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1 Original Article 술자의숙련도에따른임플란트식립경향에관한후향적연구 이홍석 1, 이성조 1, 송영균 2, 조인우 1, 박정철 1, 신현승 1 * 1 단국대학교치과대학치주과학교실 2 단국대학교치과대학보철학교실 Research of Tendency for Implant Placement According to Experience of Operator: A Retrospective Study Hong-Seok Lee 1, Sung-Jo Lee 1, Young-Gyun Song 2, In-Woo Cho 1, Jung-Chul Park 1, Hyun-Seung Shin 1 * 1 Department of Periodontology, College of Dentistry, Dankook University, Cheonan, Korea 2 Department of Prosthodontics, College of Dentistry, Dankook University, Cheonan, Korea *Corresponding author: Hyun-Seung Shin, perioshin@dankook.ac.kr OPEN ACCESS pissn : Implantology 2017; 21(4): eissn : Received: December 4, 2017 Revised: December 7, 2017 Accepted: December 12, 2017 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 ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Increasing attention has been drawn to the surgeon factor in the implant failure due to the implant fracture or osseointegration. The purpose of this study is to compare the location of implants placed by 2 surgeon groups, periodontal residents and professors, analyzing the distance between adjacent natural teeth and implants, or 2 adjacent implants. The charts and radiographs of patients who received dental implants between January 2014 and December 2015 in the Department of periodontology, Dankook University Dental Hospital were examined. A total of 1306 implants placed on maxillary and mandibular second premolar, first molar and second molar area were evaluated in this retrospective analysis. The implants were classified into two experimental groups: the implants placed posterior to the natural teeth and the implants placed posterior to the other implant. The implants in each group were also categorized into 3 subgroups by the location in the jaw whether they were in the second premolar, the first molar or the second molar areas. The distance was measured on the digital panoramic radiographs taken after the implant surgery. In the group of the implants placed posterior to the natural teeth, the distance between natural teeth and implants planted by the professors and periodontal residents were 2.94 ± 1.14 mm and 3.14 ± 1.24 mm, which showed significant difference. In the group of the implants placed posterior to the other implants, the distance between implants placed by the professors and periodontal residents were 3.35 ± 1.34 mm and 3.62 ± 1.41 mm, which showed significant difference. The implants placed in the first molar area showed significant difference in terms of the distance; 3.30 ± 1.14 mm by the professors, and 3.76 ± 1.10 mm by the periodontal residents. The following conclusion can be achieved on the basis of the results of this study. 1. In the group of the implants placed posterior to the natural teeth, the periodontal residents placed implant significantly more distally from the natural teeth than the professors. 2. In the group if the implants placed posterior to the other implants, the periodontal residents placed implant significantly more distally from the adjacent implant than the professors. In case of placing implants in the first molar area, the periodontal residents placed implant significantly more distally form the adjacent implant than the professors. Keywords: Distance of implant, Retrospective study, Surgeon factor 218

2 IMPLANTOLOGY I. 서론 임플란트는완전무치악, 부분무치악환자에있어상실치수복을위한예지성있는치료방법으로여겨지고있으며 1, 1960년대에처음치과계에소개된이후로오늘날에이르기까지그수요는꾸준히늘어나고있다 2. 그에따라치과용임플란트의성공률을높이기위해다양한표면처리방법이개발되기도하였으며 3, 상악동거상술과같은수술기법이등장하기도하는등여러방면으로의발전이이루어져왔다. 그결과다양한임상적상황에서일반적으로 90% 이상의높은생존률이보고되고있다 4,5. 그러나실제임상에서는임플란트의파절이나골유착실패등으로인한임플란트의실패가발생할수있는데, 그동안은이에대해임플란트의재료적특성이나환자의문제에대한관점으로접근하는경우많았다. 그러나 2001년 Albrektsson은스웨덴예테보리대학에서식립한 1,000개의임플란트중 40% 가단 1명의술자에의해식립되었기때문에, 술자관련위험요소에대해더강조할필요가있음을주장하는등 6, 술자에의한변수에도점점주목하는추세이다. 이러한추세를반영하여최근에는초심자를위한임플란트교육프로그램이점점늘어나고있다. 치과임플란트수술에관해서는동물또는모델실습등을통하여교육이이루어지고있지만, 아직체계적인방법은제시된바가없다. 하지만 Park 등에의해 implant surgical technique assessment and rating system (istar) 이라는평가도구가개발되거나, 내비게이션시스템을만들고자하는등더나은술자교육을위한연구가진행되고있다 7,8. 술자의임상적숙련도에서중요하게생각되는요소로는지식, 의사소통기술, 술기의 3가지요소가있다. 임플란트수술의술기에있어서평가할수있는사항은많지만그중중요하면서도쉽게측정할수있는사항으로는식립한임플란트와인접치아나임플란트와의간격을들수있다. Tarnow 등은 2개의인접한임플란트를식립할때 3 mm 이하의간격이되도록식립할경우치간골의수직적골소실을유발한다고보고하였다 9. 따라서 3 mm 이상의간격이되도록식립할것을권유하였다. 이와마찬가지로자연치와임플란트간간격역시적어도 mm 이상이어야한다고권유되고있다 이와는반대로임플란트간간격이너무멀경우, 부적절한 contour를가질뿐만아니라 cantilever 방식의힘을받게된다 13,14. 이는임플란트보철물에더많은응력이집중될수있기에가급적피하는것이권유된다 15. 따라서인접치가자연치든임플란트든너무가깝게식립하는것도피해야하지만너무멀리식립하는것도피하는것이좋다. 본연구의목적은초심자인치과병원전공의와전문가인교수진간의임플란트식립에있어서인접자연치, 임플란트와의간격을후향적으로비교하여술식에유의한차이가있는지비교하는것이다. 219

3 Original Articles II. 연구재료및방법 1. 연구대상 2014년 1월부터 2015년 12월사이에단국대학교치과대학부속치과병원치주과에서식립한임플란트중상, 하악제2소구치, 제1,2대구치부위에 surgical stent를사용하지않고식립된임플란트, 총 1306개의임플란트를대상으로진료기록부및방사선사진자료를토대로후향적분석을시행하였다. 각임플란트는자연치후방에식립한임플란트와임플란트후방에식립한임플란트로실험군을분류했다. 또한식립부위에따라제2소구치, 제1,2대구치에식립한임플란트로분류했다. 2. 연구방법 1) 방사선학적검사모든임플란트에있어서식립후촬영한디지털파노라마방사선사진을이용하여간격을측정하였다. 각임플란트의근심면최상부를기준점으로하여근심인접한치아또는임플란트의원심면까지의거리를 0.1 mm까지계측하였다. 계측시발생하는오차를줄이기위해 1인의치과의사가모든계측을시행하였다. 2) 통계학적분석각실험군에있어서계측된자료들을식립한술자에따라서비교분석하였다. 통계프로그램으로는 SPSS ver. 20 (SPSS Inc. Chicago, IL, USA) 을사용하였다. Shapiro-Wilk test나 central limit theorem 을이용하여각실험군에서정규성만족여부를확인하였고, 모수적검정방법인 Independent samples t-test를이용하여분석하였다. III. 연구결과 1. 자연치후방에식립한임플란트의비교자연치후방에식립한임플란트전체를대상으로술자에따라비교했을때, 교수진이식립한임플란트와전공의가식립한임플란트간에는통계학적으로유의한차이가있었다. 하지만식립부위별로비교했을때는유의한차이가없었다 (Table 1). 220

4 IMPLANTOLOGY Table 1. Distance between implant and mesial adjacent tooth Specialists Residents P All (mm) 2.94 ± 1.14 (n =566) 3.14 ± 1.24 (n=231) 0.027* T4-I5 (mm) 2.27 ± 0.91 (n=115) 2.29 ± 1.09 (n=35) T5-I6 (mm) 3.04 ± 1.14 (n=320) 3.21 ± 1.18 (n=134) T6-I7 (mm) 3.30 ± 1.07 (n=131) 3.47 ± 1.25 (n=62) T: natural tooth, I: implant, *: p<0.05. Hong-Seok Lee et al. : Research of Tendency for Implant Placement According to Experience of Operator: A Retrospective Study. Implantology 임플란트후방에식립한임플란트의비교임플란트후방에식립한임플란트전체를대상으로비교했을때에는술자간유의한차이가있었다. 또한제1대구치부위에식립했을때에도술자간유의한차이가있었다. 그외다른부위에서는유의한차이가발견되지않았다 (Table 2). Table 2. Distance between implant and mesial adjacent implant Specialists Residents P All (mm) 3.35 ± 1.34 (n=382) 3.62 ± 1.41 (n=127) 0.047* I4-I5 (mm) 2.56 ± 1.30 (n=66) 2.58 ± 0.91 (n=21) I5-I6 (mm) 3.30 ± 1.14 (n=121) 3.76 ± 1.10 (n=38) 0.028* I6-I7 (mm) 3.64 ± 1.37 (n=195) 3.87 ± 1.55 (n=68) I: implant, *: p<0.05. Hong-Seok Lee et al. : Research of Tendency for Implant Placement According to Experience of Operator: A Retrospective Study. Implantology 2017 IV. 총괄및고찰 자연치후방에식립한경우 mm 이상의간격이권장되는데교수진의경우 2.94 ± 1.14 mm, 전공의의경우 3.14 ± 1.24 mm로유의한차이를보였다. 식립부위별로보았을때는유의한차이를보이지는않았지만전체적으로보았을때, 교수진이더적절한간격에가깝게식립한것으로볼수있다. 임플란트후방에식립한경우 3 mm 이상의간격이권장되는데교수진의경우 3.35 ± 1.34 mm, 전공의의경우 3.62 ± 1.41 mm로유의한차이를보였다. 또한제1대구치부위에식립한경우에도각각 3.30 ± 1.14 mm, 3.76 ± 1.10 mm로유의한차이를보였으며, 다른부위에서는유의한차이를보이지않았다. 전체적으로보았을때는자연치와마찬가지로교수진이더적절한간격으로식립했다볼수있고, 전공의의경우다소먼거리에식립한것으로보인다. 221

5 Original Articles 임플란트를식립할때, 인접자연치나임플란트와의간격에대한연구는 interproximal papilla의소실이발생하지않도록일정간격이상이될것을강조한다 반면간격이너무멀때생기는단점에대해강조한연구는상대적으로수가적다. 따라서수련의가임플란트를식립하게될경우, 인접자연치나임플란트와의간격이너무짧아질것을두려워하여교수진에비해유의하게먼거리에식립하게되었을것으로생각된다. 다양한수련기관에서전공의나임플란트교육프로그램이수자가식립한임플란트에대한연구를시행한바있다. Melo 등은전공의가식립한 175개의임플란트에대해수련기간에따른생존률을비교하였는데유의차가없다고보고하였다 16. 또한 Starr 등은전공의가식립한 790개의임플란트를대상으로조사하였을때 96.6% 의생존률을보여기존의숙련된임상가들이발표한논문에비견될만큼의수치를보였다고하였다 17. Vidal 등은전공의가즉시식립한 62개의임플란트를 1년간관찰했을때 100% 의성공률을보였다고하였으며 18, 전공의가식립한하악 overdenture를위한임플란트 100개를대상으로 2년간관찰하여 97.7% 의성공률보였다고보고하였다 19. Bell 등은 University of Texas Health Science Center의치과대학학생을대상으로임플란트교육프로그램을 4년간운영하였는데임플란트식립, 보철물제작, 유지관리까지학생들이직접시행한 120개의임플란트를대상으로관찰한결과실패한경우가한건도없었다고보고하였다 20. Hussaini 등은임플란트교육프로그램이수자가식립한 217개의임플란트와숙련자가식립한 299개의임플란트를비교한결과, 생존률이각각 93.5% 와 96% 로유의한차이가없었다고보고하였다 21. 기존의연구들을봤을때초심자와전문가가식립한임플란트의성공률이나생존률을비교한결과는유의한차이가없는경우가대부분이었으나, 본연구에서임플란트식립간격을비교하였을때에는유의한차이가있다는결과가나왔다. 임플란트직경이나식립개수를고려하지않았고상, 하악이나좌우구분없이조사한점이이연구의한계점이라할수있다. 이러한점까지고려된전향적연구가진행된다면더의미있는결과를얻을수있을것으로생각된다. V. 결론 본연구의결과를바탕으로다음의결론을얻을수있다. 1. 자연치후방에임플란트를식립하였을때전공의의경우 3.14 ± 1.24 mm, 교수진의경우 2.94 ± 1.14 mm로전공의가교수진보다유의적으로더먼위치에식립하였다. 식립부위별유의차는없었다. 2. 임플란트후방에임플란트를식립하였을때전공의의경우 3.62 ± 1.41 mm, 교수진의경우 3.35 ± 1.34 mm로전공의가교수진보다유의적으로더먼위치에식립하였다. 제1대구치부위에식립한 222

6 IMPLANTOLOGY 경우에도전공의가 3.76 ± mm, 교수진이 3.30 ± mm 로전공의가교수진보다유의적 으로더먼위치에식립하였다. 그외부위에서의유의차는없었다. References 1. Albrektsson T, Dahl E, Enbom L, et al. Osseointegrated oral implants. A Swedish multicenter study of 8139 consecutively inserted Nobelpharma implants. J Periodontol. 1988; 59: Group MR. US markets for dental implants 2001: executive summary. Implant dentistry. 2001; 10: Scacchi M. The development of the ITI DENTAL IMPLANT SYSTEM. Part 1: A review of the literature. Clin Oral Implants Res. 2000; 11(Suppl 1): Levine RA, Clem D, Beagle J, et al. Multicenter retrospective analysis of the solid-screw ITI implant for posterior single-tooth replacements. Int J Oral Maxillofac Implants. 2002; 17: Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-submerged ITI implants. Part 1: 8-year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res. 1997; 8: Albrektsson T. Is surgical skill more important for clinical success than changes in implant hardware? Clin Implant Dent Relat Res. 2001; 3: Casap N, Nadel S, Tarazi E, et al. Evaluation of a navigation system for dental implantation as a tool to train novice dental practitioners. J Oral Maxillofac Surg. 2011; 69: Park JC, Hwang JW, Lee JS, et al. Development of the implant surgical technique and assessment rating system. J Periodontal Implant Sci. 2012; 42: Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol. 2000; 71: Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2004; 19(Suppl): Esposito M, Ekestubbe A, Grondahl K. Radiological evaluation of marginal bone loss at tooth surfaces facing single Branemark implants. Clin Oral Implants Res. 1993; 4: Gastaldo JF, Cury PR, Sendyk WR. Effect of the vertical and horizontal distances between adjacent implants and between a tooth and an implant on the incidence of interproximal papilla. J Periodontol. 2004; 75: Jivraj S, Chee W. Treatment planning of implants in posterior quadrants. Br Dent J. 2006; 201: VK S. Single tooth implants: Pretreatment considerations and pretreatment evaluation. J Interdiscip Dentistry. 2012; 2: Yokoyama S, Wakabayashi N, Shiota M, et al. The influence of implant location and length on stress distribution for three-unit implant-supported posterior cantilever fixed partial dentures. J Prosthet Dent. 2004; 91: Melo MD, Shafie H, Obeid G. Implant survival rates for oral and maxillofacial surgery residents: a retrospective clinical review with analysis of resident level of training on implant survival. J Oral Maxillofac Surg. 2006; 64:

7 Original Articles 17. Starr CB, Maksoud MA. Implant treatment in an urban general dentistry residency program: a 7-year retrospective study. J Oral Implantol. 2006; 32: Vidal R, Greenwell H, Hill M, et al. Success rate of immediate implants placed and restored by novice operators. Implant Dent. 2010; 19: Malmstrom H, Xiao J, Romanos G, et al. Two-Year Success Rate of Implant-Retained Mandibular Overdentures by Novice General Dentistry Residents. J Oral Implantol. 2015; 41: Fred A. Bell EJC, Jr, Archie A. Jones, Kenneth L. Stewart. Four-Year Experience With the Placement, Restoration, and Maintenance of Dental Implants by Dental Students. International Journal of Oral & Maxillofacial Implants. 1994; 9: Hussaini S, Weiner S, Ahmad M. Implant survival rates in a condensed surgical and prosthetic training program for general practitioners in dental implants. Implant Dent. 2010; 19:

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00)13-3목차1~3 An evaluation of marginal bone level change in single short implant : an 1-year follow up Tae-Hoon Lee, Joo-Hyun Kwon, Sunjai Kim, Chong-Hyun Han Department of Prosthodontics, Kangnam Severance hospital,