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Journal of Dental & Oro-facial Research Vol 12 Issue 1 Jan 2016 JDOR
MSRUAS 36
CASE REPORT
Labial Cervical Vertical Groove: Hidden Route to
Periodontal Destruction
Ashwini.S1, Nisha Singh2*, Bhavya Shetty3
*Corresponding Author Email: [email protected]
Contributors:
1Professor, Department of
periodontics, Faculty of Dental Sciences, MSRUAS, Bangalore
2Post Graduate Student, Department
of periodontics, Faculty of Dental
Sciences, MSRUAS, Bangalore
3 Reader, Department of
periodontics, Faculty of Dental Sciences, MSRUAS, Bangalore
.
ABSTRACT
A 24-year-old male patient reported to the Department of Periodontology,
with a chief complaint of dull, gnawing and intermittent pain while biting in
maxillary left central incisors. On clinical examination, localized inflamed, soft &
edematous gingival tissue associated with accumulation of plaque and calculus in
relation to #11 and#21 was observed. Phase I therapy was instituted and during
phase one therapy Labial-cervical-vertical groove (LCVG) was found on #21 which
was extending into gingival sulcus. A week after phase one therapy periodontal
examination showed a probing pocket depth of 7 mm on distobuccal aspect of #21
with no mobility. On radiographic examination, a round diffuse radiolucency was
on distal aspect of #21. This article describes the management of intrabony defect
associated with labial-cervical-vertical groove on #21 using bone graft and
restoration of groove using glass ionomer cement
INTRODUCTION:
One of the primary local etiologic factor initiating
periodontal destruction is dental plaque. It is a biofilm
of adherent bacteria and their products on all tooth
surfaces and dental prosthesis. Anatomic or
morphologic features of teeth as well as iatrogenic
factors1 contribute to its formation. These features
contribute to changes in dento-gingival relationships
thus making it more prone to harboring virulent
periodontal pathogens leading to site specific localized
periodontitis. Thorough knowledge of these potential
anatomic variations have a significant impact on
management & prognosis of involved teeth and also
would help early detection preventing any attachment
loss further.2
Internal & the external morphologic anatomic
abberations can at times present difficulty in diagnosis
and clinical management to the clinician3-5. A rare
aberration in tooth anatomy runs vertically from the
crown surface to the root, starting at the enamel on the
crown cervix extending apically, crossing the
cementoenamel junction and resembling a short
furrow is named as Labial-cervical-vertical groove
(LCVG) 6–11. This anomaly is thought to develops due
infolding of the enamel organ and Hertwig’s epithelial
root sheath that create a groove on the labial surface of
permanent maxillary incisors.6 This groove grows
deeper in the apical direction gradually and in some
scenarios run throughout the root surface.9 Palataly on
maxillary incisors a similar presentation called as
palatogingival groove is a common finding. 6,7,12,13
Enamel hypoplasia, caused by impaired function of
ameloblasts during tooth development has also been
pointed out as the etiology.13,14 Various causes for
hypoplasia forming anatomic malfunction are trauma,
disease, and nutritional issues (eg, rickets), or can be genetic or idiopathic also. The first researcher to
describe the grooves as a malformation during embryo
development was Black in 1908 15.
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These grooves are often overlooked as
etiologic factor hence this case report describes the
diagnosis and clinical management of a maxillary
central incisor with localized periodontal destruction
associated with a labial cervical vertical groove.
Case presentation
A 24 year-old male patient reported to the Department
of Periodontology, with a chief complaint of dull,
gnawing, intermittent pain with respect to upper front
teeth. On examination a localized gingival
inflammation was present with the accumulation of
plaque and calculus with respect to 21 and 22.
Periodontal examination revealed a probing pocket
depth of 7 mm on the disto-labial aspect of tooth
number 21. Intra oral radiograph examination
revealed interdental bone loss with respect to 21 and
22. Phase I therapy consisted of oral hygiene
instructions and scaling and root planing. The patient
was reviewed after a week. Clinical symptoms
subsided, but periodontal pocket was still persisted
with respect to 21 and 22, thus decision to perform
periodontal flap surgery in the upper anterior region
was taken. (Figure 1)
Figure 1: pre-operative probing depth and intra-oral peri-
apical radiograph
Following flap reflection, a groove was noticed along
the labial surface of maxillary left central incisor
which began at cervical aspect of 21 and terminated at
the middle third of the root surface. Also a class II
crater bone defect was observed after thorough
debridement.
The groove was restored with class II glass
ionomer cement and after completely isolating it, the
bone defect between 21 and 22 was filled with
demineralized bone matrix bone
xenograft(osseograft). Following this the flap was
sutured using 3-0 black braided silk suture and
periodontal pack was given to cover the surgical area.
Patient was recalled after a week for suture
removal. Periodontal healing was satisfactory with
gingival health stable. On follow up visit at 6 months,
pocket depth reduced to 2 mm and the radiographic
examination revealed bone fill with respect to 21 and
22(figure2-9). However there was bleeding on probing
due to poor oral hygiene maintenance despite adequate
reinforcement.
Fig 2: Incision.
Fig 3: Full thickness
flap reflection
Fig 4: Debridement
& extension of
LCVG using two
tone dye
Fig 5: Restoration of
groove using glass
ionomer cement
Journal of Dental & Oro-facial Research Vol 12 Issue 1 Jan 2016 JDOR
MSRUAS 38
Fig 6: Bone
grafting using
xenograft
(osseograft)
.
Fig 8: Periodontal
pack placement.
Fig 9: Six months post-operative probing depth and
intraoral peri-apical radiograph.
DISCUSSION
Periodontitis is a polymicrobial infectious disease
resulting in loss of connective tissue attachment to root
surfaces. Anatomic anomaly of tooth plays an
important etiologic factor causing ingress of
periodontal pathogens deep into sulcus thus leading to
periodontitis. This present case report describes a case
of localized periodontitis associated with labial
cervical vertical groove. Earlier the etiology of this
defect was thought to be due to trauma to the
developing tooth bud, but presently it is considered to
arise as a developmental defect due to the vertical
extension of the mammelon groove. Mass16 et al
ranked severity of LCVG in three stages i.e: 1) a mild
subgingival shallow groove below the marginal
gingiva that can be felt only by probing. 2) a moderate
groove that can be detected with the eyes, extending
subgingivally as in (1), and additionally
supragingivally on the labial crown surface, not more
than 2 mm from the marginal gingiva in the incisal
direction and 3) a severe defect extending
supragingivally more than 2 mm from the marginal
gingiva on the labial crown surface and further
subgingivally. Gingival contour associated with
LCVG was also described in three categories16 based
on their clinical presentation: a) normal coverage, ie,
the gingiva covers the groove with no change in the
regular shape of the gingival margin; b)partial
coverage, ie, the gingiva partially covers the groove
with mild change in the contour. c) irregular coverage,
ie, the gingiva covers the groove with a severe change
in the contour. Retention and growth of plaque micro-
organisms occurs in presence of this groove in
maxillary incisor region. Abdulaziz Al-Rasheed18
reported that maxillary lateral incisors with
palatogingival grooves(PRG) anomaly particularly
those with apical extension of the groove were
significantly associated with poorer periodontal health
status manifesting as more susceptibility for bleeding
on stimulation and tendency to attain deeper probing
depth.
In our case an intrabony defect directly related to
LCVG on 21 was noticed. Similar findings were
reported in 1988 by Kozlovsky7 in a case wherein he
described a periodontal lesion with vertical interdental
bone loss directly associated to maxillary central
incisor labial groove in a 25 year old female patient.
Radicular labial groove when presents along with
periodontal destruction, they can be managed by19
grinding and flattening of the groove or restoring the
groove by placement of a physical barrier between the
tooth and soft tissue flap after thorough debridement.
Intraosseous defect can be treated by regenerative
procedures using various bone grafts. Defective dento-
gingival relationships associated with deep labial
radicular groove may be managed by
gingivectomy/gingivoplasty or root coverage
mucogingival procedures.
Fig 7: Suture
placement
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Srinivas20 et al presented a case report of bilateral
facial radicular groove in maxillary central incisors of
a 24 year old male patient. Periodontal destruction
with respect to maxillary central incisor was observed
on periodontal examination. After phase one therapy
flap surgery was performed following which facial
groove was eliminated by restoring it with glass
ionomer cement. Mishal P. Shah19 reported a case of a
47-year-old male patient with complain of pus
discharge from maxillary left central incisors with dull
intermittent pain. Periodontal examination revealed
labial-cervical-vertical groove (LCVG) and probing
pocket depth of 8 mm on midbuccal aspect of #21 with
no mobility. On radiographic examination, a tear-
shaped radiolucency was present with localized bone
loss in #21. The intrabony defect was treated by flap
surgery and platelet rich fibrin after restoration of
groove with glass ionomer cement. Kishan 21 et al. also
reported a unilateral palato-radicular groove on the
maxillary right lateral incisor which was restored with
glass ionomer cement and guided tissue regeneration
technique was used to regenerate the lost periodontal
structures reporting considerable reduction in pocket
depth. In present case report, we also restored the
facial groove using glass ionomer cement. In support
of this, Thiago22 et al reported biocompatibility of both
glass ionomer cement and composites to gingival
tissues. Dexton23 sealed palatogingival groove with
Biodentine & associated intrabony defect was restored
using bone graft followed by platelet-rich fibrin (PRF)
membrane placement. This resulted in gain in
attachment, reduction in pocket depth, and bonefill in
the osseous defect at 24 month follow-up. Recently
mineral trioxide aggregate (MTA) & re implantation
have also been used in case of severe periodontal
destruction caused due to radicular grooves24-25.
However Nevil26 et al in an in-vitro study compared
the cytotoxicity of glass ionomer cement, MTA &
Biodentine on Human Gingival Fibroblasts cell line &
found that the degree of cytotoxicity decreased from
Glass-ionomer cement type IX to MTA Angelus &
Biodentine in the cell line tested for both 24hr and 48
hrs exposure period.
Conclusion
This case report presented the successful treatment of
localized periodontitis maxillary central incisor
associated with radicular labial groove. The key to
achieving long-term favorable results in this particular
type of developmental anomaly is accurate diagnosis
and elimination of inflammatory irritants and
contributory factors. Clinician's awareness
of existence of such an anomaly may help to avoid
misdiagnosis and improper treatment of these patients.
It is strongly recommended that whenever LCVG is
detected, the dentist should alert the patient to this
deformity so that cautious oral hygiene can be
implemented.
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