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: snghinsha@gmail.com

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

Journal of Dental & Oro-facial Research Vol 12 Issue 1 Jan 2016 JDOR

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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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