 6), not in occlusion andwas associated with grade I mobility. Facially thegingival sulcus had normal probing depth. The teethresponded normally to the pulp sensitivity tests. Thepatient had no significant tenderness to percussionor palpation in the maxillary anterior area. Oralhygiene was poor with calculus present all aroundthe tooth.

Periapical radiographs revealed extensive boneloss in left lateral incisor (#22) whereas no bone lossis evident in right lateral incisor (#12) (Figure.2 and7). A patent root canal was seen in both lateralincisors. Based on clinical examination andradiographic findings the case was diagnosed aslocalized periodontitis with palatoradicular groovein maxillary left lateral incisor (#22) and dentalcaries with palatoradicular groove in right lateralincisor (#12).

After prophylaxis and removal of localizedcalculus, local anesthesia (2% Lignox, Indocoremedies Ltd.) was administered and a surgical flapwas raised from the palatal aspect in relation to boththe lateral incisors and the palatoradicular grooveswere seen extending onto cervical third of the rootin #22 and onto cingulum in #12. After flapreflection, caries removal and saucerization of theenamel was done in #12 followed by restoration withlight cure GIC (Figure 3,4 and 5), whereas thoroughscaling and root planning was performed over thegroove in #22 to remove the bacteria that might havecolonized there. The diseased granulation tissue wascuretted out (with Gracey curette number 1, 2 and

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Indian J Dent Adv 2012; 4(2) 840

5,6; Hu-Friedy Manufacturing Co, Chicago, IL) toleave the soft tissue more conducive to regeneration.Later saucerisation was done with a round bur toremove the defect. A chemical conditioning of thegroove was performed by using 10% polyacrylic acid,and light cured glass ionomer cement was placedinto the defect (Figure 10,11,12). Then the localizedbony defect was filled with bone graft (G-Graft)supported by using a bioabsorbable collagenmembrane (Perio-col GTR membrane, Eucare)(Figure 13 and 14). Later the flap was approximatedand supported with figure of eight sutures (Figure15,16). Patient was instructed on postsurgeryprecautions and maintenance protocol, whichincluded doxycycline 100mg, with instructions totake two capsules immediately, then one capsuleevery day for 14 days and rinsing with 0.12%solution of chlorhexidine twice a day for 5 weeks.Patient was recalled after 2 weeks.The healing ofthe periodontium was uneventful. Sutures wereremoved. At this time complete soft tissue closurein the defect-associated interdental area was stilldemonstrable. When chlorhexidine wasdiscontinued, full mechanical interproximalcleaning in the surgically treated area wasreinstituted. The patient was recalled forprofessional tooth cleaning and reinforcement of self-performed oral hygiene measures at 1-monthintervals for 6 months. No attempt at probing ordeep scaling was made before the follow-up. Aradiograph taken 6 months (Figure 17) after thesurgery revealed bone fill of the previously existingosseous defect in #22 and the gingival health wassatisfactory in #12. Clinical examination revealedno abnormal response to percussion, palpation andmobility was within normal limits. Later the patientwas referred to the department of orthodontics forcorrection of the proclined left lateral incisor (#22).

DISCUSSION

The palatoradicular groove is a developmentalanomaly which usually begins in the central fossa,crosses the cingulum, and extends varying distancesand directions apically.2 Withers et al.4 in a study ofmilitary recruits, found palatal grooves in 8.5% ofindividuals, 0.28% of maxillary central incisors and4.4% of maxillary lateral incisors. After anexamination of 3168 extracted incisors, Kogon9

reported the prevalence to be 3.4% in central incisorsand 5.6% in lateral incisors. About half of thesegrooves (54%) extended onto the root surface; ofthose, 43% extended less than 5 mm, 47% 6 to 10mm, and 10% more than 10mm apically from thecementoenamel junction. Fifty-four percent of thepalatal grooves in this study were described as ashallow depression, 42% as a deep depression, and4% as a closed tube.

The treatment of a palatal groove presents aclinical challenge to the operator and involves amultidisciplinary approach. The prognosis of teethaffected by this anomaly depends on the location,depth, and extension of the groove and the extent ofperiodontal destruction.1

The rationale behind the selected treatmentplan was the following:

1) Removal or saucerization of the radicularportion of the groove to eliminate bacterial plaqueand calculus and to prevent bacterialrecolonization;(2) Regeneration of periodontalattachment and bone and consequentlyimprovement of the clinical conditions (reduction inpocket depth); (3) Cleaning and sealing of the coronalportion of the groove to prevent bacterialrecolonization.

Complicated by the palatal occurrence andpatient’s inability to keep the area clean, periodontalbreakdown is inevitable. It acts like a trap,facilitating the development of a combinedendodontic- periodontal lesion as there might be acommunication between the pulp canal system andthe periodontium through the accessory canals.Sometimes, it is misdiagnosed as a primaryendodontic lesion. The diagnosis might further becomplicated because the clinical picture might pointtoward a periodontal abscess, and radiographicallythe palatogingival groove might appear like avertical root fracture or an extra root canal.14

Materials such as composite and amalgam havebeen used to fill the palatoradicular groove.15,16

Although mineral trioxide aggregate sets in thepresence of moisture, it might get washed off fromthe transgingival defect. Instead, light cure glassionomer cement was chosen because it does not havethis limitation. It also has the added advantages of

Management of Palatoradicular Groove Harikumar, et, al.

Indian J Dent Adv 2012; 4(2) 841

having an antibacterial effect, chemical adhesion tothe tooth structure, adequate sealing ability,17,18 andpromoting epithelial and connective tissueattachment.

Several techniques19,20,21 have been reported inthe past for the treatment of teeth withdevelopmental abnormalities such as radiculargroove. Despite its being a periodontal hazard,Anderegg and Metzler have reported clinical successat 6 months for 10 cases treated with nonresorbablebarrier.

According to recent studies, GTR membraneacts as mechanical barrier halts the epitheliumdown growth along the root surface, allowingperiodontal ligament, cementum, and bone toregenerate. The combined technique of using graftmaterial with GTR membrane helps to reduce thepocket depth thereby improving the prognosis of thetooth. McLain and Schallhorn22 also showed thatattachment levels are maintained more predictablyin sites treated with a combined graft/GTR therapy.In the present cases clinical success might beattributed to elimination of the local factor forsupragingival and subgingival plaque accumulationby smoothing the radicular defect and filling it withrestorative material.

CONCLUSION:

Deep radicular grooves can predispose to pulpnecrosis and the establishment of combinedendodontic-periodontal lesions. Evaluation ofclinical signs and appropriate diagnostic tests areof paramount importance in order to preventincorrect diagnosis and treatment. If the cliniciansare aware of the forms in which the condition mayoccur, with the various treatment modalitiesavailable, a number of teeth with palatoradiculargrooves may be saved.

References

1. Gound GT, Glen Maze I. Treatment options for theradicular lingual groove : A review and discussion. PractPeriodont Aesthet Dent 1998; 10(3): 369-375.

2. American Association of Endodontists. Glossary ofendodontic terms, 7th ed. Chicago,IL, 2003.

3. Lee KW, Lee EC, Poon KY. Palato-gingival grooves inmaxillary incisors. A possible predisposing factor tolocalised periodontal disease. Br Dent J 1968;124:14-18.

4. Withers JA, Brunsvold MA, Killoy WJ, Rahe AJ. Therelationship of palato-gingival grooves to localizedperiodontal disease. J Periodontol 1981;52:41- 44.

5. Simon JH, Glick DH, Frank AL.Predictable endodontic andperiodontic failures as a result of radicular anomalies. OralSurg Oral Med Oral Pathol 1971;31:823- 826.

6. Everett FG, Kramer GM. The disto-lingual groove in themaxillary lateral incisor; a periodontal hazard. JPeriodontol 1972;43:352- 361.

7. Meister F, Keating K, Gerstein H, Mayer JC. Successfultreatment of a radicular lingual groove: case report. JEndod 1983;9:561- 564.

8. Ennes JP, Lara VS. Comparative morphological analysisof the root developmental groove with the palato-gingivalgroove. Oral Dis 2004;10:378-382.

9. Kogon SL. The prevalence, location and conformation ofpalato-radicular grooves in maxillary incisors. J Periodontol1986;57:231- 234.

10. Mayne JR, Martin IG. The Palatal radicular groove: twocase reports. Aust Dent J 1990;35:277-281.

11. Brunsvold MA. Amalgam restoration of a palatogingivalgroove. Gen Dent 1985;33:244-246.

12. Paul BF. Surgical management of the palatoradiculargroove and associated periodontal lesion: a casepresentation. Pract Periodont Aesth Dent 1993;33:25-28.

13. Al-Hezaimi K, Naghshbandi J. Successful treatment of aradicular groove by intentional replantation and emdogaintherapy.Dent Traumatol 2004;20:226-228.

14. Kanika Attam, Raj Tiwary,Sangeeta Talwar, ArundeepKaur Lamba.. Palatogingival groove: Endodontic-Periodontal management - Case Report. J Endod2010;36:1717-1720.

15. Robison SF,Cooley RL. Palatogingival lesions: recognitionand treatment. Gent Dent 1988;36:340-342.

16. Meister F, Keating K et.al. Successful treatment of aradicular lingual groove: Case report. J Endod 1983;9:561-564.

17. Maldonado A, Swartz ML, Phillips RW. An in vitro studyof certain properties of a glass ionomer cement. J Am DentAssoc 1978;96:785-791.

18. Vermeersch G, Leloup G, Delmee M, Vreven J.Antibacterial activity of glass-Ionomer cements, compomersand resin composites: relationship between acidity andmaterial setting phase. J Oral Rehabil 2005;32:368-374.

19. Peikoff MD, Perry JB, Chapnick LA. Endodontic failureattributable to a complex radicular lingual groove. J Endod1985;11:573-577.

20. Pack AR, Chandler NP. A combined endodontic-periodontallesion of development origin: a case report. N Z Dent J1996;92:46-48.

21. Goon WW, Carpenter WM, Brace NM, Ahlfeld RJ. Complexfacial radicular groove in a maxillary lateral incisor. JEndod 1991;17:244-248.

22. Mc Clain PK,Schallhorn RG. Longterm assessment ofcombined osseous composite grafting,root conditioning andguided tissue regeneration. Int J Periodontics RestorativeDent 1993;13:09-27.

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Indian J Dent Adv 2012; 4(2) 842

Fig: 1: Bilateral PalatoradicularGrooves

Fig:2: Pre-operative RadiographI.R.T # 12

Fig: 3: Flap Reflected I.R.T 12

Fig:4: Saucerization I.R.T. 12

Fig:5: After Sealing With LightCure GIC

Fig:6: Pre - Operative View -Proclination Of #22

Fig:7: Pre-operative RadiographI.R.T. 22

Fig:8: Probing Done I.R.T. 22

Fig:9: Radiograph Showing TheProbing Depth Done I.R.T. 22

Fig:10: Flap Reflected I.r.t. 22

Fig:11: Caries Removal AndSaucerisation Done I.R.T. 22

Fig: 12: After Sealing With LightCure Gic I.R.T. 22

Fig:13: Graft Placement I.R.T. 22

Fig:14: Collagen MembranePlacement I.R.T. 22

Fig:15: After Suturing - LabialView

Fig:16: After Suturing -palatalView

Fig:17: Follow Up Radiograph -After 6 Months

Management of Palatoradicular Groove Harikumar, et, al.