An innovative approach in the management of palatogingival groove using Biodentine™ and platelet-rich fibrin membrane
A 24-year-old male patient who had a complaint of dull and intermittent pain at the palatal side of the left maxillary lateral incisor came to Department of Endodontics. During the clinical examination, the left maxillary lateral incisor (#10) had an intact crown without caries or fracture, with negative vitality testing and a positive response to percussion []. The tooth was grade 2 mobile. Periodontal probing disclosed a periodontal pocket (9 mm) at the mesiopalatal line angle of the tooth and concomitantly, a PGG which extended into the gingival sulcus []. Facially the gingival sulcus had 8 mm probing depth. Oral hygiene was satisfactory. An occlusal radiograph revealed a large periapical lesion with a bony defect extending beyond the apical third of the root []. Gutta-percha tracing into the sinus tract and periodontal pocket revealed a communication with the periapical area. Based on the tests and the radiographic findings, the diagnosis was necrotic pulp, suppurative periradicular periodontitis and localized periodontitis secondary to the palatal groove on tooth #10.\nIn phase one therapy, oral prophylaxis was performed. Stabilization of the tooth was done with stainless steel wire and composite resin. Endodontic access was performed after placing a rubber dam and disinfecting the area with 2% chlorhexidine digluconate (Calypso, Septodont, India). Working length was determined by using electronic apex locator Root ZX (J. Morita Mfg. Corporation, Kyoto, Japan) and file in-radiograph with 15 no. K-files. The root canal was cleaned and shaped by rotary Ni-Ti ProTaper System along with Glyde (Dentsply Maillefer Company, USA) using crown down technique. The root canal was copiously irrigated with 2.5% sodium hypochlorite (Novo Dental Product, India). Access cavity was temporized with calcium hydroxide and TERM. Patient was recalled after 1 week; the tooth was asymptomatic. Root canal was irrigated again with normal saline and dried using paper points. Before obturation, master points were seated to test their suitability to canal and radiograph was taken. The canal was obturated with selected master gutta-percha cone (variable taper]) and AH-Plus sealer (Dentsply Maillefer Company, USA). The coronal gutta-percha cones were sheared off using heated instrument, and vertical compaction was done using the heated pluggers at the canal orifices. During the periodontal phase of the therapy, complete extraoral and intraoral mouth disinfection was done with betadine and local anesthesia was administered (xylocaine 2% with epinephrine 1:80,000). A surgical flap was raised from the palatal aspect and labial aspect, and the PGG was isolated to its most apical extent []. Thorough scaling and root planning was performed over the groove to remove the bacteria that might have colonized there. The diseased granulation tissue was curetted out with Gracey curette number 1/2 and 5/6; (Hu-Friedy Manufacturing Co, Chicago, IL) to leave the soft tissue more conducive to regeneration. A chemical conditioning of the groove was performed and Biodentine™ (Septodont, St. Maur-des-Fossés, France) was applied into the defect []. With the help of an air-driven surgical handpiece (Impact Air, Palisade Dental), the apical root end was resected and sealed with Biodentine™ (Septodont, St. Maur-des-Fossés, France) []. The area was kept isolated of blood and tissue fluids during the setting of the cement by using local hemostatic gelatin sponge (Pfizer Inc, New York, NY).\nA 12 ml sample of whole blood was drawn intravenously from the patient's right antecubital vein and centrifuged (REMI Model R-8c with 12 × 15 ml swing out head) under 3,000 rpm for 10 min to obtain the PRF which was jelly-like in consistency. PRF clot started to release its serum (PRF-clot exudates) and was ready for compression into the membrane. The bony defect was filled with freeze-dried bone allograft (LifeNet, Virginia Beach, VA) []. Without delay autologous PRF membrane was placed [] and the flaps were secured with 4-0 polyglactin 910 sutures (Vicryl, Ethicon, Inc., Piscataway, NJ).\nFollowing surgery, the patient was placed on doxycycline 100 mg, with instructions to take two capsules immediately, then one capsule every day for 14 days. In addition, a 0.12% chlorhexidine gluconate rinse was prescribed and ibuprofen was given for discomfort. The patient was asymptomatic postoperatively and sutures were removed after 7 days. The patient was recalled for 6 months for a period of 2 years. There was both a clinical and radiographic improvement. Clinically, there was a reduction in the pocket depth of 5 mm in 6 months and patient is asymptomatic with a 3 mm non-bleeding sulcus at the end of 24 months. There was a significant reduction in radiolucency radiographically [].