Pal A To Gingival Groove

INDIAN JOURNAL OF DENTAL ADVANCEMENTS
J o u r n a l h o m e p a g e : w w w. n a c d . i n
CASE REPORT
Palatogingival Grooves
Shankar Ram1, Uma Sudhakar2, Pramod V3, Radhika A4
Dept. Of Periodontics
Thai Moogambigai Dental College
Mugappair, Chennai-107, India
Sr. Lecturer1
Professor2
PG Student3 & 4
Article Info
Received: February 9, 2010
Review Completed: February 17, 2010
Accepted: February 28, 2010
Available Online: August, 2010
NAD, 2010 - All rights reserved
ABSTRACT:
Palatogingival grooves a developmental anamoly, initiate on the
enamel and can extend a significant distance on the root surface,
providing a plaque retentive area that is difficult to instrument.
The diagnosis of these grooves is quite difficult, as they cannot be
differentiated in the X-ray images. Specialized diagnostic
techniques like 3D computed tomography had been used for
detecting the apico-coronal and bucco-lingual extent of these
grooves.The treatment procedures employed for treating
palatogingival grooves will include pulpectomy if the tooth is
nonvital along with odontoplasty of the groove or restoration of
the groove with GIC after the elevation of mucoperiosteal flap.
Bone defects around the involved teeth also has to be treated with
grafts and membrane. This case report describes the diagnosis and
treatment of a palatogingival groove on maxillary lateral incisors.
Key words: Palatogingival groove, CT scan, Bone grafts, Guided
tissue regeneration
Introduction
Periodontitis is defined as the inflammatory
disease of tooth supporting structures caused by
microorganisms or by group of specific
microorganisms resulting in progressive destruction
of the periodontal ligament and alveolar bone with
pocket formation or recession or both1. Clinically
gingivitis and periodontitis are differentiated with
the presence of attachment loss, which is seen in the
former. Periodontitis is accompanied by periodontal
pocket formation which is a result of apical migration
of junctional epithelium along with significant
changes in the levels and density of alveolar bone.
According to the American Academy of
Periodontology (AAP) International workshop for
classification held during the year 1999, the
Email for correspondence:
shankarram_2005@yahoo.com
developmental and acquired deformities and

conditions, were grouped together as an entity that
could lead to periodontal destruction 1.
Developmental and acquired deformities are those
conditions and structural changes to the tooth and
or soft tissue that could bear a significant threat to
the Periodontium and lead to definitive attachment
loss.
These developmental and acquired deformities are
sub-classified into the following:
1.
Localized tooth related factors that predispose

to plaque induced gingivitis or periodontitis.
1.1. Tooth anatomic factors

1.2. Dental Restorations or appliances
1.3. Root fractures
1.4. Cervical root resorption and cemental tears.
IJDA, 2(2), April-June, 2010
229
2.
Mucogingival deformities and conditions

around teeth.
3.
Mucogingival deformities and conditions on

edentulous ridges.
4.
Occlusal trauma.
The tooth anatomic factors are malformation of

tooth during their developmental phase or improper
positioning of the teeth in the arch. The cervical
enamel projections and enamel pearls are one such
anatomic variations that can to plaque accumulation
and periodontal destruction. They tend to cause
more destruction when present in furcation areas like
mandibular molars where the incidence of finding
them is 15 - 25% and in maxillary molars where their
incidence is 9 - 25%. Proximal root grooves on incisors
and maxillary premolars, tooth location and
malalignment can predispose to poor oral hygiene
and eventual alveolar bone loss leading to
attachment loss. Open contacts between teeth can
also cause attachment loss because of food
impaction. Palatogingival grooves are also one such
developmental anomaly that are found primarily on
maxillary incisors and can lead to alveolar bone loss,
clinical attachment loss and pocket formation.
Palatogingival groove or Radicular Lingual
Groove (RLG) is a developmental anomaly in which
an infolding of the inner enamel epithelium and
Hertwigs epithelial root sheath create a groove that
passes from the cingulum of maxillary incisors
apically onto the root. Radicular lingual grooves can
create periodontal and pulpal pathology. This groove
creates an area where plaque accumulation can be
difficult if not impossible to control using oral
hygiene measures. Withers et al2 in 1981 observed
that palatogingival grooves are found on 2.3% of
maxillary incisors (4.4% maxillary laterals and 0.28%
of maxillary centrals) Everett1 in 1972 observed that
palatogingival grooves found on 2.8% of lateral
incisors. While Kogon 1 in 1986 Examined 3168
extracted maxillary central and lateral incisors.
Palatogingival grooves found on 4.6% of maxillary
incisors (3.4% maxillary centrals and 5.6% on
maxillary lateral incisors) 54% of palatogingival
230 IJDA, 2(2), April-June, 2010
Shankar Ram, et, al.
grooves terminated on the root with 43% of those

extending less than 5mm and 47% extending 610mm.
Case report
A male patient aged 24 years reported to the
Dept. of Periodontology, Thai Moogambigai Dental
College and Hospital Chennai with chief complaint
of sensitivity and spacing concerning upper anteriors.
The history of chief complaint revealed that the
sensitivity was mainly during consuming cold food
which started for the past 6 months and gradually
increased. Pathologic tooth migration which caused
increase in spacing between upper anteriors was
noticed by the patient for the past 2 months.
On extra-oral examination there were no
palpable lymph nodes, face was bilaterally
symmetrical and lips were competent. On intra-oral
examination gingival color was reddish, gingival
contour showed rolled out marginal gingiva and
interdental papillae was flattened, consistency was
soft and edematous and surface texture was smooth
because of loss of stippling in the upper anterior
region. Oral hygiene index was used to measure
debris and calculus which was 1.5 and the inference
being poor oral hygiene. There was no mobility
observed with the teeth and the patient had not got
his teeth extracted or lost.
Fig 1. Showing the pre operative photograph
Periodontal examination consisted of measuring

pockets at six regions of teeth ie, mesiolabial,
midlabial, distolabial, mesiopalatal, midpalatal and
distopalatal using UNC-15 probe. Periodontal
pockets of > 7 mm was present in upper laterals ie,
12 and 22 numbered teeth.
Fig 2. Showing the Periodontal pocket of 7mm on palatal surface of 22
Fig 4. Showing the CT scan images, arrows pointing to the grooves
On further clinical examination of the palatal

surface of teeth numbers 12 and 22 a fine groove
called palatogingival groove was noticed which
started at the cingulam and travelled apically and
laterally as shown in the figure below.
Fig 5. Showing the intraoral periapical radiograph
The phase I periodontal therapy consisted of oral

hygiene instructions and scaling and root planing.
After reevaluation of phase I therapy, a decision to
perform periodontal surgery in the upper anterior
region was taken. Papilla preservation flap was raised
in the upper anteriors as explained by Takeiet al in
1992.
Fig 3. Showing the palatal surface of 12 and 22 with palatogingival
grooves
Further investigations were carried out to

measure the pulpal extension of the groove and its
apical extension on the radicular surface. Apart from
routine Intraoral periapical radiographs and
Orthopantamographs, Computed Tomography or CT
scan was taken to detect and measure of the
palatogingival groove present on the teeth 12 and 22.
Fig 6. Showing papilla preservation flap
231
Fig 7. Showing the palatogingival groove
Fig 9. Showing the bone graft placed in the defect
Fig 8. After the groove on 22 being obliterated by odontoplasty
Fig 10. Showing the membrane placed on the defect
After flap elevation root surfaces were scaled and

planed. The palatogingival grooves on 12 and 22 were
treated by odontoplasty alone as the pulp was not
involved by the palatogingival groove which had
been noticed from the CT scan and vitality test was
positive. A three wall vertical bony defect present in
relation to 22 was treated with reconstructive
procedure where a synthetic hydroxyapatite alloplast
bone graft material was placed and a re-sorbable
collagen membrane was used to cover the bone
defect. Then the flap was approximated and sutured
with resorbable vicryl 4-0 sutures. Postoperative
instructions and medications were given 1). Cap
Amox 500 mg tid. 2). Tab Flagyl 400 mg tid 3). Tab Imol
plus bid.
There was no postoperative complications and

the patient was re evaluated at 1,3,6,9 and 12 months
and after 12 months as seen in the figures shown
below the healing has been complete with gingiva
being healthy and palatogingival grooves are absent.
232 IJDA, 2(2), April-June, 2010
Fig 11. Post operative photograph after 1 year of surgery, palatal

view. Palatogingival grooves are absent
foramen then endodontic treatment of the teeth has

to be completed first and periodontal treatment has
to be carried out.
Fig 12. post operative photograph labial view. Gingiva looks healthy
Discussion
The presence of a morphological defect called a
palatogingival groove is considered to be an
important contributing factor to the development of
localized chronic periodontitis, for it favors the
accumulation and proliferation of bacterial plaque
deep into the periodontium. This anomaly affects
maxillary incisors, especially lateral incisors. The
prevalence and different morphologic conditions of
the palatogingival groove were evaluated by Albaricci
MF et al3 wherein 376 maxillary lateral and central
incisors were examined. The teeth were evaluated by
a single examiner, considering their presence,
localization, origin of formation, extension and depth
in millimeters, using a magnifying glass, a precision
pachymeter and a millimeter-scaled periodontal
probe. Results showed a higher prevalence in lateral
incisors with higher prevalence in proximal
localization, origination from central fossa (57.1%) and
predominance in oblique trajectory (62.8%). Of all
these teeth, only 8.6% of palatogingival grooves
reached the root apex, while 97.1% were considered
as flat (<1mm).Thus, in the presence of a palatogingival
groove, periodontal pathologic conditions could be
more severe in proximal faces, reaching in a few cases
the tooth apex and the pulp canal.
Palatogingival grooves when present may
contribute to the pathogenesis of periodontal and
endodontic lesions. In the present case there was no
endodontic involvement as the CT scan revealed and
the teeth was vital. So odontoplasty was used to treat
the groove. Also the groove can be filled using glass
ionomer cement as explained by Ballal NV et al4 or
Silver amalgam restoration can be done to the
groove as explained by Brunsvold MA5 in 1985. If the
teeth with palatogingival groove has an involvement
of the pulp either by direct pulpal extension of the
groove or apical extension of the groove till the apical
The presence of palatogingival grooves has led

localized periodontal destruction as explained by the
epidemological study done by withers et al in 1981.
The vertical bone loss due to the periodontal lesion
can be treated using bone graft materials as
explained by Ballal NV et al 4 and a re-sorbable
membrane can also be used for guided tissue
regeneration as used by Anderegg CR et al6. As in our
case there was a presence of bone loss around the
teeth 22 only which was treated by bone graft and
resorbable membrane. On the otherhand bone loss
was not present around 12 and thus treated only by
odontoplasty. Thus, if the palatogingival groove does
not cause pulpal or periodontal pathology then
scaling and root planing with regular re evaluation
of the patient and the concerned tooth is the best
treatment option.
A combination of endodontic, intentional
replantation and Emdogain therapy was used to
sucessfully treat a maxillary lateral incisor that had a
palatogingival groove by Al-Hezaimi K et al7 in 2004.
CONCLUSION
Although the incidence of palatogingival
grooves is only 8.5%. We should have an eye to
recognize them early and diagnose their extent and
pulpal involvement in order to save the patient from
periodontal destruction
REFERENCES
1.
2.
3.
4.
5.
6.
7.
Carranzas Clinical Periodontology, 10th Edition.

Withers JA, Brunsvold MA, Killoy WJ, Rahe AJ. The
relationship of palato-gingival grooves to localized
periodontal disease. J Periodontol. 1981 Jan;52(1):41-44.
Albaricci MF, de Toledo BE, Zuza EP, Gomes DA, Rosetti EP.
Prevalence and features of palato-radicular grooves: an invitro study. J Int Acad Periodontol. 2008 Jan;10(1):2-5.
Ballal NV, Jothi V, Bhat KS, Bhat KM. Salvaging a tooth with
a deep palatogingival groove: an endo-perio treatment
a case report. Int Endod J. 2007 Oct;40(10):808-17. Epub
2007 Aug 21.
Brunsvold MA. Amalgam restoration of a palatogingival
groove. Gen Dent. 1985 May-Jun;33(3):244, 246.
Anderegg CR, Metzler DG. Treatment of the palato-gingival
groove with guided tissue regeneration. Report of 10 cases.
J Periodontol. 1993 Jan;64(1):72-74.
Al-Hezaimi K, Naghshbandi J, Simon JH, Oglesby S, Rotstein
I. Successful treatment of a radicular groove by intentional
replantation and Emdogain therapy. Dent Traumatol. 2004
Aug;20(4):226-228.
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INDIAN JOURNAL OF DENTAL ADVANCEMENTS

developmental and acquired deformities and

Localized tooth related factors that predispose

1.1. Tooth anatomic factors

Mucogingival deformities and conditions

Mucogingival deformities and conditions on

The tooth anatomic factors are malformation of

Shankar Ram, et, al.

grooves terminated on the root with 43% of those

Fig 1. Showing the pre operative photograph

Periodontal examination consisted of measuring

Shankar Ram, et, al.

Fig 2. Showing the Periodontal pocket of 7mm on palatal surface of 22

Fig 4. Showing the CT scan images, arrows pointing to the grooves

On further clinical examination of the palatal

Fig 5. Showing the intraoral periapical radiograph

The phase I periodontal therapy consisted of oral

Further investigations were carried out to

Fig 6. Showing papilla preservation flap

IJDA, 2(2), April-June, 2010

Shankar Ram, et, al.

Fig 7. Showing the palatogingival groove

Fig 9. Showing the bone graft placed in the defect

Fig 8. After the groove on 22 being obliterated by odontoplasty

Fig 10. Showing the membrane placed on the defect

After flap elevation root surfaces were scaled and

There was no postoperative complications and

232 IJDA, 2(2), April-June, 2010

Fig 11. Post operative photograph after 1 year of surgery, palatal

Shankar Ram, et, al.

foramen then endodontic treatment of the teeth has

The presence of palatogingival grooves has led

Carranzas Clinical Periodontology, 10th Edition.

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