|Year : 2013 | Volume
| Issue : 2 | Page : 90-94
Intentional replantation: A viable alternative for management of palatogingival groove
Vijay Kumar, Ajay Logani, Naseem Shah
Department of Conservative Dentistry and Endodontics, Center for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||13-Sep-2013|
3rd Floor, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Radicular groove is an anatomical malformation that often leads to combined endodontic-periodontic lesions. Treatment of complex groove presents a clinical challenge to the operator. A case of type III palatogingival groove is successfully treated with intentional replantation. With the understanding of the procedure and strict adherence to guidelines improves, practitioners can use intentional replantation as an easy and cost-effective alternative for the management of radicular groove. The paper presents a brief review of palatogingival groove and highlights an easy and predictable alternative for its management.
Keywords: Intentional replantation, palatogingival groove, radicular groove
|How to cite this article:|
Kumar V, Logani A, Shah N. Intentional replantation: A viable alternative for management of palatogingival groove. Saudi Endod J 2013;3:90-4
| Introduction|| |
Palatogingival groove is a developmental anatomic aberration affecting external and internal morphology of the tooth. The term was formulated by Lee et al.  and also known as distolingual groove, radicular lingual groove, radicular groove, and syndesmocoronoradicular groove. ,
Its prevalence ranges from 1.01% to 8.5% independent of the sex.  An incidence of 18% in the Chinese population depicts the racial influence on its occurrence.  Bilateral occurrence is rare and seen only in 0.75% of cases. The maxillary lateral incisor (LI) is most commonly (93.8%) affected tooth.  An imbalance in the growth between different areas of the maxilla and presence of central incisor, canine, and first premolar deprives the LI tooth germ of adequate space.  The etiopathogenesis is an infolding of enamel organ and the epithelial sheath of Hertwig before the calcification phase. Embryologically, it is related to a mild form of dens invaginatus, where an invagination results in a circular opening.  Although some authors assert it to be an attempt of a tooth to form a supernumerary root, the exact etiology is still not well understood and remains unclear. 
Clinically, a V-shaped notch is seen with altered or interrupted cemento-enamel junction (CEJ). It commences in the region of the cingulum and proceeds apically parallel to the long axis of the tooth for a varying distance. 
The palatogingival groove shows a broad spectrum of morphologic variations in depth, extent, and complexity with distal and mid-palatal surfaces being the most commonly affected [Table 1]. , It is difficult to identify the anomaly on radiographs due to its superimposition over the pulp canal space; however, multiple radiographic exposures with different horizontal projections can reveal a palatogingival groove as a radiolucent para pulpal line.  Based on the extension of groove over the root surface, two classifications were proposed independently by Gu YC and Goon et al. , [Table 2] and [Table 3].
The mere presence of a palatogingival groove does not indicate pathology. If the epithelial attachment is intact, the tooth and the periodontium remain healthy in most cases. It acts as a plaque trap and difficulty in cleaning the proximal locations predisposing the tooth to localized severe periodontal destruction. Bacterial and their byproducts quickly destroys the sulcular epithelium, advances apically along the groove and deeper parts of the periodontium.  Direct soft tissue connection between pulp and periodontium leading to combined endodontic-periodontic lesion is speculated by various authors. Pulpal involvement and eventual necrosis can occur due to tracking of the bacteria apically along the groove to the apex and through the accessory foramina or exposed dentinal tubules in either above or below the epithelial attachment in the lingual groove. Therefore, it becomes difficult to differentiate whether the endodontic or periodontic lesion is preliminary in the combined lesion. 
Most of these lesions can be successfully treated as long as the infection in the accessory canal and depth of the groove can be efficiently eliminated and sealed. Various therapeutic options for the management of radicular groove includes curettage of the affected tissues,  saucerization of the groove with a round bur,  sealing the groove with a variety of materials e.g., amalgam, composite, Glass-ionomer cement.  The prognosis is good if the groove is entirely located on to the crown of the tooth, terminating at the CEJ. The extension on to the root surfaces complexes the treatment plan and compromises its outcome. Surgical procedures are often required in an attempt to achieve new attachment, if the groove extends beyond the middle-third of the root apex. They include flap procedure with removal of the granulation tissue and careful scaling and root planning, use of barriers and intra-osseous graft to correct the defect, and guided tissue regeneration in an attempt to achieve new attachment.  However, the outcome is always questionable, and the failure to re-establish periodontal attachment can lead to extraction of the involved tooth. This paper presents intentional replantation as an alternate treatment option for management of complex or type III palatogingival groove.
| Case Report|| |
A 26-year-old male reported to the department of conservative dentistry and endodontics with a chief complaint of pus discharge from the upper incisor tooth region. There was no history of trauma or any other systemic illness. Clinical examination revealed an intraoral draining sinus in the labial gingival surface associated with left maxillary lateral incisor. The coronal structure was intact with no change in the color or texture. A V-shaped groove was present at mid-palatal aspect at CEJ and extending apically creating a periodontal pocket of 10 mm in depth [Figure 1]. Intra-oral peri-apical radiograph revealed peri-radicular radiolucency around the apex of the maxillary left lateral incisor [Figure 2]. Thermal and electric vitality tests were negative. A diagnosis of pulp necrosis with chronic apical periodontitis was established.
|Figure 1: Clinical picture of palatogingival groove in maxillary left central incisor tooth|
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|Figure 2: Radiograph showing large peri-radicular lesion around maxillary left lateral incisor tooth|
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Tooth was isolated under rubber dam, and endodontic treatment was initiated. Working length was established with the help of electronic apex locator, and chemomechanical preparation was performed in a crown down manner with copious irrigation with 2.0% sodium hypochlorite solution. Root canal was dried with paper points, and intra-canal calcium hydroxide dressing was placed (Prime Dental Products Pvt. Ltd., Mumbai, India). After 4 weeks interval, the patient was asymptomatic with healing of intraoral sinus tract. Root canal obturation was completed with gutta-percha and AH plus root canal sealer (AH-Plus, Dentsply, Petropolis, Brazil), and access cavity was sealed with composite resin (Esthet X HD, Dentsply, India) at this visit [Figure 3].
Sealing of palatogingival groove was planned to eliminate the periodontal defect. Since the groove was extending onto the root surface with periodontal pocket having 10 mm of probing depths, intentional replantation was opted for its management. Tooth was carefully extracted by holding with forceps coronal to CEJ [Figure 4]. The tooth was then placed in a sterile Hank's balanced salt solution (Save-A-Tooth, Pottstown, PA, USA). Extra-oral examination of the tooth revealed the groove extending up to the root apex [Figure 5]a. The granulation tissue was removed, and groove was cleaned with ultrasonics used under continuous water spray [Figure 5]b. The groove was sealed with Glass-ionomer cement (Glass ionomer cement version 2, Shofu Inc., Kyoto, Japan), and tooth was replanted into the socket [Figure 5]c. The care was taken to minimize the extra-oral time. The tooth was splinted with composite-orthodontic wire splint for 2 weeks [Figure 6] and [Figure 7]. At 1 year follow-up, patient was asymptomatic with clinical periodontal reattachment with reduced pocket depths. Peri-radicular healing was also evident on radiograph [Figure 8].
|Figure 4: Forceps extraction by holding tooth coronal to cemento-enamel junction|
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|Figure 5: (a) Palatogingival groove extending up to the root apex. (b) Palatogingival groove after cleaning by ultrasonics. (c) Palatogingival groove sealed with GIC|
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|Figure 8: Peri-apical healing evident on radiograph at one year follow-up|
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| Discussion|| |
When palatogingival groove extends to the apex, the canal shape and configuration is complex and unfavorable for thorough debridement and obturation during endodontic treatment.  Scanning electron microscopic study showed a decreased dentin thickness (360 μm) with exposed dentinal tubules and accessory foramen with a diameter varying (15-200 μm) in some parts between the groove and the pulp cavity. Presence of bacteria in the accessory channels in the depth of periodontal groove can result in treatment failure. Thus, sealing of the groove is essential to eliminate the pathways of communication between the pulp and the periodontium.  However, proper sealing of the type III or complex grooves after flap reflection is questionable.
Intentional replantation is an accepted procedure, in which a tooth is extracted and treated outside the oral cavity and then inserted into its socket to correct an obvious radiographic or clinical endodontic failure.  Literature reports the success rate to range from 52% to 95% with concern about replacement root resorption of the involved tooth. , Maintenance of viable periodontal ligament (PDL) along with intact cementum during the procedure is essential to avoid such complication. Forceps extraction was performed by holding the beaks coronal to CEJ, minimizing the injury to protective layer.  Immediate replantation with damage to less than 20% of the root surface can ensue transient replacement root resorption, which is repaired by new cementum.  However, drying of PDL with delay of 8 minutes or more in replantation and the larger injuries (>4 mm 2 ), the permanent bony ankylosis is likely to occur.  Thus, extra-oral time was kept to minimum (<5 min), and PDL were moistening with HBSS to prolong their vitality.
Re-establishment of attachment apparatus is essential to restore the health of periodontium. Saucerization of groove and application of emdogain was suggested to enhance healing and regeneration of PDL for intentionally replanted teeth.  However, the long term follow-up suggested that use of emdogain provides no added advantage. Glass-ionomer cement being less technique-sensitive, chemically bonded providing excellent seal and favorable environment for fibroblast attachment was chosen to seal palatogingival groove before replantation.  The tooth was stabilized by composite - orthodontic wire splint to aid the initial periodontal healing. The healing of periodontal ligament begins after 1 week, and two third of periodontal fibers are already formed within 2 weeks.  This provides stabilization to the tooth in alveolus and facilitates the splint removal after two weeks.
The follow-up at 1 year showed the healing of peri-radicular lesion without any signs of inflammatory or replacement root resorption. Provided the viability of PDL is maintained, it is possible to re-establish attachment with tooth structure. Thus, intentional replantation, allowing complete sealing, can be an easy and predictable option for management of palatogingival groove with a successful treatment outcome.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3]