Case Report/Clinical Techniques

Combined Endodontic Therapy and Intentional Replantation

for the Treatment of Palatogingival Groove
an Garrido, DDS, MSc,* Francesc Abella, DDS, PhD,* Ronald Ordinola-Zapata, DDS, PhD,†
Iv

Fernando Duran-Sindreu, DDS, PhD,* and Miguel Roig, DDS, PhD*

Abstract
A palatogingival groove is an anatomic malformation that
predisposes the involved tooth to a severe periodontal
defect. When the condition is complicated by pulpal ne-
P alatogingival or palatal groove is defined as an anatomic malformation of develop-
mental origin usually found on the lingual aspect of the roots of maxillary incisor
teeth (1). Such grooves usually start near the cingulum of the incisor and run apically
crosis, affected teeth often present a dilemma in terms down the cementoenamel junction, terminating at various depths along the root (2).
of diagnosis and treatment planning. In this report, we Many other terms have been used to describe this anomaly, including palatal groove
describe the case of a patient with a maxillary lateral (3, 4), developmental radicular anomaly (5), distolingual groove (6), radicular lingual
incisor with a deep palatogingival groove extending to groove (7, 8), palatoradicular groove (9, 10), radicular groove (11), and cingulora-
the root apex and severe periodontal destruction (local dicular groove (12).
pocketing). Suggested treatment modalities included The etiology of the palatogingival groove remains unclear. Some authors have pro-
curettage of the affected tissues, elimination of the posed that the defect is a mild form of dens invaginatus and results from infolding of the
groove by grinding and/or sealing with a variety of filling enamel organ and Hertwig epithelial root sheath before the calcification phase (2, 6),
materials, and surgical procedures. In this case, a com- whereas others have postulated that it is the result of a failed attempt by a tooth to form
bined treatment approach, involving both endodontic an additional root (5, 13). However, Ennes and Lara (14) suggested that an alteration of
therapy and intentional replantation after restoration genetic mechanisms may be responsible for the occurrence of the groove. The inci-
with a self-etching flowable composite, resulted in peri- dence of a palatogingival groove is reportedly between 2.8% and 18% (6, 9, 10,
odontal healing and significant healing of the periradicu- 15). The broad range of percentages reported may be caused by variations in study
lar radiolucency at 12 months. In short, intentional design, the ethnicity of participants, region, sample size, and/or diagnostic criteria.
replantation offers a predictable procedure and should Given the cervical location of this anomaly, a palatogingival groove may provide a
be considered a viable treatment modality for the man- pathway by which bacteria can penetrate the periodontal ligament (PDL) area, leading
agement of palatogingival grooves, especially for to the accumulation of bacterial plaque and contributing to localized periodontitis (2).
single-rooted teeth. (J Endod 2016;42:324–328) Once a breach in the periodontal attachment involving the groove occurs, a self-
sustaining localized periodontal pocket can develop along the length of the groove
Key Words (5). Furthermore, there may be communication between the pulp canal system and
Developmental anomalies, intentional replantation, the periodontium through the pulp cavity and/or accessory canals; thus, these grooves
maxillary lateral incisor, palatogingival groove may also lead to combined endodontic-periodontal lesions (16, 17).
Palatogingival grooves on maxillary incisors often present a dilemma in terms of
diagnosis and treatment planning. Multiple case reports have described treatment mo-
From the *Department of Restorative Dentistry and End- dalities ranging from the resection of an accessory root to periodontal regeneration with
odontics, Universitat Internacional de Catalunya, Sant Cugat various materials depending on the extent of the osseous defect (18–23). In this case
del Valles, Barcelona, Spain; and †Department of Endodontics,
Bauru Dental School, University of S~ao Paulo, Bauru, Brazil.
report, we present the case of a patient with an anatomically complicated lateral incisor
Address requests for reprints to Dr Francesc Abella, Univer- with, according to Gu’s classification (24), a type II palatogingival groove. A combined
sitat Internacional de Catalunya Dentistry Faculty, C/Josep treatment approach, involving both endodontic therapy and intentional replantation
Trueta, s/n 08195 Sant Cugat del Valles. E-mail address: after restoration with a self-etching flowable composite, resulted in almost complete
[email protected] healing of the periradicular radiolucency at 12 months.
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2015.10.009 Case Report
A 50-year-old woman was referred for root canal treatment of the maxillary right
lateral incisor (tooth #7) (Fig. 1A). The patient’s chief complaint was of a purulent
discharge from tooth #7 over the preceding 4 months. A clinical examination revealed
that tooth #7 had resin composite in the access opening without caries or fracture. As
expected, vitality testing (electric and thermal) yielded negative results, whereas percus-
sion testing yielded positive results. Testing of the adjacent and contralateral teeth eli-
cited normal responses. A draining sinus tract was evident on the adjacent labial
alveolar mucosa. The patient was unaware of any previous trauma to the maxillary ante-
rior region. Investigation of the patient’s medical history failed to identify any relevant
conditions. Tooth mobility was within physiologic limits. A more detailed clinical exam-
ination revealed a groove emerging from the cingulum that continued distoapically

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 Case Report/Clinical Techniques

Figure 1. (A) The maxillary right lateral incisor (tooth #7). A preoperative clinical photograph showing a draining sinus tract (white arrow). (B) A periapical
radiograph with a gutta-percha cone tracing the facial sinus tract to the periradicular radiolucency associated with tooth #7. Two narrow vertically oriented radio-
lucent lines were also evident within tooth #7. (C) Communication of the radicular groove (pink arrow) with the pulp chamber. (D) An image of the obturated root
canal. (E) A postoperative radiograph.

down the palatal aspect of the root. Periodontal probing around the irrigation with 4.2% sodium hypochlorite (NaOCl) in a plastic syringe
maxillary incisors revealed local pocketing almost to the apex on the with a closed-end needle (Hawe Max-i-Probe; Kerr-Hawe, Bioggio,
distopalatal region of tooth #7. Facially, the gingival sulcus had a normal Switzerland) was performed at each step of instrumentation. After
probing depth. Oral hygiene was poor, and calculus surrounded the root canal preparation, a final irrigation was performed, which alter-
tooth. nated between 17% EDTA and 4.2% NaOCl solution. The last NaOCl irri-
Radiographic examination revealed an extensive periradicular gation was activated with a size 20 K-file (Satelec Acteon Group,
radiolucency involving the apical two thirds of the root of tooth #7. Merignac Cedex, France) under passive ultrasonic activation for 1 min-
The sinus tract was traceable, with a gutta-percha cone to the distal ute. The root canal was obturated with warm vertical condensation us-
area (Fig. 1B). In addition, 2 narrow, vertically oriented radiolucent ing System B (SybronEndo Corp, Orange, CA) for down pack and
lines were evident on the radiographs. We diagnosed a combined Obtura II (SybronEndo Corp.) for backfilling (Fig. 1D and E). The ac-
endodontic-periodontal lesion with periodontal breakdown associated cess cavity was etched, primed, and filled with light-cured resin com-
with a palatogingival groove and concomitant pulpal necrosis. During posite (Filtek Supreme XTE; 3M ESPE, Seefeld, Germany).
this appointment, an interdisciplinary treatment plan was formulated; At an evaluation appointment 2 months later, the pocket depth
the patient was informed that tooth #7 had a questionable long-term associated with the palatogingival groove had not decreased, and it
prognosis because of the length of the radicular groove and the ability bled on probing as expected. The patient was asymptomatic but,
to treat the defect periodontally. because the facial sinus tract persisted, she was scheduled for an inten-
Three weeks later, after prophylaxis and removal of the localized tional replantation. The patient was prescribed antibiotics (amoxicillin
calculus, the resin composite in the access opening was removed under plus clavulanic acid 1 g daily) starting the day before surgery and
rubber dam isolation (Hygenic Dental Dam; Colt
ene Whaledent, Lange- continuing for another 6 days (25) and was instructed to rinse her
nau, Germany). When the pulp chamber was reached, the root canal mouth with a 0.12% solution of chlorhexidine twice daily for 1 week.
orifice and palatogingival groove were visible. Figure 1C shows the To avoid tooth fracture and minimize mechanical damage to the PDL,
communication between the radicular groove and the pulp chamber. elevators were not used to luxate the tooth before extraction
The root canal was shaped using a size 10 and 15 K-files (Dentsply Mail- (Fig. 2A). A rubber dam was placed around the handle of the forceps
lefer, Ballaigues, Switzerland) to obtain a manual glide path. Instrumen- to maintain constant pressure on the crown. The tooth was extracted
tation was completed using Mtwo nickel-titanium rotary instruments gently with no intraoperative complications; subsequently, the patient
(VDW GmbH, Munich, Germany) with an X-Smart endodontic motor was instructed to bite on moist gauze during the extraoral procedures.
(Dentsply Maillefer). The instrumentation sequence was size 10, The extracted tooth was gently rinsed with physiologic saline. Un-
0.04; 15, 0.05; 20, 0.06; 25, 0.06; 30, 0.05; and 35, 0.04. Copious der a dental microscope (DF Vasconcellos, S~ao Paulo, SP, Brazil), the

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Case Report/Clinical Techniques

Figure 2. (A) Elevators were not used to luxate the tooth before extraction. (B) The palatogingival groove and the root apex (1 mm) were removed with a small
diamond bur. (C) Sealing of both the palatogingival groove and the root apex using a self-adhesive dental composite (Vertise Flow). (D) A postoperative radiograph
taken immediately after tooth replantation. (E) A postoperative radiograph at a 3-month recall. (F) Probing revealed no pockets extending beyond 3 mm.

palatogingival groove extending to the root apex was clearly visible. No Discussion
abnormalities, such as fractures, cracks, or accessory canals, were de- A palatogingival groove is a developmental anomaly of the maxil-
tected. The tooth was held gently by the crown and root with physiologic lary central and lateral incisors. It usually begins in the central fossa,
saline–soaked gauze during the extraoral procedure. The root end was crosses the cingulum, and extends apically although the distance and
resected with a high-speed turbine using copious water. Subsequently, direction of this extension vary (2, 5, 9). Gu’s findings (24) confirmed
the radicular groove was removed with a small diamond bur, the root that these radicular grooves exhibit a broad spectrum of morphologic
apex was flattened, and a class I cavity was prepared (Fig. 2B). Both the variations; the grooves are markedly variable in depth, length, location,
palatogingival groove and the root apex were filled with a self-adhesive and complexity. Kogon (9) investigated 3168 extracted maxillary lateral
dental composite (Vertise Flow; Kerr Corp, Orange, CA) (Fig. 2C). Using and central incisors; 4.6% possessed a palatogingival groove. Approx-
a surgical curette, periapical granulation tissue was removed from the imately half of all grooves terminated at the root, and 58% extended
periapical region without damaging the socket wall. The complete ex- more than 5 mm from the cementoenamel junction. Fifty-four percent
traoral procedure lasted 4 minutes. The tooth was then replanted of the palatogingival grooves in Kogon’s study were described as shallow
into its alveolar bone (Fig. 2D) and splinted with a semirigid splint depressions, 42% as deep depressions, and 4% as closed tubes.
for 7 days. Palatogingival grooves act as a nidus for plaque formation, often
At a 3-month recall, the sinus tract had closed, and the patient was promoting the development of a combined endodontic-periodontal
asymptomatic (Fig. 2E). Probing revealed no pockets extending beyond lesion via communication between the pulp canal system and the perio-
3 mm (Fig. 2F). At a 1-year recall, the tooth showed almost complete dontium through accessory canals. These circumstances can lead to
periapical healing (Fig. 3A). The tooth remains asymptomatic, and misdiagnosis of the groove as a primary endodontic lesion.
the patient is comfortable (Fig. 3B).

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Figure 3. (A) A radiograph showing excellent periradicular healing of tooth #7 at a 1-year postsurgical follow-up examination. (B) A buccal view clinical photo-
graph showing no gingival recession.

Misdiagnosis may also occur because the clinical picture is suggestive of sized the importance of preserving the PDL and limiting the extraoral
a periodontal abscess, whereas radiographically a palatogingival groove time to 30 minutes (33, 34). An extraoral time greater than
can resemble a vertical root fracture or an extra root canal (24, 26). 30 minutes increases the possibility of replacement resorption (35).
The successful management of a tooth with a palatogingival groove In this case, the tooth was held gently at both the crown and root
is dependent on both effective periodontal treatment and resolution of with gauze soaked in physiologic saline. The total extraoral time was
the associated localized periodontal defect (19). Endodontic therapy is only 4 minutes, allowing us to avoid the application of any solution,
indicated once the pulp has become necrotic. However, conventional such as tetracycline, citric acid, EDTA, or enamel matrix derivative, to
endodontic treatment alone is insufficient because the bacteria live the root surface to enhance PDL fiber attachment or prevent ankylosis
outside the root, yielding a self-sustaining lesion (27). Ultimately, the (25, 36).
outcome of treatment for periodontal defects determines the prognosis Several materials have been used to fill palatogingival grooves (37,
of these teeth. Shallow grooves can often be treated successfully (12), 38). Although mineral trioxide aggregate sets in the presence of
whereas deep grooves present complex endodontic-periodontal prob- moisture, it can get washed off transgingival defects (26). Glass ionomer
lems with a poor prognosis (5, 27). Fortunately, new treatment options cement is suitable because it does not have this drawback (39, 40).
are available with better potential to save such teeth. Although the Recently, an innovative, resin-based material that combines self-
treatment of palatogingival grooves has not been evaluated in a adhesion and flowability was developed (Vertise Flow), introducing a
controlled investigation, multiple case reports describe different new category of restorative materials termed self-adherent composite
treatment modalities (5, 26, 27). Suggested treatment approaches resins. The exclusion of rinsing and drying steps in their application
include curettage of the affected tissues, elimination of the groove by is an attractive clinical advantage because the risk of contamination is
grinding and/or sealing with a variety of filling materials, and surgical reduced, and the bonding procedure is less sensitive to potential over-
procedures (18–23). drying or overwetting (41, 42). Despite the appeal of the simplified
In this case, intentional replantation was the chosen treatment mo- handling of single-step adhesives, some aspects of their bonding mech-
dality. Intentional replantation is not a new procedure. According to anism, such as the etching potential in various clinical situations and
Dryden and Arens (28), Pierre Fauchard first described its use in the bond durability, are still being studied.
18th century. Over time, the indications for intentional replantation In this case, periodontal surgery, involving elimination of the pal-
have evolved. Peer (29) listed a wide range of indications, including fail- atogingival groove and sealing with a choice of filling materials, was an
ure of root canal treatment, anatomic limitations, problems with acces- option (4, 26). The groove extended beyond the middle third of the root
sibility, persistent chronic pain, accidental exarticulation, involuntary apex, necessitating the use of barriers and/or intraosseous grafts to
rapid orthodontic extrusion, and patients with objections to periradic- correct the defect (4, 26). However, the palatal surgical approach is
ular surgery and trismus. Intentional replantation is an accepted end- difficult, especially for a type II palatogingival groove such as this
odontic treatment procedure in which a tooth is extracted and (27, 37). Aware of the prognosis associated with intentional tooth
treated outside the oral cavity and then reinserted into its socket to cor- replantation, we decided that this was the treatment of choice.
rect an obvious radiographic or clinical endodontic failure (29). It In this report, we described the successful management of a com-
should no longer be considered a last-resort treatment prescribed bined endodontic-periodontal lesion precipitated by a type II palatogin-
only for ‘‘hopeless teeth’’ as proposed by Grossman (30). Although gival groove (24), the prognosis of which was considered poor. The
intentional replantation is not a frequently performed procedure, it treatment outcomes achieved in this case were no pockets extending
yields a tooth survival rate of 88% according to a recent meta- beyond 3 mm, no gingival recession, and significant resolution of the
analysis (31). radiographic radiolucency at a 12-month follow-up. There is no reason
One important concern related to the procedure is the extraoral to believe continued healing will not occur. Therefore, this case shows
time, which should be as short as possible (28–31). The literature that intentional replantation is a reliable and predictable procedure and
on avulsed teeth reflects our understanding of the significance of should be considered more often as a treatment modality for palatogin-
extraoral time, especially dry time (32). Many researchers have empha- gival grooves.

JOE — Volume 42, Number 2, February 2016 Treating a Palatogingival Groove 327
Case Report/Clinical Techniques
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328 Garrido et al. JOE — Volume 42, Number 2, February 2016