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1 Oral Biology Research, 2018; June 30, 42(2): Copyright c 2018, Oral Biology Research Institute DOI: /obr Case Report ORAL BIOLOGY RESEARCH Rehabilitation of mandibular partial edentulous patient with remaining unilateral teeth using implant-assisted removable partial denture Hyo-Gyoung Yi, Kwang-Yeob Song, Seung-Geun Ahn, Ju-Mi Park, and Jae-Min Seo* Department of Prosthodontics, School of Dentistry and Institute of Oral Bio-Science, Chonbuk National University, Jeonju 54896, Republic of Korea (Received May 8, 2018; Revised version received Jun 4, 2018; Accepted Jun 5, 2018) ABSTRACT For patients with a few remaining teeth, if an implant supported fixed partial denture is difficult due to the patient s systemic or local conditions, or due to their economic situation, a removable partial denture may be considered as a treatment option. If a few teeth remain unilaterally to the midline, placement of the implant on the contralateral side and designing an implant-assisted removable partial denture (IARPD) may improve the retention and support of the removable partial denture and protect weak abutment teeth. In this case, a partially edentulous patient with a few remaining teeth located unilaterally on the mandible was treated using a maxillary distal extension removable partial denture and mandibular IARPD after implant placement on the mandibular edentulous area. We achieved an esthetically and functionally satisfying outcome. KEY WORDS: Distal extension removable partial denture, Implant, Implant-assisted removable partial denture, Partial edentulism 서 론 부분무치악환자는고정성보철, 가철성국소의치, 임플란트지지고정성보철로수복될수있으며, 소수의잔존치아가있는경우에는고정성보철로치료하는것이불가능하여가철성국소의치나임플란트지지고정성보철수복치료를시행하게된다. 그러나환자의전신적, 국소적그리고경제적여건에따라임플란트지지고정성보철수복이어려운경우가철성국소의치를고려해볼수있다 [1]. 그러나후방연장국소의치는장기간사용시수직고경을상실하거나교합평면의부조화가발생할수있고외팔보효과에의해잔존치에응력이집중되어환자의불편감을유발할수있으며저작기능의회복이불안정하다. 이를극복하기위해무치악부위에임플란트를식립해부가적인유지와지지를얻는임플란트보조국소의치 (implant-assisted removable partial denture, IARPD) 에대한관심이높아지고있다 [2,3]. *Corresponding author: Jae-Min Seo Department of Prosthodontics, School of Dentistry and Institute of Oral Bio-Science, Chonbuk National University, 567 Baekje-daero, Deokjingu, Jeonju 54896, Republic of Korea Tel.: , Fax: jmseo@jbnu.ac.kr 국소의치는지대치에의한대칭적인지지가중요하며, 중심선에대해편측으로소수의치아만남은경우지점선에대해지대치에유해한스트레스를가하게된다. 이런경우전략적위치에최소한의임플란트를식립하는것이추천된다 [4]. 국소의치를위한임플란트는지지에가장유리한위치에식립되어야국소의치의회전운동이효과적으로억제된다. 의치상에서지지받지못하는부위에임플란트를적용하면이러한회전운동을없애거나지렛대의길이를감소시켜지렛대효과를줄일수있다 [5]. 본증례는하악우측에편측으로지대치가존재하는상하악양측성후방연장부분무치악환자에서하악좌측측절치와견치사이, 제 1소구치와제 2소구치사이에임플란트를식립하고상악은전통적국소의치를, 하악은 Locator 유지장치를부착한임플란트보조국소의치를제작하여심미적, 기능적으로만족할만한임상결과를얻었기에보고하고자한다. 증례보고 본환자는 79세여성으로상하악의치로인한불편감과무치악부위의통증을주소로본과에내원하셨으며, 수년전에제작한상하악써베이드보철물및국소의치를사용

진단과정에서관찰된내용을근거로무치악부위가넓은하악좌측에임플란트를식립하고기능성과심미성을회복하기위해전악수복하기로결정하였다. 환자는고령으로인해광범위한수술을원하지않았고경제적인치료를원하였다.

2 Hyo-Gyoung Yi et al. Fig. 1. Pre-treatment panoramic radiograph. 하고있었다. 초진시구내사진및파노라마방사선사진상에서상하악구치부무치악부위에중등도의치조골흡수와다수의구치부치아상실이관찰되었고, 임상검사에서 #43의도재파절, #31, 41의 1~2도의치아동요도, #43, 45, 46의타진및저작시통증을보였고 #11, 21, 22, 31 의보철물하방에 2차우식이의심되어보철물제거후지대치평가가필요하였다 (Fig. 1 and 2). 진단과정에서관찰된내용을근거로무치악부위가넓은하악좌측에임플란트를식립하고기능성과심미성을회복하기위해전악수복하기로결정하였다. 환자는고령으로인해광범위한수술을원하지않았고경제적인치료를원하였다. 잔존치아의우식및치주치료후보철치료를계획하였으며, 첫번째방안으로가용골이풍부한 #44 위치및 #32에서 #35 부위에임플란트식립후잔존 치아와임플란트를포함한고정성수복을하고무치악부위에통상적인후방연장국소의치를제작하거나, 두번째방안으로임플란트식립후잔존치아에만고정성수복을시행하고상악은국소의치를, 하악은임플란트보조국소의치를고려하였다. 하악임플란트보조국소의치의유지장치는 Locator (Zest Anchors Inc., Escondido, CA, USA) 로선택하였다. 초진시예비인상채득하고안궁이전및악간관계채득하여반조절성교합기 (Hanau modular articulator system 190, Whip Mix Co., Luisville, KY, USA) 에진단모형을장착하였다. 교합면간거리, 전정간거리, 안모계측, 심미, 발음등을참고하여수직고경평가한결과수직고경상실을보이지않아기존의수직고경을유지하기로하였다. 이상적인교합평면을가지도록전악납형형성을시행하였고우측방운동시에는견치유도교합, 좌측방운동시에는의치의안정과임플란트에가해지는응력의분산을위해견치부터소구치까지군기능교합을부여하고전방운동시에는상악좌우측중절치에의해유도되도록하였다 (Fig. 3). 이후납형형성을토대로임시보철물을제작하여, 환자에게장착하였다. 상하악잔존치의기존의보철물을제거한결과 2차우식이심하게진행되어 #14, 24, 31, 46의발거가필요하였다. #31, 46 발치시하악은우측중절치부터우측제 2소구치까지편측으로소수의치아가잔존하게되며, 치주적으로약한하악우측중절치는직접적으로의치의유지를부담하기에는부적절하여대합치및반대 Fig. 2. Intra-oral status in the initial examination. (A) Maxillary occlusal view, (B) right lateral view, (C) frontal view at maximum inter-cuspal position, (D) left lateral view, and (E) mandibular occlusal view

mandibular occlusal view, and (H) anterior movementanterior side: group function. 측치아와대칭적위치이면서가용골이풍부한하악좌측측절치부터소구치부위에임플란트식립을계획하였다.

3 Rehabilitation of mandibular partial edentulous patient Fig. 3. Diagnostic wax up model. (A) Lateral movement-right side: canine guidance, (B) maxillary occlusal view, (C) lateral movement-left side: group function, (D) right lateral view, (E) frontal view, (F) left lateral view, (G) mandibular occlusal view, and (H) anterior movementanterior side: group function. 측치아와대칭적위치이면서가용골이풍부한하악좌측측절치부터소구치부위에임플란트식립을계획하였다. 스텐트를이용하여컴퓨터단층사진을촬영하였으며, 환자가 #44 부위에는임플란트치료를원하지않아해당상실치부위는통상적인고정성보철수복으로치료계획을변경하였다. 무치악부위가용골에적합한길이와직경의임플란트를선택하였으며고령인점을감안하여임플란트식립시추가적인골유도재생술은시행하지않기로하였다. 따라서골유도재생술을시행하지않고도임플란트고정성보철수복보다더자유롭게가용골이풍부한위치에임플란트를식립할수있으며, 외팔보효과의감소에의해임플란트에가해지는응력이감소될수있도록보철적치료계획의두가지방안중에서두번째방안을선택하였다. 본원보철과에서 #32와 #33 사이, #34와 #35 사이에해당하는위치에임플란트 (#32와 #33 사이 : mm, #34 와 #35 사이 : mm (TS III SA, Osstem, Seoul, Korea)) 를식립하고 #14, 24, 31, 46을발거했다 (Fig. 4). 임플란트식립및발치 1주뒤임시의치를장착하였다. 본원보존과에서 #21, 23, 43, 45의근관치료와 #11, 13의우식치료를하였으며, 치주과에서잔존지대치의치주치료를시행하였다. 환자는 2개월간임시보철물사용후심미적, 기능적으로만족해하여, 최종보철물을제작하기로하였다. 부가중 Fig. 4. Panoramic radiograph after implants placement on mandibular left edentulous area. 합형실리콘인상재 (Aquasil Ultra XLV, Monophase, Dentsply Caulk, Milford, USA) 를이용하여상하악국소의치지대치의최종인상을채득하고작업모형을제작하였다 (Fig. 5). 악간관계를채득하고작업모형을교합기에장착후, 최종보철물을제작하였다. 임시치아상태의모형을참고로왁스업하여스캔하였다. #13, 12, 11, 21, 22, 23, 41, 42는지르코니아코어 (Upcera Zirconia Block, Liaoning Upcera Co., Guangdong, China) 에상부도재 (IPS e.max Ceram, Ivoclar Vivadent, Schaan, Germany) 를축성한지르코니아- 도재전장보철물로, #43=45는단일구조지르코니아보철

Hyo-Gyoung Yi et al. Fig. 5. Mater cast fabrication for fixed prostheses.

물로제작하고레진시멘트 (RelyX Ultimate, 3M ESPE, St. Paul, MN, USA) 로최종합착하였다 (Fig. 6).

개인트레이를제작하여모델링컴파운드 (Peri compound, GC, Tokyo, Japan) 를이용하여변연형성후부가중합형실리콘인상재 (Aquasil Ultra XLV, LV, Dentsply Caulk, Milford, USA) 를이용하여최종인상채득하였다.

4 Hyo-Gyoung Yi et al. Fig. 5. Mater cast fabrication for fixed prostheses. (A) Maxillary final impression, (B) mandibular final impression, (C) maxillary master cast, and (D) mandibular master cast. Fig. 6. Definitive fixed prostheses. 물로제작하고레진시멘트 (RelyX Ultimate, 3M ESPE, St. Paul, MN, USA) 로최종합착하였다 (Fig. 6). 상악의양측성후방연장국소의치와하악의임플란트보조국소의치제작을위하여하악좌측임플란트에 Locator 지대주를체결후알지네이트인상재 (Aromafine Plus, GC, Tokyo, Japan) 로예비인상채득하였다. 개인트레이를제작하여모델링컴파운드 (Peri compound, GC, Tokyo, Japan) 를이용하여변연형성후부가중합형실리콘인상재 (Aquasil Ultra XLV, LV, Dentsply Caulk, Milford, USA) 를이용하여최종인상채득하였다. 이후통법대로국소의치를제작하고최종의치를교합조정후구강내에장착하였다. 의치의침하보상을위해장착 2주후 Locator 유지장치의 male part를자가중합아크릴릭레진 (Pattern Resin LS, GC America Inc., Alsip, IL, USA) 을이용해직접법으로부착하고전치부심미성을개선하고치주적으로약한 #41에가해지는측방력을최소화하기위해 #41의가공선을제거하였다 (Fig. 7). 의치장착후전방 Fig. 7. Locator attachments connection. (A) Locator abutments & processing caps were connected to the implants. (B) Ventral view of mandibular IARPD. Metal housing and blue nylon patrix were inserted

position, (F) left lateral view, (G) working side during right lateral excursion, (H) mandibular occlusal view, and (I) balancing side during right lateral excursion. Fig. 9.

5 Rehabilitation of mandibular partial edentulous patient Fig. 8. Mandibular IARPD. (A) Balancing side during left lateral excursion, (B) maxillary occlusal view, (C) working side during left lateral excursion, (D) right lateral view, (E) frontal view at maximum inter-cuspal position, (F) left lateral view, (G) working side during right lateral excursion, (H) mandibular occlusal view, and (I) balancing side during right lateral excursion. Fig. 9. Replacement of resin occlusal plane with zirconia occlusal plane. (A) Working cast fabrication by pick-up impression of maxillary RPD. (B and C) CAD design of zirconia occlusal plane by double scanning method. (D) Final maxillary RPD after cementation of zirconia occlusal prostheses on the occlusal surface. 운동시구치부이개및우측방운동시견치유도교합, 좌측방운동시군기능교합을이루고있음을재확인하였 다 (Fig. 8). 환자에게잔존자연치아와 Locator 지대주를포함한구강위생및의치관리에대한교육을시행하였다

6 Hyo-Gyoung Yi et al. Fig. 10. Post-treatment panoramic radiograph. 최종의치장착 5개월후의치에대한환자의적응과안정적인교합을확인한뒤에하악의지르코니아보철물과대합되는상악의치의레진인공치의마모에의한가철성국소의치의지지의감소및대합치의정출로인한교합평면의부조화를방지하기위해 #14, 15 인공치의교합면을지르코니아로교체하기로하였다. 상악국소의치를 pick up 인상채득하고기존의인공치교합면을삭제한후 ( 기능교두 : 2 mm, 비기능교두 : 1.5 mm, 치경부에서변연두께 : 1 mm) double scanning 방법으로제작한지르코니아보철물을삭제된인공치위에레진시멘트 (RelyX Unicem, 3M ESPE, St. Paul, MN, USA) 를이용하여합착하였다 (Fig. 9). 환자는기능적, 심미적으로만족하였으며, 의치장착후 1일, 1주, 2주, 1개월, 5개월, 6개월, 7개월, 1년의정기적인재내원을통해구강위생관리의정도, 교합상태의변화유무등을검사하였다 (Fig. 10). 고찰 임플란트보조국소의치에서임플란트의성공률은 93~100% 로다양하며, 전통적국소의치에비해높은환자만족도를보인다 [2]. Wismeijer 등 [6] 은기존의치에비해임플란트유지국소의치에서환자만족도, 저작효율, 의치안정성, 발음에대한만족도가유의하게증가하였다고보고하였다. Ohkubo 등 [3] 도전통적인국소의치와치유지대주를연결한임플란트지지국소의치를비교한결과임플란트지지국소의치에서저작시간이짧고교합접촉중심이후방으로위치하였으며유의하게높은교합력과환자만족도를보였다고하였다. 국소의치를위한임플란트식립위치선정시고려사항으로는의치의지지, 안정, 유지와잔존치조제의해부학적형태, 전략적인지대치의상실여부, 대합치의상태, 최후방지대치의상태가있다 [5]. 임플란트식립위치에관한다양한의견이제시되었는데, Grossmann 등 [7] 은가장강 한힘이가해지는최후방부를추천하였으나, 후방치조제가부족하거나지대치의예후가불량한경우및클라스프를생략하고싶은경우에는좀더전방부를추천하였다. Cunha 등 [8] 은유한요소분석에서임플란트가전방에위치할수록임플란트에가해지는응력은증가하지만, 지대치에가해지는응력과전체적인응력은감소하므로전치부치아만잔존시지대치에가까운제 2소구치부위에임플란트를식립할것을추천하였다. 반면, Kim 등 [9] 은하악후방연장국소의치에서제 2대구치에위치한임플란트주변골에더낮은응력집중도를보였고, 제 1대구치에위치한임플란트는임플란트의변위와전방지대치에가해지는응력이더적어, 무치악부지지가주목적이라면후방부에식립할것을, 건전하지못한지대치를보조할때에는좀더전방지대치에가깝게식립할것을추천하였다. Bortolini 등 [10] 은견치또는제 1소구치가골질과골량이적당해주요식립위치로언급하였다. Brudvik [11] 은대구치부위에식립시 Kennedy class I 또는 II에서 III로변화되어 biomechanical configuration이향상되며, 견치부위는최후방지대치가측절치일때지지와유지를제공하며전방부클라스프생략으로전방지대치에좋은심미적, 치주적예후를제공한다고하였다. Binon[12] 은식립위치가고정성보철수복처럼중요하지는않다고하였으며, 식립위치보다는하중의방향이임플란트의장축을따라가해지는것이더욱중요하다고하였다. 국소의치설계시이상적인의치의지지와유지를얻기위해서는지대자연치아와식립될임플란트가넓은네개의꼭지점을가진사다리꼴이되도록임플란트를식립해외팔보효과를방지해야한다 [13]. 특히대칭적인지지가결여된편측성으로치아가잔존하는경우에국소의치설계시반드시이점을고려하여좌우및전후방적으로전략적인위치에임플란트를식립해야한다. 임플란트보조국소의치의유지장치로사용되는 Locator 유지장치는자가배열, 이중유지, 유지력이상실되지않으면서약간의회전을허용하는특성이있고수직적으로필요한공간이작다는장점이있다. 그러나다른유지장치들과같이반복적인의치의착탈과기능시하중에의한유지장치의마모로인한유지력상실과나일론부품의교체, 지대주함요부의치태축적에의한피개의치의완전한장착의방해, 지대주의풀림, 의치의재이장, 인공치또는의치의파절등이 Locator 유지장치와관련된유지관리문제로보고되고있다 [14]. 따라서환자에게구강위생관리교육과함께정기적인내원시 Locator 지대주의풀림이나마모여부를검사하고유지력저하시나일론부품을교체하는것이필요하며잔존치조제의흡수에따른의치상의침하를방지하기위해주기적인의치상의재이장을실시해야한다

7 Rehabilitation of mandibular partial edentulous patient 본증례는상악은전치부만잔존하고하악은편측으로소수치아가잔존하는환자로구치부지지와저작기능의회복이필요하였으며, 하악은외팔보효과를방지하고추가적인유지와지지를얻기위해임플란트식립이추천되는상황이었다. 치주적으로약한전방지대치를보호하기위해하악우측중절치에근접하면서도수평적가용골이풍부한 #32와 #33 사이를전방임플란트식립위치로선 택하였으며, 대합치및반대측자연치아와대칭적위치면서수평적가용골이풍부한 #34와 #35 사이를후방임플란트식립위치로선택하였다. 따라서잔존자연지대치와추가되는임플란트가비교적넓은사다리꼴분포를이루도록하였다. 향후잔존치아와임플란트및국소의치의지속적인평가및유지관리가요구된다. 결 론 중심선에대해편측으로소수의치아가잔존하는환자의가철성국소의치수복에서는중심선을기준으로반대측의전략적위치에임플란트를식립하여임플란트보조국소의치를제작하면의치의유지와지지그리고잔존지대치의예후를향상시킬수있다. 이를위해서는체계적인진단과정이필요하고다양한요인을고려하여적절한위치에임플란트를식립하고응력분산을하는것이중요하며주기적인유지관리가필수적이다. Conflict of Interest The authors declare that they have no competing interests. ORCID Hyo-Gyoung Yi Kwang-Yeob Song Seung-Geun Ahn X Ju-Mi Park Jae-Min Seo References 1. Budtz-Jorgensen E. Restoration of the partially edentulous mouth-a comparison of overdentures, removable partial dentures, fixed partial dentures and implant treatment. J Dent 1996;24: doi: / (95) Lee JH, Kim DG, Park CJ, Cho LR. A literature review on implant assisted removable partial denture. J Dent Rehabil Appl Sci 2012;28: Ohkubo C, Kurihara D, Shimpo H, Suzuki Y, Kokubo Y, Hosoi T. Effect of implant support on distal extension removable partial dentures: in vitro assessment. J Oral Rehabil 2007;34: doi: /j x. 4. Lee BR, Kim JH. Rehabilitation of maxillary partial edentulous patients using implant assisted removable partial denture. J Korean Acad Prosthodont 2014;52: doi: /jkap Carr AB, Brown DT. McCracken s removable partial prosthodontics. 12th ed. St. Louis: Mosby; p. 66, Wismeijer D, Tawse-Smith A, Payne AG. Multicentre prospective evaluation of implant-assisted mandibular bilateral distal extension removable partial dentures: patient satisfaction. Clinical Oral Implants Res 2013;24: doi: /j x. 7. Grossmann Y, Nissan J, Levin L. Clinical effectiveness of implant-supported removable partial dentures: A review. of the literature and retrospective case evaluation. J Oral Maxillofac Surg 2009;67: doi: /j.joms Cunha LD, Pellizzer EP, Verri FR, Pereira JA. Evaluation of the influence of location of osseointegrated implants associated with mandibular removable partial dentures. Implant Dent 2008;17: doi: /ID.0b013e b2. 9. Kim JH, Cho JH, Lee CH. Influence of the length and location of implants on distal extension removable partial dentures: finite element analysis. J Dent Rehabil Appl Sci 2015;31: doi: /jdras Bortolini S, Natali A, Franchi M, Coggiola A, Consolo U. Implant-retained removable partial dentures: an 8- year retrospective study. J Prosthodont 2011;20: doi: /j X x. 11. Brudvik JS. Advanced removable partial dentures. Chicago: Quintessence; p Binon P. The role of screws in implant systems. Int J Oral Maxillofac Implants 1994;9: Zitzmann NU, Rohner U, Weiger R, Krastl G. When to choose which retention element to use for removable dental prostheses. Int J Prosthodont 2009;22: Cha MS, Kim DG, Park CJ, Cho LR. A literature review on locator attachment for implant overdenture. J Dent Rehabil Appl Sci 2013;29: doi: /jdras

ISSN eissn Case Report Full mouth rehabilitation utilizing implant-assisted removab

ISSN eissn Case Report Full mouth rehabilitation utilizing implant-assisted removab http://dx.doi.org/10.14368/jdras.2016.32.3.214 ISSN 2384-4353 eissn 2384-4272 Case Report Full mouth rehabilitation utilizing implant-assisted removable partial denture with a canted occlusal plane: a