Management of Type III palatogingival groove in permanent maxillary lateral incisor with intentional replantation

Aaliya Rehman; Huma Iftekhar; Rajendra Kumar Tewari; Surendra Kumar Mishra

doi:10.4103/jorr.jorr_25_21

CASE REPORT

Year : 2022 | Volume : 14 | Issue : 2 | Page : 136-141

Management of Type III palatogingival groove in permanent maxillary lateral incisor with intentional replantation

Aaliya Rehman, Huma Iftekhar, Rajendra Kumar Tewari, Surendra Kumar Mishra
Department of Conservative Dentistry and Endodontics, AMU, Aligarh, Uttar Pradesh, India

Date of Submission	06-Apr-2021
Date of Decision	23-Nov-2021
Date of Acceptance	03-Jan-2022
Date of Web Publication	01-Jul-2022

Correspondence Address:
Huma Iftekhar
Department of Conservative Dentistry and Endodontics, AMU, Aligarh, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jorr.jorr_25_21

Abstract

A palatogingival groove (PGG) is a developmental deformity that may cause a severe periodontal breakdown or combined endodontic and periodontal defect. In the present case, a 24-year-old patient reported a complaint of pain in the upper left front tooth region for 3 months. Clinical and radiological examination revealed a PGG in the permanent maxillary left lateral incisor. Cone-beam computed tomography showed multiple shallow grooves on the root surface and a deep palatal groove extending to the apex. Interdisciplinary management comprising endodontic therapy and intentional replantation was formulated. After endodontic procedure, tooth #22 was gently extracted. The shallow grooves were removed by odontoplasty. A Class II cavity was made in the deep palatal groove and was connected with the root-end preparation. The cavity was sealed with biodentin up to the cementoenamel junction and the coronal portion was sealed with light-cured glass-ionomer cement. The tooth was replanted in socket and splinted for 7 days. Follow-up visits revealed the functional status of tooth and complete bony healing. Tooth discoloration was successfully managed with intracoronal bleaching with sodium perborate. A 12-month radiographic follow-up revealed no evidence of root resorption or ankylosis.

Keywords: Biodentin, developmental deformity, intentional replantation, maxillary lateral incisor, palatogingival groove

How to cite this article:
Rehman A, Iftekhar H, Tewari RK, Mishra SK. Management of Type III palatogingival groove in permanent maxillary lateral incisor with intentional replantation. J Oral Res Rev 2022;14:136-41

How to cite this URL:
Rehman A, Iftekhar H, Tewari RK, Mishra SK. Management of Type III palatogingival groove in permanent maxillary lateral incisor with intentional replantation. J Oral Res Rev [serial online] 2022 [cited 2023 Mar 31];14:136-41. Available from: https://www.jorr.org/text.asp?2022/14/2/136/349705

Introduction

The maxillary lateral incisor is often affected by numerous developmental anomalies due to its location in an embryologically susceptible area. It might get trapped in between the central incisor and canine tooth germ as it lags behind these two teeth in the phase of development.^[1] The crown of the lateral incisor undergoes mineralization later than that of the central incisor and canine, thereby it has a probability of getting infolded. The dental organ and Hertwig's epithelial root sheath in folding could give rise to the formation of either a dens invaginatus (DI) or a palatogingival groove (PGG).^[2] However, PGG parallels DI in pathogenesis, it is manifested as an external defect and is less extensive unlike DI.^[3]

PGG is a developmental deformity that originates in the central fossa area, moves across the cingulum, and extends apically to varying depth and distance, sometimes reaches even up to the apex. Typically, PGG is located on the palatal aspect of maxillary incisors, the reported incidence being 2.8%–18%.^[4] The wide range of incidence may be attributed to the difference in study design, diagnostic criteria, race, and region. There are various suggested etiologies for PGG, alteration during growth may lead to infolding of the dental organ,^[2] it could be a variant form of DI,^[2] could result from a genetic alteration,^[5] could result from an attempt of formation of an extra root.^[6],[7]

Gu has classified PGG based on severity: Type I – the groove ends before the coronal third of the root and is shallow; Type II – the groove extends ahead of the coronal third, it is long but shallow and is usually associated with a simple and normal root canal morphology; and Type III – the groove is deep and extensive it moves beyond the coronal third and is associated with complex root canal system. Developmental anomalies with deformed morphology of dental structure (talon's cusp, dens in dente, accessory root, and PGG) might serve as a niche for bacteria and plaque deposition and, if not addressed and eliminated, could cause periodontal destruction. The irritants may facilitate the onset of inflammation in pulpal and periodontal tissues through any possible communication between the two as they can move in either direction with much ease. Thus, the PGG may manifest as a localized periodontal pocket or a combined endodontic-periodontal disease.

PGG often makes diagnosis and treatment arduous. Various treatment modalities are being offered for its management depending on its extent, depth, periodontal destruction, and pulpal involvement. A tooth with multiple grooves has been rarely reported in the literature.^[8],[9] To the best of our knowledge, no case of PGG with multiple grooves has been reported in the literature with comprehensive endodontic and surgical management. Herein, we present an immature maxillary left lateral incisor with a deep PGG along with the presence of multiple grooves all over the root.^[4] The case was managed successfully with endodontic therapy and intentional replantation.

Case Report

A 24-year-old male patient presented to the Department of Conservative Dentistry and Endodontics with the complaint of pain in the upper left front tooth region for 3 months. The medical and family history was noncontributory. There was no history of dental trauma. Extraoral examination revealed no significant findings. Intraoral clinical evaluation showed discolored maxillary left lateral incisor (#22) and a sinus tract on the buccal mucosa [Figure 1]a. Tooth #22 was slightly rotated and was wider mesiodistally.

Figure 1: (a) Discolored maxillary left lateral incisor (#22) and a sinus tract on the buccal mucosa. (b) Palatogingival groove with talon cusp extending deep inside the root. (c) IOPA showed immature status of tooth #22; the root outline showed discontinuity toward the mesial aspect of the aspect. (d) Periodontal pocket (7 mm) associated with palatogingival groove

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Further examination revealed a PGG extending deep inside the root [Figure 1]b. A small talon was present palatally. Tooth #22 responded positively to the percussion test. Pulp sensibility tests (thermal and electric) gave a negative response. A probing depth of 7 mm was present on the palatal aspect [Figure 1]c. Probing depth on facial and proximal aspects was within the physiologic limit. The tooth had Grade I mobility. The intraoral periapical radiograph showed immature status of tooth #22; the root outline showed discontinuity toward the mesial aspect of the apex [Figure 1]d. The discontinuity gave an impression of ongoing external resorption on the lateral root surface; however, the root outline could be traced with some ragged margins on the angulated radiographs. Therefore, a differential diagnosis of external root resorption or a deep palatogingival (groove extending to the apex) was made.

After prescribing medication for pain, the patient was advised a three-dimensional examination to visualize the bizarre anatomy. However, the pain was not relieved, and an emergency access opening was performed under local anesthesia and rubber dam isolation. The tooth had a constricted access opening at the level of cementoenamel junction (CEJ). It was copiously irrigated with 1.5% NaOCl with a side-vented needle (30-Gauge, Krident, 3D-Endo Irrigation Disposable Dental Probe) adjusted 2-mm short of the apex. Working length determination was done. After placing intracanal medicament, the cavity was temporarily sealed, and the patient was sent for cone-beam computed tomography (CBCT).

CBCT images showed extensive periapical bone loss in relation to tooth #22 [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e. However, the true extent of the bone loss was revealed by the sagittal and coronal sections. The sagittal section showed intact lingual plate with some horizontal bone loss. Axial sections confirmed the presence of a single root canal, which was wider mesiodistally. The PGG extended up to the apex as viewed at the different root levels. The shaded surface display revealed multiple shallow grooves on the root surface present all over the root [Figure 2]f. However, a deep (>1 mm) PGGs extended to the apex.^[4] The root was slightly deformed. Therefore, a confirmative diagnosis of pulpal necrosis and periodontal breakdown from a PGG was made.

Figure 2: Cone-beam computed tomography images of tooth #22 (a and b) axial view showing deep palatogingival groove. Coronal view (c) showing extensive periapical bone loss. Sagittal view (d) showing intact lingual cortical plate. Shaded surface display (e and f) showing deep palatogingival groove extending up to the apex

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After analyzing the clinical and three-dimensional case presentation, interdisciplinary management was formulated. It comprised thorough oral prophylaxis, root canal treatment completion, followed by intentional replantation. Because of the difficulty in accessibility during palatal surgery, the palatal groove's extension to the apex, and the presence of multiple shallow grooves all over the root, intentional replantation was preferred over the palatal flap surgery. The proposed treatment's risks and benefits were thoroughly explained to the patient, and written consent was taken.

By the end of 2 weeks, the tooth was totally asymptomatic, and the sinus tract had closed. Oral prophylaxis was done. Under the rubber dam application, the tooth was copiously irrigated, and obturation was performed with the lateral condensation technique. The patient was then scheduled for the surgical procedure.

Surgical procedure

A single operator and two assistants completed the surgical procedure. The patient was asked to rinse the mouth with 0.12% chlorhexidine mouthwash before the surgical procedure. Tooth #22 was anesthetized and extracted carefully with forceps to avoid any trauma to the tooth and socket wall [Figure 3]a. Elevators were not used during extraction. The patient was given moist gauze to bite during the extraoral procedure. The extracted tooth was lightly held by crown with forceps and was rinsed gently with normal saline. The tooth was inspected under the microscope (Carl Zeiss surgical, Oberkochen, Germany); the deep palatal groove with associated plaque was well exhibited [Figure 3]b. Multiple shallow, small grooves were also present all over the root. There were no other abnormalities such as cracks or fractures on the surface of the root. An intermittent gentle rinse of normal saline was done to avoid dryness.

Figure 3: (a) Atraumatically extracted tooth #22 with associated biofilm. (b) Tooth #22 with deep palatal groove. (c) Retrograde preparation is done. (d) Biodentin filled in the prepared cavity. (e) Tooth #22 replaced back in socket

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A retrograde cavity was prepared in the apex using ultrasonic tips, and the palatal groove was removed [Figure 3]c. A Class II cavity was made in the palatal groove by joining it with the apex. The shallow grooves were removed by odontoplasty using a composite polishing bur (Super-Snap Rainbow Technique Kit, Shofu, USA). The prepared cavity was treated with EDTA gel to remove the smear layer. Biodentin (Septodont, Saint Maur des Fosses, France) was mixed, and then the retrograde cavity and the groove were filled up to the level of CEJ [Figure 3]d. Light-cured glass-ionomer cement (GIC) (Fusion i-Seal^®, Prevest DenPro^®) was used for restoring the prepared cavity above CEJ. The tooth was then kept in moist saline gauze; meanwhile, the extraction socket was gently rinsed with saline, and the granulation tissue was removed with a curette without damaging the socket. The tooth was then replaced in the extraction socket by mild digital pressure [Figure 3]e. The complete extraoral procedure lasted for 7 min. A periapical radiograph was taken to confirm the correct placement of the tooth . A semirigid split was given for 7 days. The tooth was relieved from occlusion contact from the opposite tooth. The patient was prescribed medication, and postoperative instructions were given. An emergency contact number was provided, and the patient was recalled after 7 days for removal of the split.

Follow-up

Follow-up visits were scheduled at 3, 6, 9, and 12 months. At the 3-month follow-up, the tooth was completely symptom-free, the palatal pocket depth was reduced to 2 mm. Periapical radiograph revealed resolution of the periapical pathology [Figure 4]a.

Figure 4: (a) Intracoronal bleaching done. (b) 12-month radiograph showing complete bony healing

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At 6-month follow-up, the periapical radiographs revealed remarkable bony healing. The lamina dura of teeth #22 could be traced all over the tooth, and there was no sign of ankylosis. At this visit, intracoronal bleaching was initiated for managing the discoloration. At 3 weeks, the tooth lightened from C3 shade to B1 shade.

At 12-month follow-up, clinical examination revealed function status of tooth #22, and radiographic examination showed excellent bony healing with no signs of resorption or ankylosis [Figure 4]b.

Discussion

The rationale for the interdisciplinary treatment planned was to eliminate the PGG completely, thereby removing the plaque and associated biofilm providing a clean surface for restoring the prepared cavity with biocompatible filling material preventing future recolonization by bacteria and to facilitate the regeneration of the periodontium.

The PGG may cause a localized periodontal breakdown or it may communicate with the pulp giving rise to a combined endodontic and periodontal disease. There may be accessory canals communicating from periodontium to the pulp or direct communication may exist between them. This might lead to misdiagnosis of a case as a true endodontic lesion rather than considering it to be a combined lesion. The diagnosis of PGG may even get complicated as sometimes the groove appears as an extra root or a vertical root fracture. In the present case, the PGG looked like a resorptive lesion on the intraoral periapical radiographs. Thus, CBCT is highly recommended in such cases as it enables a three-dimensional view of the groove's location, extent, and depth. It also enables correct visualization of the associated cortical bone loss.

The success of the cases with PGG depends on effective periodontal management and complete resolution of the periodontal defects. In cases with pulpal involvement, a conventional root canal treatment is indicated once the pulp becomes necrotic. The PGG serves as a niche for the bacteria and is present on the external root surface. Endodontic treatment alone would not be sufficient for its management. Hence a comprehensive endodontic and periodontal approach is required, the prognosis for such treatment would depend on the location, extent, depth of the PGG, the extent of the periodontal damage, and accessibility to the lesion.

Teeth with Type 1 Gu's classification can be managed by simple odontoplasty and thorough scaling and root planing followed by curettage of the granulation tissues. However, teeth with Type 2 or 3 Gu's classification need extensive treatment aiming at the elimination of the PGG and subsequent sealing with a biocompatible material, or it may require surgical intervention as well.^{[4],[10],[11],[12]}

In the present case report, the PGG extended to the apex. There were two possible treatment options available for eliminating and sealing the palatoradicular groove; one was a palatal flap surgery and another being an intentional replantation. A detailed analysis of all the existing factors, such as difficulties in gaining accessibility during a palatal flap surgery, presence of localized periodontal destruction, an intact lingual plate with a horizontal bone loss instead of a vertical bone loss, presence of shallow groove on the proximal root surface, were made. Hence, intentional replantation was opted as the most suitable treatment option.

With the advancements in surgical techniques and armamentariums, intentional replantation has emerged as a viable treatment option for the management of complex PGG. A systematic review reported a survival rate of intentionally replanted teeth to be near 88%;^[13] however, according to some contemporary studies, it was as high as 95%.^[14] Thus, it is no longer considered the last treatment resort opted only in hopeless conditions rather, it has been a well-accepted treatment modality, especially in treating complex PGG cases.^[14],[15]

Nevertheless, the precise execution of all the surgical steps and minimizing the extraoral time yields the best outcome with intentional replantation. Procedures with an extraoral time of 15 min or less are reported to have higher success rates.^[16] The likelihood of replacement resorption increases when the extraoral time exceeds a limit of 30 min. In the present report, the extraoral time lasted for 7 min; thus, it allowed the operator to avoid the use of tetracycline or any other solution for enhancing PDL attachment or preventing ankylosis.

Sealing of the groove forms an important factor in obtaining desirable treatment outcomes in PGG cases. Although biocompatible and having the ability to set in the presence of moisture, mineral trioxide aggregate gets washed off from the transgingival defects. In many reported cases, GIC has been used as a sealing material as it provides adequate sealing and has antibacterial effects, but it is associated with the formation of long junctional epithelium.^[17] It fails to regenerate the lost periodontal cells essential for obtaining complete periodontal healing. Thus, limiting its use to the level of CEJ will avoid the formation of long epithelium.

Biodentin is used as a filling material in the present case, it is reported to have superior sealing properties than MTA.^[18],[19] It has a better consistency and rapid setting time, thereby reduces the risk of dislodgment and contamination.^[20] It displays bioactivity by activating angiogenesis and activates the pulp progenitor cells to promote healing and remineralization.^[21] However, it has very low radio-opacity; thus, the retrograde filling's radiographic visualization becomes difficult.

Twelve-month follow-up records showed the successful outcome; the tooth was asymptomatic and functional. The pocket depth was reduced from 7 mm to a physiologic limit of 2 mm, and there was complete resolution of the periapical radiolucency.

Conclusion

In a single-rooted tooth with complex PGG, intentional replantation may serve as a predictable and reliable procedure. Hence, intentional replantation should not be regarded as the last resort, instead it should be considered a more reliable treatment option for severe PGG.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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