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1 구순구개열 Vol. 11, No 악정형장치를이용한구순구개열환자의상악골전방견인 서울대학교치의학대학원치과교정학교실 ABSTRACT Maxillary Protraction in the Cleft Patients Using the Orthopedic Appliances Seung-Hak Baek Department of Orthodontics, School of Dentistry, Seoul National University Cleft lip and palate patients often develop maxillary retrusion due to the combined effects of the congenital deformity and the scar tissue after surgical repairs. Maxillary protraction in the cleft patients using orthopedic appliances (i.e. face mask) or distraction osteogenesis during early childhood helps to achieve more balanced skeletal harmony and favorable occlusion for future growth to occur. Kinds, indication, protocol for use of the traditional orthopedic appliances will be discussed. Also the facemask with miniplate system recently developed will be introduced. Key Words : Maxillary protraction, Cleft patients, Orthopedic appliance I. 서론구순구개열환자는수술후에발생된반흔조직에의하여상악골의전방과측방성장에제한이발생되며, 상대적으로정상성장을하는하악골에의하여 III급부정교합이발생된다 (Figure 1). 백등의연구 1) 에의하면 III급부정교합의발생빈도가구순열, 구순치조열에비하여구개열은약 4 배, 구순구개열은약 5.5 배정도높게나타나서, 구개 (palate) 의이환정도가심해짐에따라 III급부정교합의발생률이높아짐을알수있다. 따라서조기에상, 하악골성장의균형을맞추고정상적인교합상태를회복하여주기위하여악정형장치또는골신장술을사용하여상악골의전방견인을시도하게된다. 본종설에서는악정형장치를이용한상악골전방견인술에대하여설명하고자한다. 구순구개 11:37~48,

Congenital defect by cleft Post-natal repair of cleft by surgery Scar tissue occurred from surgery The most powerful and least controlled force causes collapse of the

Petit type face mask II. 본론 1. 적응증 상악골후퇴에의한경도에서중증도사이의 III급부정교합 정상또는 hypodivergent growth pattern 양호한전치부수직피개 유치열또는초기영구치열기 2.

2 Congenital defect by cleft Post-natal repair of cleft by surgery Scar tissue occurred from surgery The most powerful and least controlled force causes collapse of the dental arches. Anterior and lateral growth deficiency of the maxilla Figure 1. 구순구개열환자의 III 급부정교합발생원인을설명하는모식도 A B Figure 2. A. Delaire type face mask, B. Petit type face mask II. 본론 1. 적응증 상악골후퇴에의한경도에서중증도사이의 III급부정교합 정상또는 hypodivergent growth pattern 양호한전치부수직피개 유치열또는초기영구치열기 2. 장치의개발 Delaire 2,3) (Figure 2A) 가상악골전방견인을위하여 face mask를소개하였고, Petit 4,5) (Figure 2B) 는장치의구조를사용하기편하게변형하였다. Turley 6) 는환자개개인에맞는 customized face mask 를제작할것을권유하였다. 3. 장치의구성 Face mask 부분과구강내고정원 (Intraoral anchorage system) 으로나눌수있다. 38

구순구개열 Vol. 11, No. 1 2008 A B C Figure 3.

3 구순구개열 Vol. 11, No A B C Figure 3. 구강내고정원의예. A. Labiolingual appliance, B. Bonded RPE, C. Rectangular archwire with soldered hook A G C H B D F E Figure 4. 상악골을전방견인할때 RPE 를동시에사용하면상악골주변봉합부가탈구되어상악골전방견인효과가극대화된다. 구강내고정원의종류로는 labiolingual appliance, Quad-Helix, banded Rapid palatal expansion(rpe), bonded RPE, rectangular archwire with soldered hook 등을들수있다 (Figure 3). 그중에서도 RPE 를가장많이사용하고있다. 39

Maxilla 30 Figure 5. 상악골후방부의하방이동을최소화하기위하여상악견치전방부에서교합평면에대하여전하방 30~45 도로견인력을부여해야한다. RPE 사용목적은상악골주변의봉합부를탈구시켜상악골전방견인효과를극대화하기위함이며 (Figure 4), 7-10) 확장은 0.25mm 2 / day, 기간은 1~2 주정도이다. 4. 상악골전방견인력의크기, 방향및기간편측당 350~400g의크기로하루 14시간이상사용해야한다.

4 Maxilla 30 Figure 5. 상악골후방부의하방이동을최소화하기위하여상악견치전방부에서교합평면에대하여전하방 30~45 도로견인력을부여해야한다. RPE 사용목적은상악골주변의봉합부를탈구시켜상악골전방견인효과를극대화하기위함이며 (Figure 4), 7-10) 확장은 0.25mm 2 / day, 기간은 1~2 주정도이다. 4. 상악골전방견인력의크기, 방향및기간편측당 350~400g의크기로하루 14시간이상사용해야한다. 상악골후방부의하방이동을최소화하기위하여상악견치전방부에서교합평면에대하여전하방 30~45 도로견인력을부여해야한다 (Figure 5). 11,12) 만약상악골후방부가하방이동되면하악골이시계방향으로회전되어전치부수직피개가감소하게된다. 5. 상악골전방견인장치에의한치료효과상악골이전방견인됨과동시에상악골후방부의하방이동에따른반시계방향회전과상악전치와구치부의전방이동이발생된다 (Figure 6A). 하악골은시계방향회전이발생하여전안면고 경 (anterior facial height) 이증가된다. 그리고하악전치와구치는상악전치와구치에대하여상대적으로후방이동된다 (Figure 6B). III급부정교합환자가치료를받지않은상태에서는 A 점은 0.5 mm, Pog 은 1.7 mm 전방성장한다 (1.2 mm Pog 성장우세 ). 그러나상악골전방견인장치를사용하면 A 점은 2.1 mm 전방성장, Pog 은하악골의시계방향회전에따라 1 mm 후방이동한다 (3.1 mm A 점의상대적인전방이동 ). 따라서상악골전방견인장치를사용하면 A 점이 Pog에비하여상대적으로 4.3mm 전방위치하게되므로치료효과가발생한다고볼수있다 (Figure 6C). 11) 6. 치료기간일반적인 III급부정교합의경우에는다음과같은기간이소요된다. 전치부반대교합개선 : 3~4 개월 전치부수직피개및구치부관계개선 : 4~6 개월 40

구순구개열 Vol. 11, No. 1 2008 A B C Changes with no treatment -0.3 1 0.8 1.7 AP Rx -1.2 mm 0.5-0.5 0 0.5 1 1.

상악골전방견인장치에의한치료효과모식도 상악골 A 점의 2~4 mm 전방이동 : 8~12 개월 총 1년 6개월에서 2년정도사용이필요함그러나구순구개열환자의경우는이보다더긴치료기간이요구된다. 7.

5 구순구개열 Vol. 11, No A B C Changes with no treatment AP Rx -1.2 mm Pog Ii Is A Changes with treatment 4.3 mm AP Rx 3.1 mm A Is Ii Pog Figure 6. 상악골전방견인장치에의한치료효과모식도 상악골 A 점의 2~4 mm 전방이동 : 8~12 개월 총 1년 6개월에서 2년정도사용이필요함그러나구순구개열환자의경우는이보다더긴치료기간이요구된다. 7. 구순구개열환자의치료증례 Labiolingual appliance, Quad-Helix, banded RPE, bonded RPE, rectangular archwire with soldered hook 등을구강내고정원으로사용하여 face mask 를사용하여전치부반대교합을개선할수있다 (Figure 7, 8, 9). 41

6 Figure 7. 편측성구순구개열환자에서 Quad Helix 로상악을확장하면서 face mask 를사용하여전치부반대교합을해소한증례 Figure 8. 편측성구순구개열환자에서 labio-lingual appliance 로구강내고정원을부여하고 face mask 를사용하여전치부반대교합을해소한증례 42

구순구개열 Vol. 11, No. 1 2008 Figure 9. 구개열환자에서 bonded RPE 로상악을확장하고, labio-lingual appliance 와 rectangular archwire with soldered hook 을순차적으로사용하여구강내고정원을부여하고 face mask 를사용하여전치부반대교합을해소한증례 8.

7 구순구개열 Vol. 11, No Figure 9. 구개열환자에서 bonded RPE 로상악을확장하고, labio-lingual appliance 와 rectangular archwire with soldered hook 을순차적으로사용하여구강내고정원을부여하고 face mask 를사용하여전치부반대교합을해소한증례 8. 치료시기조기에치료할수록치료효과가좋다는주장 12-17) 과연령과치료효과가관계없다는주장 8,11) 이있다. 그러나치료개시시기가늦어지면치료기간이길어질것은당연한것으로생각된다. 9. 기존의연구결과에대한비교및검토일반적으로상악골확장을동반하여상악골전방견인을시도한경우가많았고, 견인력은편측당 400g 내외가사용되었다. 치료기간은 1년정도이었고상악골전방견인량은 2~3 mm 정도였다 (Table 1). 그러나구순구개열환자의경우는정중구개봉 합이없는경우가많고구개와입술부분에반흔조직이존재하므로, 일반적인 III급부정교합환자와동일하게적용하기는곤란하다고할수있다. Tindlund 등 18) 은구순구개열환자에서상악골전방견인을시행한결과 ANB 가정상화되고하악골이후방회전되었으나그정도는개인차가상당하다고하였다. Jia 등 19) 은구순구개열환자에서사춘기전에상악골전방견인을시행한결과상악골전방성장이가속화되었으며그정도는정상대조군과같았다고하였다. 그러나하악골의후방회전은구순구개열환자가정상대조군보다컸다고하였다. Tindlund 와 Rygh 20) 는편측성과양측성구순구개열환자의상악골전방견인을비교한결과상 43

8 악골전방견인량은편측성이양측성보다크게나타났으나, 상안면고경 (upper facial height) 증가와교합평면의시계방향회전은양측성이편측성보다크게나타났다고보고하여, 구순구개열환자의유형에따라상악골전방견인효과가다르게나타남을알수있었다. 10. 구순구개열환자를위한상악골전방견인장치와술식의개발 Omnell 과 Sheller 21) 은상악유견치를발치하고재식립시켜서의도적으로골유착을유발한후상악골을전방견인하였다. Rachmiel 등 22) 은상악골을 down-fracture 시키지않고 incomplete Le Fort I osteotomy 를한후 9주간 face mask 를사용하여전방견인한후 3주간가골형성을위하여유지시키는술식을시행하였다. 평균 7.2 mm 의상악골전방견인이이루어졌으며상악골의하방이동은거의일어나지않아서하안면고경 (lower facial height) 의증가는미미하였다는결과를보고하였다. Liou와 Tsai 23) 은상악골확장장치를사용하여 9주간하루 1 mm 확장과축소를반복하면서구강내장치를사용하여하악치열궁을고정원으로하고 15주정도상악골을전방견인하는장치와술식을발표하였다. Table 1. 상악골전방견인에관한연구결과의비교 Author Year Expansion Force level Treatment time (months) Movement of A point Nanda 1980 Haas 500 g mm Ishii 1987 No expansion 250 g mm Tindlund 1989 Quad-helix 700 g mm Merwin 1997 Hyrax 400 g mm Nartallo-Turley 1997 Hyrax g mm da Silva 1998 Haas 350 g mm Gallagher 1998 Slow expansion g mm/yr Baik 1998 Hyrax g mm Pangrezio-Kulbersh 1998 Bonded RPE g mm Kapust 1998 Hyrax g mm Bacetti 1998 Bonded RPE 400 g mm Ngan 1998 Hyrax 400 g mm Sung 1998 Hyrax g mm 44

구순구개열 Vol. 11, No. 1 2008 ZA Mx KG Figure 10. Miniplate system 을이용한상악골전방견인술을위한 miniplate 의식립장소와고정방법의모식도 11.

9 구순구개열 Vol. 11, No ZA Mx KG Figure 10. Miniplate system 을이용한상악골전방견인술을위한 miniplate 의식립장소와고정방법의모식도 11. Miniplate system 을이용한상악골전방견인술의소개이술식은차등 24) 이골격성 III급부정교합환자의상악골전방견인에이용한것을저자가구순구개열환자에게응용한것이며, 최등 25) 이본학회지에증례를발표한바있다. 전통적인상악골전방견인장치와의주요한차이는구강내고정원대신에 miniplate와 self-tapping screw를고정원으로사용하여 skeletal anchorage 를얻는것이다. 상악제1소구치에서제1대구치부위의치은점막을절개하고 zygomatic buttress를노출시킨후, miniplate 를조정하여골조직에밀착시키고 self-tapping screw를사용하여고정한다 (Figure 10). 이때근심말단부를상악측절치와견치사이나견치와제1소구치사이로노출시킨채로연조직을봉합해야한다. 약 4~8 주정도의고정기를부여한후통상적인방법으로악정형력을부여한다. III급부정교합과전치부개방교합소견을동반 한구개열환자에서 miniplate system을이용한상악골전방견인술을시행하여구치부교합관계의현저한개선을이루었고 (Figure 11), 측모두부계측방사선사진중첩소견과계측치비교에서 A 점의 3 mm 전방이동, Pog 의 5.2 mm 후방이동에의하여 ANB 가 5도개선된것을볼수있다 (Figure 12). 1) 장점절대고정원을이용하여악정형력을부여할수있고, 상악골의반시계방향회전과상악전치의순측경사가작으며, 치아와연결되어있지않으므로상악전방견인중에도교정장치를독립적으로사용할수있으며, 교정치료목적의고정원으로도사용할수있다. 2) 단점수술이필요하며, miniplate 가 loosening 될가능성이있다는것이다. 45

Figure 11. 구개열환자의 miniplate system 을이용한상악골전방견인술전후의얼굴과구강내사진비교소견 Measurement 2006. 08.24 2008. 01.

98 ANB =5.54 0.42 FHR 54.60 52.71 FMA33.44 36.47 IMPA84.09 79.31 IIA123.76 122.67 ODI 47.18 54.13 2006.08.

10 Figure 11. 구개열환자의 miniplate system 을이용한상악골전방견인술전후의얼굴과구강내사진비교소견 Measurement Gonial angle Bjork Sum Body to ACB SNA SNB ANB = FHR FMA IMPA IIA ODI APDI A-N per Pog-N Per Figure 12. 구개열환자의 miniplate system 을이용한상악골전방견인술전후의측모두부계측방사선사진과중첩소견과계측치비교 46

11 구순구개열 Vol. 11, No III. 결론상악골열성장을보이는구순구개열환자의치료시적응증을고려하여조기에악정형장치를사용한다면상, 하악골의전후방성장조화를이룰수있을것으로생각된다. 편측성또는양측성구순구개열및구개열등의유형에따른악정형치료효과가다르게나타날수있으므로이에대한연구가필요할것이다. 참고문헌 1. Baek SH, Moon HS, Yang WS. Cleft type and Angleʼs classification of malocclusion in Korean cleft patients. Eur J Orthod. 2002;24(6): Delaire J. Maxillary development revisited: relevance to the orthopaedic treatment of Class III malocclusions. Eur J Orthod. 1997;19(3): Delaire J. The frontomaxillary suture. Theoretical bases and general principles of the application of postero-anterior extraoral forces to the orthopedic mask. Rev Stomatol Chir Maxillofac. 1976;77(7): Petit H. Introduction to the biomechanical study of the facial mask and its accessories. Orthod Fr. 1983;54(2): Petit HP. The prognathic syndrome: a complete treatment plan around the facial mask. Rev Orthop Dento Faciale. 1982;16(4): Turley PK. Orthopedic correction of Class III malocclusion with palatal expansion and custom protraction headgear. J Clin Orthod. 1988;22(5): Baik HS. Clinical results of the maxillary protraction in Korean children. Am J Orthod Dentofacial Orthop. 1995;108(6): Sung SJ, Baik HS. Assessment of skeletal and dental changes by maxillary protraction. Am J Orthod Dentofacial Orthop. 1998;114(5): Kapust AJ, Sinclair PM, Turley PK. Cephalometric effects of face mask/ expansion therapy in Class III children: a comparison of three age groups. Am J Orthod Dentofacial Orthop. 1998;113(2): Yu HS, Baik HS, Sung SJ, Kim KD, Cho YS. Three-dimensional finite-element analysis of maxillary protraction with and without rapid palatal expansion. Eur J Orthod. 2007;29(2): Ngan PW, Hagg U, Yiu C, Wei SH. Treatment response and long-term dentofacial adaptations to maxillary expansion and protraction. Semin Orthod. 1997;3(4): Merwin D, Ngan P, Hagg U, Yiu C, Wei SH. Timing for effective application of anteriorly directed orthopedic force to the maxilla. Am J Orthod Dentofacial Orthop. 1997;112(3): Takada K, Petdachai S, Sakuda M. Changes in dentofacial morphology in skeletal Class III children treated by a modified maxillary protraction headgear and a chin cup: a longitudinal cephalometric appraisal. Eur J Orthod. 1993;15(3):

12 14. Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I. Skeletal effects of early treatment of Class III malocclusion with maxillary expansion and face-mask therapy. Am J Orthod Dentofacial Orthop. 1998;113(3): Suda N, Ishii-Suzuki M, Hirose K, Hiyama S, Suzuki S, Kuroda T. Effective treatment plan for maxillary protraction: is the bone age useful to determine the treatment plan? Am J Orthod Dentofacial Orthop. 2000;118(1): Saadia M, Torres E. Sagittal changes after maxillary protraction with expansion in class III patients in the primary, mixed, and late mixed dentitions: a longitudinal retrospective study. Am J Orthod Dentofacial Orthop. 2000;117(6): Franchi L, Baccetti T, McNamara JA. Postpubertal assessment of treatment timing for maxillary expansion and protraction therapy followed by fixed appliances. Am J Orthod Dentofacial Orthop. 2004;126(5): Tindlund RS, Rygh P, Bøe OE. Orthopedic protraction of the upper jaw in cleft lip and palate patients during the deciduous and mixed dentition periods in comparison with normal growth and development. Cleft Palate Craniofac J. 1993;30(2): Jia H, Li W, Lin J. Maxillary Protraction Effects on Anterior Crossbites Repaired Unilateral Cleft Versus Noncleft Prepubertal Boys. Angle Orthod 2008;78: Tindlund RS, Rygh P. Maxillary protraction: different effects on facial morphology in unilateral and bilateral cleft lip and palate patients. Cleft Palate Craniofac J. 1993;30(2): Omnell ML, Sheller B. Maxillary protraction to intentionally ankylosed deciduous canines in a patient with cleft palate. Am J Orthod Dentofacial Orthop. 1994;106(2): Rachmiel A, Aizenbud D, Ardekian L, Peled M, Laufer D. Surgically-assisted orthopedic protraction of the maxilla in cleft lip and palate patients. Int J Oral Maxillofac Surg. 1999;28(1): Liou EJ, Tsai WC. A new protocol for maxillary protraction in cleft patients: repetitive weekly protocol of alternate rapid maxillary expansions and constrictions. Cleft Palate Craniofac J. 2005;42(2): 차봉근, 이남기, 최동순. Miniplate anchorage를이용한골격성 III 급부정교합아동의상악전방견인치료. 대한치과교정학회지 2007;37(1): 최재평, 명훈, 황순정, 서병무, 이종호, 정필훈, 김명진,, 최진영. 성장기구순구개열환자에서 skeletal anchorage system 을이용한 maxillary protraction: 증례보고. 대한구순구개열학회지. 2006;9: 교신저자, 서울대학교치과대학치과교정학교실서울시종로구연건동 28 번지우편번호 : / 전화 : / drwhite@snu.ac.kr 48

연구에따르면, 골격성고정원을이용한경우상악치아의이동이거의없는반면에, 구내장치를구강내고정원으로이용한경우유의하게상악구치의근심이동및상악전치의전방경사가동반된다고하였다. 이상적인 facemask의치료결과는순수한상악의전방견인효과를얻는데있기때문에이러한불필요한상악치아의이동은고정원소실로

연구에따르면, 골격성고정원을이용한경우상악치아의이동이거의없는반면에, 구내장치를구강내고정원으로이용한경우유의하게상악구치의근심이동및상악전치의전방경사가동반된다고하였다. 이상적인 facemask의치료결과는순수한상악의전방견인효과를얻는데있기때문에이러한불필요한상악치아의이동은고정원소실로 ISSN (print) 1226-8496 ISSN (online) 2288-3819 http://dx.doi.org/10.5933/jkapd.2014.41.4.298 A Comparative Study of Facemask Therapy with Two Types of Bonded Expander Eunha Lee, Kitae Park Department of