Case Report 임플란트수술을위한골유도재생술 (Guided bone regeneration) 시조직접착제를사용한골증대술 지영덕 * 원광대학교치과대학구강악안면외과학교실교수 Bone Augmentation with Fibrin Sealant during Guided

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1 임플란트수술을위한골유도재생술 (Guided bone regeneration) 시조직접착제를사용한골증대술 지영덕 * 원광대학교치과대학구강악안면외과학교실교수 Bone Augmentation with Fibrin Sealant during Guided Bone Regeneration for Implant Surgery, DDS, MSD, PhD * Professor, Department of Oral & Maxillofacial Surgery, College of Dentistry, Wonkwang University, Iksan, Korea * Corresponding author:, Department of Oral & Maxillofacial Surgery, Sanbon dental hospital, College of Dentistry, Wonkwang University, 1142, Sanbon-dong, Gunpo-city, Gyeonggi-do 15865, Korea. Tel: Fax: omschee@wku.ac.kr pissn eissn Implantology 2020; 24(1): Received: February 25, 2020 Revised: March 9, 2020 Accepted: March 10, 2020 ORCID OPEN ACCESS Abstract The idea of using a fibrin sealant in the augmentation of the alveolar ridge defects seems attractive because it can produce a dense fibrin clot with sufficient adhesive strength to hold particulate bone in a required configuration. The aim of this clinical investigation is to evaluate the possibility of obtaining bone augmentation around osseointegrated implants by using fibrin sealing system with grafting material. Buccal and lingual local anesthesia was injected. A lingual crestal incision was made connecting the edentulous space. Vertical buccal releasing incisions were performed. A full-thickness flap was then elevated until the mucogingival junction to achieve a tension-free adaptation of the soft tissues. The defects were filled with granules of allograft and alloplast mixed with a fibrin-fibronectin sealing system. Seven-months after surgery, implants were inserted in a prosthetically driven position. At 2nd surgery, a hard bone like tissue was detectable at the defect sites receiving allograft bone grafts with a fibrin-fibronectin sealing system and well maintained. Clinical cases show that the vertical alveolar bone height is well-maintained after alveolar bone augmentation using fibrin sealant because of its sufficient adhesive strength to hold particulate bone in a required configuration. Keywords: Dental implants, Fibrin sealant, Bone augmentation Copyright The Korean Academy of Oral & Maxillofacial Implantology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Implantology Vol. 24, No. 1,

2 Ⅰ. 서론성공적인임플란트수술을위해서매식할부위의골질과골량을파악하는것이중요하다. 골량이부족한곳에서임플란트의장기예후는불량하기때문에성공적인임플란트치료는식립부위의적절한골량에따라좌우된다. 1 그러나임플란트주위염으로인해만성적염증상태로치조골이상실되었거나치아발치후무치악상태로오래있을경우골흡수가일어나기존치아가있었던적절한위치에임플란트를식립하는것이어렵다. 이런경우적절한위치에임플란트를식립하기위해서골증대술및골이식술이필요하게되고이들방법중골유도재생술 (Guided bone regenertion) 이가장잘알려져있으며그밖에방법으로는치조제확대술 (Alveolar Ridge Enlargement), 블록골이식술 (Block bone graft) 등이있다. 2 동종골및합성골을사용한골유도재생술은다른골증대술에비해술식이간단하여임플란트를위한골이식술이필요할때많이사용된다. 골유도재생술은높이와폭이부족한골주변으로차단막으로공간을만들어주어남아있던골조직에서골형성능을가진세포의분화와이주를유도하여골재생을달성하려는술식이다. 3 이때차단막의모양을유지시켜주고혈관주위의조직과모세혈관이골이식재를골격으로삼아골유도세포들의이주를돕기위해다양한골이식재가사용될수있다. 4 이때사용하는골이식재의크기는보통 0.5~1.0 um정도의크기의입자모양으로특히수직적으로골결손부가있는곳에골증대술을시행할때그형태를유지하기어려워사용하기힘들다. 이때조직접착제를사용하여이식재의형태를골결손부와맞게덩어리지게형성한뒤골유도재생술을사용하면원하는형태의골증대술을쉽게할수있을것으로사료된다. 조직접착제는단순한외과적봉합으로는해결하지못하는넓은면적의조직의유착을위하여개발되기시작한것으로현재골이식재의고정, 혈관봉합술, 연조직에서조직들의유착과지혈등의목적으로광범위하게연구되고사용되고있다. 5 본증례는하악구치부에수직적으로중증의골결손부가발생하여골증대술이어려운환자에서골유도재생술시조직접착제를함께사용하여골증대술을시행한후지연임플란트를식립하여양호한결과를얻었기에보고하고자한다. Ⅱ. 증례보고 1. 첫번째증례 46세남성이개인병원에서 #36, #37부위 10년전한임플란트가흔들린다는주소로본원에내원하였다. #36, 37임플란트의동요가있었으며치은열구내배농이동반한임플란트주위염이관찰되었고방사선사진상심한골소실이관찰되었다. 불편을호소하는 #36, #37부위임플란트를제거하였으며제거한부위에심한골결손양상을보여조직접착제를사용한수직적, 수평적골증대술후임플란트식립을 14 Implantology Vol. 24, No. 1, 2020

3 계획하였다 (Fig. 1). 하악좌측구치부에국소마취 (2% lidocaine with 1:100,000 epinephrine, Yuhan, Korea) 후판막을거상하였으며임플란트제거부위에골결손이심한것이관찰되었다 (Fig. 2A and 2B). 골증대술을위해동종골 (Oragraft R, LifeNet, USA), 합성골 (Q-Oss+ R, Osstem implant, Korea) 을사용하였고, 조직접착제 (Tisseel R, Baxter, Vienna, Austria) 를혼합하여수직, 수평골증대술을시행하였 Fig. 1. CaseI Pre-operative panoramic view: Severe bone loss on #36,37 implant removal area. (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) Fig. 2. CaseI Intraoral views of bone graft & implant surgical procedure (A) Pre-operative clinical gingiva, (B) Flap elevation, (C) Preparation bone material with fibrin sealant, (D) Bone graft, (E) Cover with collagen membrane, (F) Tension free suture, (G) 1st surgery flap elevation, (H) Implant insertion, (I) 2nd surgery flap elevation, (J) Healing abut. insertion. Implantology Vol. 24, No. 1,

4 Fig. 3. CaseI Panoramic view Final restoration setting. 다 (Fig. 2C and 2D). 골증대술시행후흡수성차단막 (Cytoplast RTM R, Osteogenics, USA) 을사용하여골이식부위를피개하였으며 (Fig. 2E) 협측판막에골막감장절개를시행하여장력없이 1차봉합을시행하였다 (Fig. 2F). 골증대술후항생제및진통제를복용하였으며수술부위는특이한소견없이잘치유되었다. 7개월뒤국소마취하에판막을거상하였고이식된골은잘유지되어있어 (Fig. 2G) 추가골이식수술없이임플란트 (TS III R, Osstem implant, Korea) 를식립하였다 (Fig. 2H). 5개월뒤임플란트이차수술을시행하였고임플란트와이식골이잘유착되어있는양상을보였으며 (Fig. 2I and 2J) 임플란트보철을시행하였다 (Fig. 3). 2. 두번째증례 51세남성이 #35, #36, #37, #44, #45, #46, #47 부위임플란트식립을하고싶다는주소로내원하였다. 개인병원에서양측임플란트를식립후사용하다가임플란트주위염으로인해하악좌측제1소구치부위임플란트만남겨놓은채구치부임플란트가모두제거된상태로상당한골흡수가관찰되었다. 부착치은대가많이소실되어있었으며기존임플란트제거로인해수직적으로골결손이심하여조직접착제를사용한수직적골증대술후지연임플란트식립이계획되었다 (Fig. 4). 좌, 우측골증대술및임플란트식립은나누어시행되었다. 하악우측구치부에국소마취를시행한후판막을거상하였고 (Fig. 5A) 임플란트제거부위에수직적으로심한골결손부가관찰되었다 (Fig. 5B). 동종골 (Oragraft R, LifeNet, USA) 과합성골 (Q-Oss+ R, Osstem implant, Korea) 을섞어서사용하였고골이식제에조직접착제 (Tisseel R, Baxter, Vienna, Austria) 를사용하여골결손부에적용할수있도록뭉쳐서이식할골을준비하였다 (Fig. 5C). 골결손부에수직적, 수평적골증대술을시행하였으며 (Fig. 5D) 흡수성차단막 (Cytoplast RTM R, Osteogenics, USA) 을사용하여골이식부위를피개하였다 (Fig. 5E). 협측판막에골막감장절개를시행하여 3-0 polyglycolic 16 Implantology Vol. 24, No. 1, 2020

5 acid 봉합사로장력없이 1차봉합을단순봉합및매트리스봉합을사용하여시행하였다 (Fig. 5F). 7개월뒤국소마취하에판막을거상하였고이식된골형태가잘유지되어있어 (Fig. 5G) 임플란트 (TS III R, Osstem implant, Korea) 를식립하였다 (Fig. 5H). 6개월뒤임플란트이차수술을시행하였으며임플란트가이식된골에잘유착되어있는것으로보였으며 (Fig. 5I) 임플란트보철이시행되었다 (Fig. 7). 하악좌측골증대술이하악우측골증대술후 3개월뒤에시행되었다. 국소마취하에판막을거상한뒤 Fig. 4. Case II Pre-operative panoramic view: Severe bone loss in both mandible implant removal areas. (A) (B) (C) (D) (E) (F) (G) (H) (I) Fig. 5. CaseII(Right mandible) Intraoral views of bone graft & implant surgical procedure: (A)Preoperative clinical gingiva, (B)Flap elevation, (C)Preparation bone material with fibrin sealant, (D)Bone graft, (E)Cover with collagen membrane, (F) Tension free suture, (G)1st surgery flap elevation, (H)Implant insertion, (I)2nd surgery flap elevation. Implantology Vol. 24, No. 1,

6 (Fig. 6A) 우측과동일한방법으로동종골 (Oragraft R, LifeNet, USA) 및합성골 (Q-Oss+ R, Osstem implant, Korea) 에조직접착제 (Tisseel R, Baxter, Vienna, Austria) 를사용하여반고형의덩어리형태로좌측골결손부에골증대술을시행하였다 (Fig. 6B). 골이식후흡수성차단막 (Cytoplast RTM R, Osteogenics, USA) 을이용하여이식부위를피개한후 (Fig. 6C) 장력없이 1차봉합을시행하였다 (Fig. 6D). 좌측골증대술 7개월뒤임플란트식립을위해국소마취하에판막을거상하였고이식된골이잘유지되어 (Fig. 6E) 임플란트 (TS III R, Osstem implant, Korea) 를식립하였다 (Fig. 6F). 5개월뒤임플란트이차수술을시행하였으며이식된골및임플란트는잘유착되어있었고 (Fig. 6G) 임플란트보철을시행하였다 (Fig. 7). (A) (B) (C) (D) (E) (F) (G) Fig. 6. CaseII(Left mandible) Intraoral views of bone graft & implant surgical procedure: (A)Flap elevation, (B)Bone graft on defect site, (C)Cover with collagen membrane, (D)Tension free suture, (E)1st surgery flap elevation, (F)Implant insertion, (G)2nd surgery flap elevation. Fig. 7. CaseII Panoramic view - Final restoration setting. 18 Implantology Vol. 24, No. 1, 2020

7 Ⅲ. 고찰결손된치조골의골증대술을위해치조제확대술, 블록골이식술등다양한방법이사용되고있지만차단막과골이식재를사용한골유도재생술이조작의용이성및술식의편의성으로인해임플란트를위한골재생술식에많이사용되고있다. 6, 7 이러한골유도재생술의성공률을높이기위해서는이식된골의안정과공간유지능력, 차단막의안정, 골수기원세포의재생부위로의용이한접근, 장력없는일차봉합이필요하다. 8 하지만넓은부위의골결손부나수직적으로골결손부가생겼을경우차단막과입자형골이식재의형태를유지시키기어려워골유도재생술을수행하기에힘들다. 이런경우입자형골이식재에조직접착제를사용하여반고형의덩어리형태로골결손부에적용하여골유도재생술을쉽게수행할수있다. 이밖에다른골이식방법으로는블록골이식술을사용하거나 Titanium mesh로공간을유지하는골증대술을이용할수있다. 하지만블록골이식술은공여부에서자가골을블록형태로채취하는어려움과외과적손상이일어나고이부에서블록형태의골을채취하였을때무감각증및이상감각증이일어날가능성이있어특별한주의가요구된다. 9 수직적으로골이식을위해 Titanuum mesh를이용해공간유지를통한골증대술도사용될수있지만 Titanium mesh사용시수술시간이많이걸리고 Titanium mesh의초기노출이발생하여염증이생길가능성이있다. 10 골증대술을위한조직접착제의사용은혈소판의성장인자를골증대술에이용하기위해자가혈액을채취한후원심분리기로 PRP(Platelet rich plasma) 와 PRGF(Plasm rich in growth factors) 를분리한후입자형골이식재와혼합한뒤조직접착제를사용하여덩어리형태의골을만들어치조골증대술에사용되었다. 11 이후혈소판의성장인자를이용하기위해 PRF(Platelet rich fibrin) 과 CGF(concentrated growth factor) 등으로발전해사용되어왔으며최근정맥에서혈액을채취한뒤원심분리후자가섬유접착제 (Autogenous fibrin glue) 를이용하여입자형골이식재에적용한덩어리형태의 Sticky bone이소개되었다. 12 그러나자가섬유접착제를임상에서사용할경우환자의정맥에서혈액을채취하여야하며, 채취한혈액에서자가섬유접착제를분리하기위한시간이필요하고장비가준비되어있어야하는단점이있다. 이러한단점을극복하고자상품화된조직접착제가임상에서사용되고있으며상품화된조직접착제로는 Tisseel R (Baxter, Vienna, Austria), Greenplast R (Green Cross, Yongin, Korea), Beriplast R (Aventis Behring, Marburg, Germany), Hemaseel R (Haemacure, Sarasota, Floida, USA) 등이있다. 이들제품들은인체에서채취한혈액응고인자를포함하는 Fibrinogen성분과, Thrombin의두가지주요성분으로구성되며이들두성분을혼합하여사용할수있도록제조되어임상에서편리하게사용할수있는장점이있다. Hallman등 13 은상악동골증대술시이종골에조직접착제 (Tisseel R, Baxter, Vienna, Austria) 를혼합하여사용하여성공적으로임플란트를식립할수있었다고보고하였다. 본증례에서사용한조직접착제는 Tisseel R (Baxter, Vienna, Austria) 로서 27 에동결건조상태로 Implantology Vol. 24, No. 1,

8 보관되었다가사용전에외부상온에서해동을거쳐수술시에사용되었다. 임플란트를위해골유도재생술시에상품화된조직접착제는혈액을채취할필요가없으며필요시언제든지즉시사용할수있고, 사용하기위해재료를준비하는시간도수분내로짧게소요되어입자형골이식재에적용하여넓은부위의골결손부나수직적으로골결손부가생겼을경우에편리하게사용될수있다. Ⅳ. 결론본임상증례에서중증의치조골위축및수직적골결손부가있는부위에골유도재생술시조직접착제를함께사용하여수술시간의단축및혈액채취등의환자의불편감없이골증대술을시행할수있었으며지연임플란트식립시골증대술을시행한부위의골이잘형성되어적절한위치에임플란트를식립할수있었다. Acknowledgements 이논문은 2019 년도원광대학교의교비지원비에의해서수행됨. References 1. Lekholm U, Adell R, Lindhe J. Marginal tissue reactions at osseointegrated titanium fixtures.(ii) A cross-sectional retrospective study. Int J Oral Maxillofac Surg 1986;15: Buser D, Dula K, Belser U, Hirt HP, Berthold H. Localized ridge augmentation using GBR, I. Surgical procedures in the maxilla. Int J Periodontics Restorative Dent 1993;13: Chang YY, Kang DH, Park JC, Kim JH, Yun JH, Kim ST, et al. Treatment of dehiscence or fenestration defect on maxillary anterior implants using guided bone regeneration: Case report. J Korean Acad Implant Dent 2011;30(1): Fugazzotto P. GBR using bovine bone matrix and resorbable and nonresorbable membranes. Part1:hitologic results. Int J Periodontics Restorative Dent 2003;23: Matras H. Fibrin sealant in maxillofacial surgery. Facial plastic Surg 1985;2: Dahin C, Linde A, Gottlow J, Nyman S. Healing of bone defects by guided tissue regeneration. Plast Reconstr Surg 1998;81(5): Buser D, Dula K, Hirt HP, Schenk RK. Lateral ridge augmentation using autograts and barrier membranes. A clinical study in 40 partially edentulous patients. Int J Oral Maxillofac Surg 1996;54: Wang HL1, Al-Shammari K. HVC ridge deficiency classification: a therapeutically oriented classification. Int J Periodontics Restorative Dent 2002;22(4): Sethi A, Kaus T. Ridge augmentaion using mandibular block bone grafts: Preliminary results of an ongoing prospective study. Int J Oral Maxillofac Implants 2001;16: Implantology Vol. 24, No. 1, 2020

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