Labial-cervical-vertical groove: A silent killer-Treatment of an intrabony defect due to it with platelet rich fibrin.

A 47-year-old male patient reported to the Department of Periodontology, with a chief complaint of pus discharge from maxillary left central incisors with dull intermittent pain. On clinical examination, a localized gingival inflammation was present with soft edematous tissue with the accumulation of plaque and calculus with #11 and #21. Periodontal examination depicts a periodontal pocket depth of 11 mm on mesial aspect and 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. On careful examination, labial-cervical-vertical groove (LCVG) was found on #21 which was extending into gingival sulcus. This article reports the effectiveness of platelet rich fibrin for the treatment of intrabony defect associated with labial-cervical-vertical groove of #21.

INTRODUCTION

Diverse morphological tooth anomalies are found in various shapes, textures, and prevalence. They can be sporadic or syndromes, nutritional, environmental, genetic, and ethnic related. Most of these tooth-born deformations (e.g., shovel-shaped incisors, tuberculum Carabelli, variations in number and shape of cusps, dens invaginatus, taurodontism, palatogingival groove) have been extensively investigated.[12345]

Labial-cervical-vertical groove (LCVG), which starts on the cervical enamel and extends to the radicular surface, has also been described as a notch.[6789101112] It is assumed that this malformation is a developmental anomaly in which an infolding of the enamel organ and Hertwig's epithelial root sheath create a groove on the labial surface of permanent maxillary incisors.[6] Causative factors for this malfunction may be due to trauma, disease, and nutritional issues, or can be genetic or idiopathic. LCVG runs vertically from the crown surface to the root, starting at the enamel on the crown and extends apically, crossing the cementoenamel junction and resembling a short furrow. This furrow gradually grows deeper in the apical direction and may, occasionally, run throughout the root surface.[8] LCVG has a prevalence ranging from 3 to 6.5%.[79]

Anatomic factors, such as cervical enamel projections, enamel pearls, and radicular grooves are associated with advanced localized periodontal destruction. The presence of LCVG may exacerbate some clinical aberrations, such as esthetic deficiency of the gingival marginal contour, accumulation of plaque and, consequently, gingival pocket with bone loss as well as failure in endodontic and periodontal treatments.[10] Kozlovsky et al.[6] describe a 25-year-old female in which a periodontal lesion with vertical bone loss was directly related to the labial groove on a maxillary central incisor. This type of dental deformity has been scarcely investigated and reported in the dental literature.

To the best of our knowledge and based on the available data, there are no reported cases of intrabony defect associated with LCVG treated with platelet rich fibrin (PRF). This article reports the effectiveness of PRF for the treatment of intrabony defect associated with LCVG in the area of maxillary left central incisor.

CASE REPORT

A 47-year-old male patient reported to the Department of Periodontology, with a chief complaint of pus discharge from maxillary left central incisors with dull intermittent pain. There was no relevant medical history. The patient was a non-smoker. On clinical examination, a localized gingival inflammation was present with soft edematous tissue with the accumulation of plaque and calculus with #11 and #21. Periodontal examination depicts a pocket depth of 11 mm on mesial aspect and 8 mm on midbuccal aspect of #21 [Figure 1] with no mobility. Fremitus was found to be negative precluding the possibility of trauma from occlusion and tooth was found to be vital electric and thermal pulp testing. On radiographic examination, a tear-shaped radiolucency was present with localized bone loss in #21 [Figure 2a]. On careful examination, LCVG was found on #21 which was extending into gingival sulcus.

Figure 1

Pre operative pocket depth of 11 mm on mesial aspect and 8 mm on midbuccal aspect of #21

Figure 2

(a) Pre operative radiolucency with #21; (b) Post operative radiograph with #21 at 6 months

The patient was subjected to complete scaling and thorough root planning. The patient was given oral hygiene instructions. The patient was reviewed after 2 weeks. Clinical symptoms subsided, but the deep pocket was still present and hence a periodontal surgery was carried out to eradicate the underlying problem. The procedure was explained to the patient and the consent was obtained for the same. Routine blood investigations were done.

After assuring surgical asepsis, a pre-procedural rinse with 0.2% chlorhexidine gluconate was accomplished. After administration of local anesthetic (2% lignocaine with 1:80000 adrenalin), the papilla preservation flap (Takei et al.) was adopted since there was sufficient space between the maxillary central incisors. A full-thickness flap was reflected on both facial and palatal surfaces. The exposed root surfaces were thoroughly scaled and root planed and bone defect carefully curetted. LCVG noted on #21 [Figure 3a], terminated in the cervical third of root surface was sealed with glass ionomer cement (Fuji II; GC Corporation, Tokyo, Japan) [Figure 3b].

Figure 3

(a) LCVG noted on #21; (b) LCVG was sealed with glass ionomer cement

The PRF was prepared following the protocol developed by Choukroun et al. Briefly, the procedure of PRF preparation: 10 ml intravenous blood was collected by venepuncture at the antecubital fossa. This was transferred into 10 ml sterile tube without anticoagulant and immediately centrifuged at 3000 rpm for 10 min. Fibrin clot formed in between the acellular plasma on top and the red blood cells at the bottom were separated using sterile tweezers and scissors [Figure 4].

Figure 4

PRF obtained

PRF was placed in the intrabony defect with #21 [Figure 5]. Suturing was done using 3-0 black silk. Then periodontal dressing was given.

Figure 5

PRF was placed in the intrabony defect with #21

The patient received post-operative instructions and was prescribed post-operative antibiotic – amoxicillin 500 mg thrice for 7 days and analgesic – aceclofenac 100 mg twice for 3 days.

Then, 1 week postoperatively, the dressing was removed and saline irrigation was done. The patient was monitored at regular intervals and was under maintenance therapy. At the end of 3 months and 6 months, clinical examination and intraoral periapical radiographs of the treated area were taken. The clinical measurements were repeated and compared to the baseline values.

On examination during subsequent follow-ups, treated area showed satisfactory healing without any post-operative complications. LCVG was completely sealed off. The pocket depth was 2 mm on mesial and 1 mm on midbuccal aspect at 6 months [Figure 6]. Periodontal health was stable and bone regeneration was noticed in radiograph [Figure 2b]. The patient was satisfied with the result.

Figure 6

Post operative pocket depth of 2 mm on mesial and 1 mm on midbuccal aspect of #21 at 6 months

DISCUSSION

Periodontitis is a multifactorial infectious disease affecting primarily a subset of subjects and subset of sites. Recent microbiological data have acknowledged that before disease progression can occur, a susceptible host and site are required, in addition to the presence of pathogenic bacteria. Retrospective studies clearly suggest a strong association between anatomic aberrations (LCVG) and periodontal attachment loss.

The maxillary incisor region is an area of embryological hazard. Anatomic aberrations like root grooves can occur here, which form stagnant sites or ecological niches favoring the retention and growth of micro-organisms. Grooves may facilitate plaque growth by providing surface areas sheltered from cleaning efforts as well as host defense mechanisms. Later, bacterial selection and growth may be influenced by anaerobic conditions established inside the grooves. LCVG starts on the cervical enamel and extends to the radicular surface. These grooves can be classified into mild, moderate, and complex based on its depth and extent. It has been pointed out that defect may vary from a simple, shallow developmental groove, to a complete lack of closure of calcified tissues, allowing for a direct soft tissue connection between the pulp and the periodontium. These grooves are deep initially after root formation and become shallower with age. The presence of LCVG may exacerbate some clinical aberrations, such as esthetic deficiency of the gingival marginal contour, accumulation of plaque and, consequently, gingival pocket with bone loss, as well as failure in endodontic and periodontal treatments.[10] Kozlovsky et al.[6] describe a 25-year-old female in which a periodontal lesion with vertical bone loss was directly related to the labial groove on a maxillary central incisor. We have also observed an intrabony defect directly related to LCVG on #21.

In the presence of periodontal disease, the therapeutical options for LCVG consist of grinding and flattening the affected area of the tooth or placement of a physical barrier between the tooth and soft tissue flap. The intra osseous defect, if present can be grafted with various bone graft materials.

PRF was first described by Choukroun et al. It is considered as a second-generation platelet concentrate and has been used in various surgical procedures in an attempt to enhance wound healing. It is prepared from the patient's own blood thereby eliminating the possibility of disease transmission or foreign body reactions. The preparation technique of PRF is simple and requires no special equipment. Blood is drawn into standard glass/silica coated blood collection tubes and centrifuged at a predetermined speed to ensure cell separation. No anticoagulants are used during the procedure and natural coagulation can therefore take place. This unique preparation technique allows PRF to trap at least 95% of the platelets of the collected blood into a fibrin mesh.[13] The fibrin mesh can then be easily manipulated into a membrane that allows it to be transferred to any surgical site. Here, high concentrations of the collected platelets allow for the slow release of growth factors (GFs) from the platelet granules.[14] These GFs include vascular endothelium growth factor (VEGF), platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), epidermal growth factor (EGF), hepatocyte growth factor (HGF), insulin-like growth factor (IGF), and transforming growth factor-β (TGF-β). All of these play a role in replacing lost tissue, resurfacing of the wound, and restoring vascular integrity. Compared to other platelet concentrates, PRF releases these factors at a sustained rate over a longer period, thereby optimizing wound healing.[15] Recently, PRF has also been shown to stimulate the growth of osteoblasts and periodontal ligament cells, both of which are significant for the regeneration of periodontal defects.[1315161718]

Currently, PRF has been successfully tested in a number of procedures including maxillofacial surgery, periodontal surgery, and implantology.[1315161718] Mazor et al. successfully used PRF as the only grafting material in a series of sinus augmentation procedures.[17] In a similar 6-year follow-up study, Simonpeiri et al. were able to demonstrate that using PRF as a sole grafting agent was a viable long-term option in sinus augmentation procedures.[18] Shah successfully used PRF along with DFDBA in alveolar ridge augmentation.[19]

PRF has also been used successfully to treat periodontal defects. In a series of clinical trials conducted by Pradeep and Sharma it was shown that PRF could be used as a guided tissue regeneration (GTR) membrane to affect periodontal regeneration in three wall bony defects and degree II furcation lesions.[20] Del Corso et al. published several case reports showing the successful use of PRF membranes in the management of both single and multiple gingival recession defects.[21] The clinical results were maintained successfully for at least 1 year. Ramakrishnan et al. and Shah confirmed this observation and showed that PRF could be used for root coverage procedures.[222324]

In the presented case, LCVG was sealed with glass ionomer cement (Fuji II; GC Corporation, Tokyo, Japan) and associated intrabony defect was treated with PRF. Periodontal condition was stable and bone regeneration was evident at grafted site.

The LCVG is a potential problem area, which should be evaluated and treated accordingly. The groove can lead to combined endodontic periodontic lesions, which are difficult to deal with; attention has been brought to its presence and clinical significance.