JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2009  |  Volume : 1  |  Issue : 3  |  Page : 55-61

Treatment of a rare retrograde lesion -A case report

1 Department Of Periodontics, Santosh Dental College & Hospital, Ghaziabad, NCR, New Delhi, India
2 Department Of Conservative Dentistry and Endodontics, Tagore Dental College and Hospital, Chennai, Tamilnadu, India

Date of Web Publication23-Feb-2011

Correspondence Address:
D Gopalakrishnan
Department Of Periodontics, Santosh Dental College & Hospital, Ghaziabad, NCR, New Delhi
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Source of Support: None, Conflict of Interest: None

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Background: The retrograde periodontal lesion is a very rare condition of endodontic origin with secondary periodontal involvement. The presence of a concomitant palato-radicular groove (PRG) on a maxillary lateral incisor is not a common developmental anomaly. We report on the successful treatment of this condition through endodontic and periodontal therapy.
Methods: This case report describes a pulpal periodontal condition occurring on a left maxillary lateral incisor in a 30-year-old male, which was successfully treated by conventional endodontic therapy followed by periodontal treatment which included odontoplasty and apical flap surgery with bone grafting.
Results: A 2-year follow-up, which included a radiographic evaluation and surgical re-entry, revealed excellent healing with complete bone fill around the involved defect and total resolution of the lesion.
Conclusion: The basis of our successful treatment was an accurate and timely diagnosis and elimination of all inflammatory irritants and other contributory factors. It is important for all clinicians to be aware of the existence of this abnormality.

How to cite this article:
Gopalakrishnan D, Balagopal S. Treatment of a rare retrograde lesion -A case report. J Int Clin Dent Res Organ 2009;1:55-61

How to cite this URL:
Gopalakrishnan D, Balagopal S. Treatment of a rare retrograde lesion -A case report. J Int Clin Dent Res Organ [serial online] 2009 [cited 2022 Jan 28];1:55-61. Available from: https://www.jicdro.org/text.asp?2009/1/3/55/77031

   Introduction Top

Retrograde periodontitis is a pulpal derived condition which is a known cause of severe, localized destruction of periodontal tissues and only a few cases have been reported in literature [1],[2],[3],[4],[5] . The following anatomical etiology have been attributed as possible causes of retrograde periodontal lesions: palato-radicular groove (PRG), root /tooth fractures, cemental agenesis/hypoplasia, root anomalies, fibrinous communications and trauma-induced root resorption [6] . PRG, a developmental anomaly caused by the infolding of enamel organ and Hertwig's epithelial root sheath most commonly occurs on the palatal aspect of maxillary incisors [7],[8],[9],[10],[11] . The nature of PRG varies in depth, extent, and complexity from case to case and are closely related to prognosis and clinical implications of the affected teeth 12 There are also reports of successful treatment of localized periodontal defects with or without pulpal pathoses caused by PRG [13],[14],[15],[16],[17],[18],[19],[20],[21] .

In this case report, a multidisciplinary approach is discussed in which a conventional endodontic treatment of a maxillary left lateral incisor with a complex PRG was done followed by odontoplasty and bone grafting of the osseous defect to successfully resolve the pulpal-periodontal lesion.

   Case Description Top

A 30-year-old man presented himself to the department of periodontics at our school clinic with pain on the left maxillary lateral incisor which had started 2 days earlier. The patient reported a history of trauma around the involved tooth which was attributed to a fall 18 months earlier in another state in India. The patient subsequently visited a general dentist in that state who placed a temporary restoration for immediate attention to the condition at that point of time. Intra-oral examination of the soft tissue around tooth 22 appeared normal [Figure 1]. On the palatal aspect of the tooth, a palato-radicular groove (PRG) was noted crossing over the cingulum of the tooth 22 [Figure 2]. On percussion, severe pain was experienced compared to the adjacent teeth. A probing depth of 9 mm existed on the palatal aspect of the tooth along the PRG. Radiographic examination revealed a retrograde lesion around the tooth extending in the coronal direction almost 75% of the length of the root with an intact inderdental septum [Figure 3]. Retrograde periodontitis combined with a necrotic pulp was diagnosed after considering the patient's history and clinical and radiographic evaluation. The patient was referred to an endodontist.
Figure 1: Clinical view at initial visit

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Figure 2: Palato-radicular groove (PRG) crossing over the cingulum of the tooth 22

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Figure 3: Radiograph of the retrograde lesion before endodontic treatment.

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Intitial endodontic treatment of the affected tooth included endodontic obturation of the root canal with gutta percha and endomethasone cement sealer, which was accomplished in a single visit. The patient was seen after a month for endodontic assessment, where a radiograph showed complete healing of the periapical lesion [Figure 4], and then referred back to the periodontist for evaluation and treatment of the periodontal defect associated with PRG.
Figure 4: Radiograph at 1 month following endodontic treatment.

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The presurgical examination indicate the 9 mm probing depth still existed on the palatal aspect of tooth 22 along the PRG. Under local anesthesia (lignocaine with adrenaline 1:80000), a mucoperiosteal flap was raised using intrasulucular incisions on the facial and palatal aspects of tooth 22. The PRG was eliminated by odontoplasty with a tapering fissure bur. The periodontal osseous defect was debrided and the root conditioned with a saturated solution of tetracycline-HCl [Figure 5]. The periodontal osseous defect was filled with bioactive glass [Figure 6]. The mucoperiosteal flap was repositioned and sutured [Figure 7] and a periodontal dressing was placed. Post-operative instructions such as, do not brush in the surgical area for 1 week, do not bite on any hard object accidentally on the surgical area and other routine periodontal post-operative surgical instructions were given to the patient.
Figure 5: Periodontal osseous defect after debridement and root conditioning with a saturated solution of tetracycline-HCl

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Figure 6: Periodontal osseous defect was filled with bioactive glass material.

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Figure 7: Surgical site after suturing

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The sutures and the dressing were removed after 1 week. Healing was uneventful and the surgical site was thoroughly irrigated with saline. The patient was instructed to use a 0.12% chlorhexidine mouth rinse for 3 weeks. Recall appointments were made at the third and sixth months and at the end of the first and second years; intra-oral periapical radiographs were taken at each visit [Figure 8], [Figure 9], [Figure 10] and [Figure 11]. An increase in radiodensity of the surrounding bone demonstrated an excellent regeneration of the destroyed osseous tissue. Clinically, probing depth was reduced from the original 9 mm to 3mm at the end of second year. Surgical re-entry was done at the second year examination to determine if further periodontal therapy was required. However, re­entry showed there was an excellent and total bone fill in two years [Figure 12] and no additional periodontal treatment was needed. The results were confirmed radiographically [Figure 11].
Figure 8: Radiograph at 3rd month.

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Figure 9: Radiograph at 6th month.

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Figure 10: Radiograph at 1st year.

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Figure 11: Radiograph at 2nd year.

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Figure 12: Surgical re-entry at the end of 2 years.

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   Discussion Top

The entrance of the infectious material into the pulp cavity is often due to the presence of accessory canals either in the crown or the root portion of the groove [8] . The ability to eradicate inflammatory irritants results in the successful treatment of PRG. The shallow groove in a single rooted tooth seen in the current case was effectively treated by odontoplasty as has been demonstrated in similar situations. We have shown that, by eliminating the pulpal infection followed by odontoplasty of the PRG, the main etiology of the disease is removed. The next issue for these patients is restoring the missing supporting structures; in our case, we elected to use bioactive glass; however, the choice of materials and methods is the discretion of the periodontist [19],[20] . We found out an excellent and complete bone fill in two years which was never reported in any of the previous literature of this kind and this proved to be the uniqueness of this case.

   Conclusion Top

successful treatment of a retrograde periodontal lesion around a maxillary lateral incisor associated with a PRG with a unique total bone fill in two years was presented in this case report. Accurate diagnosis and the elimination of inflammatory irritants and other contributory factors are the keys to long-term favorable result in this type of developmental anomaly. It is important for general dental clinicians to be aware such conditions exist to ensure appropriate diagnosis and referral for treatment planning.

   References Top

1.Seltzer S, Bender IB, Ziontz M. The inter-relationship of pulp and periodontal disease. Oral Surg Oral Med Oral Pathol 1963; 16:1474-1490.   Back to cited text no. 1
2.Simring M, Goldberg M. The pulpal pocket approach: Retrograde periodontitis. J Periodontol 1964; 35:22-48.   Back to cited text no. 2
3.Bender IB, Seltzer S. The effect of periodontal disease on the pulp. Oral Surg Oral Med Oral Pathol 1972; 33:458-474.   Back to cited text no. 3
4.Simon JHS, Glick DS, Frank AL. The relationship of endodontic-periodontic lesions. J Periodontol 1972; 43:203-208.   Back to cited text no. 4
5.Simon TH, De Deus QD. Endodontic-periodontal relations. In: Cohen S, Burns RC, eds. Pathways of the Pulp, 5th ed. St. Louis: Mosby Year Book, Inc.; 1991; 548-573.   Back to cited text no. 5
6.Dongari A, Lambrianidis T. Periodontally derived pulpal lesions. Endod Dent Traumatol 1988; 4:49-54.   Back to cited text no. 6
7.Lee KW, Lee EC, Poon KY. Palato-gingival grooves in maxillary incisors. A possible predisposing factor to localized periodontal disease. Br Dent J 1968; 124; 14-18.   Back to cited text no. 7
8.Everett FG, Kramer GM. The disto-lingual groove in the maxillary lateral incisor; a periodontal hazard. J Periodontol 1972; 43:352-361.   Back to cited text no. 8
9.Withers JA, Brunsvold MA, Killoy WJ, Rahe AJ. The relationship of palato-gingival grooves to localized periodontal disease. J Periodontol 1981; 52:41-44.   Back to cited text no. 9
10.Kogon SL. The prevalence, location and conformation of palato-radicular grooves in maxillary incisors. J Periodontol 1986; 57:231-234.   Back to cited text no. 10
11.Hou GL, Tsai CC. Relationship between palato-radicular grooves and localized periodontitis. J Clin Periodontol 1993; 20:678-682.   Back to cited text no. 11
12.Goon WW, Carpenter WM, Brace NM, Ahlfeld RJ. Complex facial radicular groove in a maxillary incisor. J Endod 1991; 17:244-248.   Back to cited text no. 12
13.Meister F Jr, Keating K, Gerstein H, Mayer JC. Successful treatment of a radicular lingual groove: Case report. J Endod 1983; 9:561-564.   Back to cited text no. 13
14.Brunsvold MA. Amalgam restoration of palato-gingival groove. Gen Dent 1985; 33:244-246.  Back to cited text no. 14
15.Friedman S, Goultschin J. The radicular palatal groove a therapeutic modality. Endod Dent Traumatol 1988;4:282-286.   Back to cited text no. 15
16.Kozlovsky A, Tal H, Yechezkiely, Mozes O. Facial radicular groove in maxillary central incisor. A case report J Periodontol 1988; 59:615-617.   Back to cited text no. 16
17.Robison SF, Cooley RL. Palato-gingival groove lesions: Recognition and treatment. Gen Dent 1988; 36:340-342.   Back to cited text no. 17
18.Jeng JH, Lu HK, Hou LT. Treatment of an osseous lesion with a severe palato-radicular groove: A case report. J Periodontol 1992; 63:708-712.   Back to cited text no. 18
19.Anderegg CR, Metzler DG. Treatment of the palato-gingival groove with guided tissue regeneration. Report of 10 cases. J Periodontol 1993; 64:72-74.   Back to cited text no. 19
20.Andreana S. A combined approach for treatment of developmental groove associated periodontal defect: A case report. J Periodontol 1998; 69:601-607.   Back to cited text no. 20
21.Gound TG, Maze GI. Treatment options for the radicular lingual groove: A review and discussion. Pract Periodontics Aesthetics Dent 1998; 10:369-375.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]


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