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1 Vol. 31 No. 3, December 2012 근단부의국소적골절단술을동반한변형된치조제분할술 : 증례보고 송찬종, 김홍순, 설동주, 이백수, 최병준, 오주영 경희대학교치의학전문대학원구강악안면외과학교실 A modified alveolar ridge splitting technique with apical osteotomy: a case report Chan-Jong Song, Hong-Soon Kim, Dong-Ju Seol, Baek-Soo Lee, Byung-Joon Choi, Joo-Young Ohe Department of Oral and Maxillofacial Surgery, School of Dentistry, KyungHee University, Seoul, Korea Several techniques such as onlay block bone grafting, guided bone regeneration, ridge split technique/ridge expansion technique, distraction osteogenesis and etc. were performed to form sufficient alveolar buccolingual width for implant insertion in narrow alveolar ridge. Ridge split technique was recognized as very useful method for expansion the narrow edentulous ridge and implant placement simultaneously. Ordinary ridge split technique consists of splitting the vestibular (horizontal) and buccal (vertical), displacing the vestibular cortical bone by greenstick fracture, separating from the bone marrow and creating a middle gap for implant insertion. We mostly can expand the alveolar bone in ridge area through this technique. However, in some cases, the alveolar bone is thinner in apical area than ridge area, especially in maxillary incisior and premolar area. In these cases, performing the ordinary ridge split technique can cause the perforation of apical alveolar bone when drilling or placement of implant. We performed the different ridge expansion technique with apical osteotomy locally in narrow maxillary premolar edentulous area and implant insertion simultaneously for prevention of the perforation. So, we report this case with a review of literature. (JOURNAL OF DENTAL IMPLANT RESEARCH 2012;31(3):67-72) Key Words: Ridge split technique, Narrow alveolar ridge, Apical osteotomy 서론 발치후장기간시간이경과한치조골부위는일반적으로잔존치조골의수직적높이또는협설측폭경이부족한경우가많아임플란트식립시여러가지한계점을드러낸다. 특히 5 mm 이하의좁은폭경의치조골을갖는경우에는임플란트주위로최소 1 mm 의 bony housing을확보하기위해서는추가적인골이식술이나골증대술이필요하게된다 1). 위축된치조골의협설측폭경증대를위해서골유도재생술 (guided bone regeneration [GBR]), 치조제분할술 (ridge splitting technique), inlay 및 onlay 골이식술, 수평적골신장술 (distraction osteogenesis) 등의다양한술식들이사용되고있는데, 이들방법은각각의장단점들을가지고있다. GBR 시행시많은양의분쇄골을사용할경우, 안정성이나성공률이떨어지게되고, 이를개선하기위해추가적인 titanium mesh나흡수혹은비흡수성차단막이요구되므로비용이증가하게되며, 골이식후임플란트 1차수술까지골성숙을위해많은시간을기다려야한다 2). Block 골이식을시행할경우부가적인공여부수술이추가되기때문에더많은시간과술식이필요하여환자가느끼는불안과통증또한더할것이다. 이에비하여, 치조제분할술은치조골의수직적골절단과협측피질골의부전골절 (green-stick fracture) 을통해치조골을협설로증대시켜보다용이하게임플란트식립공간을확보해줄수있다 3). 또한협설면의피질골이이식골에대해 housing effect를줄수있고, 혈행공급이충분하므로임플란트의골유착또한증진시킨다 4). 통상적인치조제분할술은임플란트식립부위근원심협측에각 1개씩의수직골절단과치조제부위의수평골절단을통한치조골확장술식으로서, 주로치조제부분의폭경을확장시키는술식이다. Received October 8, Revised October 30, Accepted November 10, cc This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( commons.org/ licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 교신저자 : 이백수, , 서울시동대문구회기동 1 번지, 경희대학교치의학전문대학원구강악안면외과학교실 Correspondence to: Baek-Soo Lee, Department of Oral and Maxillofacial Surgery, School of Dentistry, KyungHee University, 1, Hoegi-dong, Dongdaemun-gu, Seoul , Korea. Tel: , Fax: , leebs@khu.ac.kr JOURNAL OF DENTAL IMPLANT RESEARCH

68 송찬종등 : 근단부의국소적골절단술을동반한변형된치조제분할술 : 증례보고 하지만, 상악전치부및소구치부위에서는치조정 (alveolar crest) 에비하여근단부의치조골이더얇은경우가흔히있는데, 이런경우에서는통상적인치조제분할술을시행할경우임플란트식립시근단부의천공이발생할가능성이높다.

1) 결손 부위의근원심폭경을고려하여각각 1개의임플란트를식립하여수복하기로계획하였다. 술전 Cone-Beam 컴퓨터단층촬영영상에서식립부위의치조골량이나상태를확인해본결과상악좌측부위는다소양호한상태를보였으나우측부위는협설측으로골량이부족한상태를보였다. 특히, 치조정보다는근단부에서협소한협설측폭경을나타냈다.(Fig. 2) 1.

3) 술전 Cone-Beam 컴퓨터단층촬영영상에서예상했던대로치조정보다는근단부에서협소한협설측폭경을확인할수있었다. Fig. 1. Preoperative panoramic image.

2 68 송찬종등 : 근단부의국소적골절단술을동반한변형된치조제분할술 : 증례보고 하지만, 상악전치부및소구치부위에서는치조정 (alveolar crest) 에비하여근단부의치조골이더얇은경우가흔히있는데, 이런경우에서는통상적인치조제분할술을시행할경우임플란트식립시근단부의천공이발생할가능성이높다. 이에저자들은상기의통상적인치조제분할술과는다르게국소적인근단부골절단술 (apical osteotomy) 을통하여임플란트근단부위의치조골폭경증가와임플란트동시식립을시행한증례를문헌고찰과함께보고하고자한다. 증례보고 20세남성환자로전신병력은없으며, 상악좌측측절치와견치, 상악우측견치의선천적결손을주소로내원하였다.(Fig. 1) 결손 부위의근원심폭경을고려하여각각 1개의임플란트를식립하여수복하기로계획하였다. 술전 Cone-Beam 컴퓨터단층촬영영상에서식립부위의치조골량이나상태를확인해본결과상악좌측부위는다소양호한상태를보였으나우측부위는협설측으로골량이부족한상태를보였다. 특히, 치조정보다는근단부에서협소한협설측폭경을나타냈다.(Fig. 2) 1. 수술방법수술은 2% lidocaine (1 : 100,000 epinephrine 포함 ) 국소마취하에이루어졌다. 1) 1단계 : 판막거상판막은전층으로형성하였으며, 상악우측중절치원심의치간유두를보존하는수직절개와치조정절개, 상악우측제1소구치원심의수직절개를시행하였다.(Fig. 3) 술전 Cone-Beam 컴퓨터단층촬영영상에서예상했던대로치조정보다는근단부에서협소한협설측폭경을확인할수있었다. Fig. 1. Preoperative panoramic image. 2) 2단계 : 수직적골절단치조정상에가이드드릴을이용하여적절한임플란트식립위치를표시하고, piezoelective device를이용하여식립위치의근원심부위순측골상에수직골절단을시행하였다.(fig. 4) (A) (B) Fig. 2. (A) Preoperative cone-beam computed tomography image on Rt. Mx. canine (sagittal view). (B) Preoperative cone-beam computed tomography image on Lt. Mx. canine (sagittal view).

Song CJ, et al: A modified alveolar ridge splitting

3. Flap elevation. Fig. 6. Gap expanding. Fig. 4.

3) 3 단계 : 수평적골절단 식립될임플란트의길이를고려하여수직골절단선을연결하는수

5) 4) 4 단계 : 간극확장 단계적으로 drilling 후골절단기구들을이용하여치근단쪽협측

6) 5) 5 단계 : 임플란트식립 계획했던크기의임플란트식립후간극이더확장되면서치근단

3 Song CJ, et al: A modified alveolar ridge splitting technique with apical osteotomy: a case report 69 Fig. 3. Flap elevation. Fig. 6. Gap expanding. Fig. 4. Vertical osteotomy. Fig. 7. Implant placement. 3) 3 단계 : 수평적골절단 식립될임플란트의길이를고려하여수직골절단선을연결하는수 평골절단은근단부쪽으로약 2 mm 길게시행하였다.(Fig. 5) 4) 4 단계 : 간극확장 단계적으로 drilling 후골절단기구들을이용하여치근단쪽협측 피질골을벌려주었다.(Fig. 6) 5) 5 단계 : 임플란트식립 계획했던크기의임플란트식립후간극이더확장되면서치근단 쪽바깥피질골이좀더벌어지는것을관찰할수있다.(Fig. 7) Fig. 5. Horizontal osteotomy. 6) 6 단계 : 골이식 입자형탈단백우골 (Bio-Oss R, Geistlich) 과동종골 (Orthoblast II R, Isotis) 를혼합하여간극주위에이식하고, 흡수성콜라겐

4 70 송찬종등 : 근단부의국소적골절단술을동반한변형된치조제분할술 : 증례보고 Fig. 8. Bone grafting. Fig. 9. Suturing. (A) (B) (C) Fig. 10. (A) Postoperative panoramic image. (B) Postoperative cone-beam computed tomography image on Rt. Mx. canine (sagittal view). (C) Postoperative cone-beam computed tomography image on Rt. Mx. canine (horizontal view).

5 Song CJ, et al: A modified alveolar ridge splitting technique with apical osteotomy: a case report 71 차폐막 (Bio-Gide R, Geistlich) 으로피개하였다.(Fig. 8) 7) 7단계 : 봉합감장절개없이 4-0 vicryl 및 black silk로봉합시행하였다.(fig. 9) 2. 결과치조골이식후흔히발생될수있는합병증인근단부의열개에의한나사선의노출을방지할수있었으며, 술후 Cone-Beam 컴퓨터단층촬영영상에서확인할수있듯이근단부골절단술을시행한부위에불완전골절이되도록골절단을시행함으로써협소한근단부협설측폭경이증가한것을관찰할수있었다.(Fig. 10A, B) 또한임플란트매식체주위로 mm 정도의적절한협측피질골이확보된것을확인할수있었다.(Fig. 10C) 또한, 수술후 6개월관찰시안정적인협설측폭경을나타내었으며, 심미적인보철을완성할수있었다. 고찰 치조제분할술은 1992년 Simion 등 5) 에의해서제안되었으며, 골절도와 chisel 등을이용하여불완전골절을일으켜 implant bed 및골이식부를형성하는술식이다. Simion 등 5) 은이술식이 self-spacing making structure를형성하여골유도세포의이동을허락하여골재생을촉진한다고하였으며, Shimoyama 등 6) 은치조제분할술후즉시임플란트식립을추천하였으며, Oikarinen 등 7) 은치조제분할술후임플란트를식립한경우그성공률이 86 97% 로이른다고보고하여, 치조제분할술이임플란트성공에있어서신뢰할만한술식이라고하였다. 치조제분할술을성공시키기위한최소골량에대해서도많은연구가있어왔다. Scipioni 등 8) 은치조골을분리한이후에잔존협측골의두께가최소한 1.5 mm 이상되어야한다고하였으며, Qahash 등 9) 은 2 mm 이상의협측골이필요하다고하였다. 여러연구의결과를고려해볼때, 1.5 mm 이상의협설측골이확보된다면임플란트식립시골흡수없이양호한결과를얻을수있을것으로보인다. 하지만, 치조제분할술시행시잘못된수직적골절단선으로인한 malfracture, 협측및설측치조제의골흡수, 초기고정의실패등과같은단점이존재하게된다. 따라서, 치조정부위의수평적골폭경은충분하나근단부의골흡수가큰경우에는본증례와같은변형된치조제분할술을시행하게될경우, 치조정부위는수직적골절단선이없기때문에 malfracture를방지할수있게된다. 또한, 협설측폭경이충분한치조정부위에서양호한임플란트초기고정을얻을수있게되며, 임플란트식립후근단부의간극에골이식을시행하여골유착을유도할수있다. 여러연구에서골간극이 3 mm 이상이될경우골이식을권장하고있으며, Jensen 등 10) 이나 Danza 등 11) 은간극이좁을경우골이식을하지않거나 collagen sponge 또는 platelet rich plasma (PRP) 만을적용하는것을권장한다. 골이식에는모든종류의이식재가가능하며, 자가골이가장이상적이나이종골혹은동종골도신뢰할만한결과를나타내었다. 본증례에서는간극이넓지는않았으나위치한임플란트의나사선이노출되었기때문에, 이종골과동종골을혼합하여골이식을시행하였고차폐막을사용하여식립된임플란트주변의치조골두께를확보하였다. 이처럼변형된치조제분할술은근단부에서협설로심하게위축된치조골에서짧은기간내에양호한골형성을보이는술식으로사료되며, 상대적으로적은양의이식골로골이식과동시에임플란트식립이가능하고시술시피질골을최대한으로보존하여주의깊게시행한다면양호한골유착을확인할수있을것으로생각된다. REFERENCES 1. Blus C, Szmukler-Moncler S. Split-crest and immediate implant placement with ultra-sonic bone surgery: a 3-year life-table analysis with 230 treated site. Clin Oral Implants Res 2006;17: Jensen J, Sindet-Pedersen S. Autogenous mandibular bone grafts and osseointegrated implants for reconstruction of the severely atrophied maxilla: a preliminary report. J Oral Maxillofac Surg 1991;49: Enislidis G, Wittwer G, Ewers R. Preliminary report on a staged ridge splitting technique for implant placement in the mandible: a technical note. Int J Oral Maxillofac Implants 2006;21: Guirado JL, Yuguero MR, Carrión del Valle MJ, Zamora GP. A maxillary ridge-splitting technique followed by immediate placement of implants: a case report. Implant Dent 2005; 14: Simion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. Int J Periodontics Restorative Dent 1992;12: Shimoyama T, Kaneko T, Shimizu S, Kasai D, Tojo T, Horie N. Ridge widening and immediate implant placement: a case report. Implant Dent 2001;10: Oikarinen KS, Sàndor GK, Kainulainen VT, Salonen-Kemppi M. Augmentation of the narrow traumatized anterior alveolar ridge to facilitate dental implant placement. Dent Traumatol 2003;19: Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent 1994;14: Qahash M, Susin C, Polimeni G, Hall J, Wikesjö UM. Bone healing dynamics at buccal peri-implant sites. Clin Oral Implants

6 72 송찬종등 : 근단부의국소적골절단술을동반한변형된치조제분할술 : 증례보고 Res 2008;19: Jensen OT, Cullum DR, Baer D. Marginal bone stability using 3 different flap approaches for alveolar split expansion for dental implants: a 1-year clinical study. J Oral Maxillofac Surg 2009;67: Danza M, Guidi R, Carinci F. Comparison between implants inserted into piezo split and unsplit alveolar crests. J Oral Maxillofac Surg 2009;67:

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untitled Vol. 33 No. 3, December 2014 Bio-col 테크닉을이용한상악전치부임플란트의식립증례 서정민, 박현경, 박우현, 이영빈, 윤현경 국립경찰병원통합치과전문임상의과 A case of maxillary anterior implant placement using a Bio-col technique Jeong-Min Seo, Hyun-Kyung Park,