Indian Journal of Dental Sciences

CASE REPORT
Year
: 2021  |  Volume : 13  |  Issue : 1  |  Page : 46--49

Misdiagnosis or missed diagnosis? Cone-beam computed tomography-aided multidisciplinary management of maxillary central incisor with palatogingival groove


R Kurinji Amalavathy1, KM Vidya2, Sonali Nabil Sarooshi1, Hrudi Sundar Sahoo1,  
1 Department of Conservative Dentistry and Endodontics, Sathyabama University Dental College and Hospital, Chennai, Tamil Nadu, India
2 Department of Oral and Maxillofacial Pathology, Sathyabama University Dental College and Hospital, Chennai, Tamil Nadu, India

Correspondence Address:
R Kurinji Amalavathy
Department of Conservative Dentistry and Endodontics, Sathyabama University Dental College and Hospital, Jeppiar Nagar, Rajiv Gandhi Salai, Chennai - 600 119, Tamil Nadu
India

Abstract

Palatogingival groove is a developmental anomaly that is most often seen on maxillary incisors, with a predilection for lateral incisors. It begins in the central groove and can extend to varying lengths and depths into the root. This groove can communicate with the pulp internally and periodontium externally, thereby establishing a milieu for the development of complex endodontic-periodontic lesion. In this article, we report multidisciplinary management of a maxillary central incisor, which was mistaken to be a vertical root fracture instead of a palatogingival groove. We also discuss the significance of early recognition of this lesion, differential diagnosis, and it's interdisciplinary management with the aid of cone-beam computed tomography.



How to cite this article:
Amalavathy R K, Vidya K M, Sarooshi SN, Sahoo HS. Misdiagnosis or missed diagnosis? Cone-beam computed tomography-aided multidisciplinary management of maxillary central incisor with palatogingival groove.Indian J Dent Sci 2021;13:46-49


How to cite this URL:
Amalavathy R K, Vidya K M, Sarooshi SN, Sahoo HS. Misdiagnosis or missed diagnosis? Cone-beam computed tomography-aided multidisciplinary management of maxillary central incisor with palatogingival groove. Indian J Dent Sci [serial online] 2021 [cited 2021 Feb 27 ];13:46-49
Available from: http://www.ijds.in/text.asp?2021/13/1/46/305980


Full Text



 Introduction



Aberrant anatomy of the root and the root canal system is often encountered in endodontic practice. A good understanding of the internal and external anatomical features of the root, its variations and anomalies would minimize treatment failure and eventual loss of teeth.[1] Such anatomical aberrancies are more prevalent in mandibular anterior teeth, compared to their maxillary counterpart. However, certain studies have revealed that the maxillary incisor teeth have a higher tendency for root and root canal aberrations caused by anomalies such as dens invaginatus and palatogingival groove (PGG).[1]

PGG is defined as “a developmental anomaly in the root that, when present, is usually found on the lingual surface of maxillary incisor teeth.”[2] It starts from the central fossa, crosses over the cingulum and the cementoenamel junction (CEJ) to varying depths and distances down the root.[3] The groove may be located on the mesial, distal, or most commonly midpalatal surfaces of the incisors.[4] The literature showed a higher occurrence rate of PGG in maxillary lateral incisor (4.4%–5.6%) than the centrals (0.28%–3.4%).[4],[5],[6] Although there are numerous case reports of PGG in maxillary lateral incisor with complications and its successful management in the scientific literature, there are very few clinical case reports of PGG in the central incisors.[7],[8] More often, the presence of PGG has been reported as the cause of failure of endodontically treated maxillary incisor teeth.[5],[9],[10] As PGG is a rare occurrence in maxillary central incisor, its notoriety has often been overlooked since it is mostly concealed in plaque and calculus, making its diagnosis and management clinically challenging. This article presents a rare case of PGG in maxillary central incisor with localized periodontitis and secondary involvement of pulp. The article also highlights the early clinical recognition of PGG with the rationale for its management, emphasizing on interdisciplinary approach.

 Case Report



A 24-year-old male reported to the department of conservative and endodontics with a complaint of pain in the upper front tooth region for the past 4 days. The pain was continuous, nocturnal and aggravated with hot and cold food. The patient also gave a history of consulting a private practitioner for the same complaint who had advised extraction of maxillary central incisor citing a diagnosis of vertical root fracture. The patient sought a second opinion as he was reluctant on loosing his upper front tooth. On clinical examination of #11, the clinical crown was intact with no evidence of caries. The patient was unsure of any past trauma. The tooth was hypersensitive to vertical and horizontal percussion. There was inflammation of the marginal gingiva on the palatal aspect of #11, and probing revealed an isolated pocket of depth more than 5 mm with bleeding along the mesiopalatal line angle of the tooth [Figure 1]a. The palatal aspect of the crown also revealed a crack-like fissure covered in plaque originating from the central fossa, crossing the cingulum and probably extending into the root [Figure 1]b. The contralateral tooth (#21) appeared normal. The patient also presented with a Talons cusp in the lingual aspect and hypoplastic enamel in the labial aspect of #31 [Figure 1]c. Differential diagnosis included vertical root fracture and PGG.{Figure 1}

The intraoral periapical radiograph showed a radiolucent line running parallel to the root canal from the cingulum region extending to the midroot level with a widening of the periodontal ligament space in relation to the mesial and apical aspect of #11 [Figure 2]. Electric pulp testing elicited a delayed response indicating irreversible inflammation of the pulp. A final diagnosis of Type II PGG[11] on the mesiopalatal aspect of tooth #11 associated with symptomatic irreversible pulpitis, and periradicular periodontitis was made. A low field of view cone-beam computed tomography (CBCT) following ALARA principles was advised to measure the extent of PGG, to aid in treatment plan, and to rule out the presence of any other associated anomaly. On assessing the multiplanar CBCT images, a single straight root canal and a mild invagination in the mesiopalatal aspect extending into the middle third of the root with loss of lamina dura and minimal loss of alveolar bone confirming the presence of PGG [Figure 3]a and [Figure 3]b.{Figure 2}{Figure 3}

Treatment

A written consent regarding the treatment plan and prognosis was taken from the patient. A combined endodontic-periodontic treatment approach with the aid of CBCT was planned. The CBCT (Galileos, Dentsply Sirona) images were processed in a DICOM viewer software (HOROS software available at https://horosproject.org). In the first phase of treatment, endodontic treatment was initiated under local anesthesia and rubber dam isolation of #11. The root canal was accessed, cleaned, and shaped with the hand k-files (Mani Inc., Japan); an intracanal calcium hydroxide (Dentocal, Steadman Pharmaceuticals, India) dressing was placed and temporized.

Two weeks later, the second phase of the treatment was initiated that involved the completion of the endodontic treatment and commencement of periodontal surgery. Local anesthetic was administered (2% lignocaine with 1:100,000 adrenaline), and the prepared root canal was obturated in a lateral condensation technique followed by restoration of the entrance cavity with Ketac Molar (3M™ ESPE, Germany). The surgical site was disinfected (Betadine scrub), and a full-thickness mucoperiosteal flap was raised in the palatal aspect from #12 to #22. With the help of estimated measurements from CBCT images, the palatal extension of the flap was established. Under a dental magnifying loupe (×3.5 magnification), the granulation tissue covering the PGG was debrided using Gracey curettes, and the root surface was thoroughly scaled. A shallow groove was seen extending from the central groove, crossing the cingulum, and extending beyond the coronal third of the root. The software-assisted 3D reconstruction of CBCT images also indicated a groove at the mesial surface of the root measuring approximately 7 mm from the CEJ [Figure 3]c. Odontoplasty was done using a diamond abrasive to smoothen the groove. CBCT-assisted measurements of the groove enabled a conservative ododontoplasty. Biodentine™ (Septodont, France) was placed to seal the PGG. The material was allowed to set for about 8–9 min without contamination from the surgical site [Figure 3]d. The flap was then approximated and interrupted 3-0 silk sutures were placed. The patient was advised postoperative analgesics and antibiotics along with 0.12% chlorhexidine mouth rinse for 2 weeks. Sutures were removed after 7 days, and the healing appeared satisfactory. The 3rd month [Figure 4]a and 1-year follow-up intraoral radiograph [Figure 4]b and intraoral photograph [Figure 4]c revealed a healthy periodontal attachment in relation to #11 evidenced by the reduction in the probing depth (2 mm) and healthy marginal gingiva.{Figure 4}

 Discussion



Authors have classified PGG based on location, depth, and complexity of the groove, degree of invagination toward the pulp cavity, and associated root canal anatomy.[12] In most cases, the epithelial attachment remains intact over the groove. The funnel-like shape of the PGG provides an ideal nidus for the accumulation of plaque, which breaks down the epithelial attachment and the deeper parts of the periodontium, establishing a “self-sustaining pocket.” This periodontal breakdown can eventually jeopardize the pulp.[2],[5] Various pathways of communication to the pulp have been observed in teeth with PGG. However, the accessory foramina in the regions adjacent to the groove are considered the primary means of communication between the periodontium and the pulp, leading to retrogenic pulpal necrosis even though the groove does not extend to the entire length of the root.[5],[9],[12] This might have been the cause of pulpal pathology in this case as well. Alteration of the tooth surface morphology (odontoplasty or saucerization) and concurrent sealing of the groove have been suggested to eradicate the bacterial colonization and allow periodontal regeneration.[13] Hence, the granulation tissue and the deposits in the PGG were curetted and scaled. To visualize and readily access such a defect followed by elimination and sealing with an optimum material is always a challenge. Hence, the dental magnifying loupe and the CBCT multiplanar images were helpful in deciding and executing a conservative mucoperiosteal flap to visualize, eliminate, and seal the defect. The sealing material used in this case was Biodentine, a tricalcium silicate-based material is popularly known as “Dentine replacement and repair material.” It has a quicker setting time, improved handling characteristics, and biocompatibility compared to mineral trioxide aggregate's. It promotes better adhesion and growth of fibroblast, thus enhancing hard-tissue regeneration and soft-tissue reattachment. It forms hydroxyapatite crystals at the dentin-material interface, thereby providing an improved seal.[14],[15] In the current case, it has helped to achieve the successful seal of the PGG and clinical reattachment.

 Conclusion



The clinician has to consider PGG as one of the etiologic factors on encountering pathology in maxillary incisors. A thorough clinical examination of the incisors cannot be overemphasized. The presence of radicular groove may not always indicate pathology, but the awareness of its existence and the knowledge of undesirable consequences associated with it might ensure correct diagnosis and better prognosis. Nevertheless, a judicial use of advanced imaging technique such as CBCT and enhanced visualization with the help of a dental magnifying loupe is always helpful to a clinician in limiting an invasive surgical procedure without compromising the prognosis of a treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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