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1 상악동거상술부위에식립한임플란트의실패후골유도재생술을통한치조제재건과재식립 : 증례보고 강주현, 차재국, 이중석, 정의원, 최성호 연세대학교치과대학치주과학교실, 치주조직재생연구소 Implant replacement and GBR for the treatment of failed implants on augmented sinus area: A case report Joo Hyun Kang, Jae Kook Cha, Jung-Seok Lee, Ui-Won Jung, Seong-Ho Choi Department of Periodontology, Research Institute for Periodontal Regeneration, College of Dentistry, Yonsei University Corresponding Author: Seong-Ho Choi, DDS, PhD. Department of Periodontology, College of Dentistry, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, , Korea Tel: , Fax: , shchoi726@yuhs.ac ABSTRACT This was a case of peri-implantitis on augmented sinus area which resulted in removal of fixtures and graft materials. After thorough debridement, maxillary alveolar bone was reconstructed using a combination of autogenous bone from mandibular ramus and micromacroporous biphasic calcium phosphate. Re-implantation was followed by consolidation period of 3 months. 6 years after re-implantation, reconstructed site shows favorable healing and bone level height without further progression of bone loss. This study presents a successful outcome of the compromised alveolar bone status after peri-implantitis occurrence on the sinus augmented area. Key words: sinus augmentation, peri-implantitis, reconstruction 35

2 I. Introduction Ⅱ. Case report 임플란트가널리보급됨에따라임플란트주위질환도더불어발생율이증가하고있는추세이다. 임플란트주위염은골유착된임플란트주위의연조직과경조직을침범하여지지골의상실을초래하는염증과정으로정의된다 1). 골유착이과하게상실되거나임플란트의근단측 1/3까지골소실이진행되어심한동요도를보이는임플란트는정상기능의회복이거의불가능하므로제거되어야한다. 임플란트제거후, 재생술식을통해결손된골조직을다시재생시키고새임플란트식립을고려할수있다. 상악동거상술 (sinus augmentation) 은상악구치부무치악부위에골량이부족할때에임플란트식립을가능하게하는술식으로측방접근법과치조정접근법두가지의술식이보편적이다 2). 상악동증대술의합병증은불안정한창상치유, 혈종, 부골, 일시적인상악동염이대부분이며술후지연합병증으로는이식재의상실, 임플란트의상실또는실패등이있다 3,4). 본증례는우측상악동골이식과임플란트식립후 1년 10개월째에임플란트주위염이이식부에발생한예로서결국임플란트를제거하고골유도재생술로결손된골조직을재건후임플란트재식립을시행하였다. 상악동거상술후임플란트를식립한경우이에실패시거상술을동반하지않은경우에비해재건하기어렵고, 이에관한증례보고가드문바, 문헌고찰과함께보고하는바이다. 본증례의 47세남자환자는 2005년전체적인잇몸검사를주소로연세대학교치과대학병원치주과에내원하였고, 임상적및방사선학적검사를통해전반적인만성치주염과 #16, 26, 27 치아의상실로진단하였으며치주치료와함께임플란트식립을계획하였다. 병력상고혈압을제외한내과적및상악동질환의기왕력은없었으며상악우측구치부에서 5 mm 이하의잔존치조골량을보여우측상악동거상술을통한이식후단계적으로임플란트를식립하기로계획하였다 (Fig. 1a,b,c). 국소마취하에골막을포함한전층판막을형성후골창을형성하고, 상악동점막을거상한후, micromacroporous biphasic calcium phosphate (MBCP; Biomatlante, Vigneux de Bretagne, France) 와 irradiated cortical bone (ICB; Rocky Mountain Tissue Bank, Aurora, CO) 를혼합하여골이식을시행하였다. 골막절개를동반하여연조직의긴장없이일차봉합을시행하였다. 수술과정중에는상악동점막천공등의합병증은발생하지않았다 (Fig. 2a). 상악동거상술 4개월후만성치주염으로인한골소실진행과동요도증가로인하여 #17 치아를추가적으로발치하였고그후로부터 2개월후 #16, 17 부위에 Brånemark System (Nobel Biocare, Göteborg, Sweden) 임플란트식립을시행하였다 (Fig. 2b). 18개월후에최종 Fig. 1. Radiographic images a. pre-operative panoramic radiograph, b. micro computed tomographic images of right upper molars area (cross sectional view), c. micro computed tomographic images after extraction of hopeless teeth. 36

Fig. 2. Radiographic images a. post-operative panoramic radiograph after sinus augmentation, b. postoperative panoramic radiograph after implant placement, c.

3a), 동요도는보이지않았다. 검사시 #16, 17 임플란트부위에전반적으로 9 mm의탐침깊이가측정되었다 (Fig. 3b). 이에임플란트주위염으로진단후외과적처치를계획하였다. 외과적시술전비외과적처치를선행하여스케일링과 2% minocycline hydrochloride (Periocline; Sunstar Inc., Osaka, Japan) 을적용하였다.

3 Fig. 2. Radiographic images a. post-operative panoramic radiograph after sinus augmentation, b. postoperative panoramic radiograph after implant placement, c. post-operative panoramic radiograph after bridge delivery. 보철물수복을완료하였다 (Fig. 2c). 수복완료후 2년간장기미내원으로경과관찰이불가능하다가 한달전부터오른쪽임플란트부위잇몸이부었다 는주소로재내원하였으며, 파노라마사진상 #16, 17 임플란트의근원심측으로약 3.5 mm 정도의골흡수가관찰되었으며 (Fig. 3a), 동요도는보이지않았다. 검사시 #16, 17 임플란트부위에전반적으로 9 mm의탐침깊이가측정되었다 (Fig. 3b). 이에임플란트주위염으로진단후외과적처치를계획하였다. 외과적시술전비외과적처치를선행하여스케일링과 2% minocycline hydrochloride (Periocline; Sunstar Inc., Osaka, Japan) 을적용하였다. 2주후내원시국소마취를시행한후수 평절개만을가하여 #16, 17 임플란트주위의판막을거상한뒤염증조직제거과정에서 sinus augmentation material 이흘러나왔고임플란트의동요도가 (++) 로증가하였다. 협측과구개측모두 apical involvement 상태를보였고환자의동의하에임플란트를제거하였다 (Fig. 3c). Fixture 제거후염증조직과 residual material 을모두제거하고 fixture 자리에 periocline 을도포후판막을이차봉합하였다. 제거 4일이후소독과 8일후발사를시행했으며한달후경과관찰시염증의잔존소견없었으며연조직의결손양상이관찰되었다. #16, 17 임플란트의제거 6개월후임상적으로치은의부종및배농등의염증소견없었으며환자의불편감도 Fig. 3. Radiographic image and clinical photographs after 2 years of implant restoration a. panoramic view, b. buccal view, c. occlusal view after fixture removal. 37

Fig. 4. Clinical photographs a. pre-operative view, b. intra-operative view of screw placement for tenting effect, c. flap closure, d. bone graft donor site (mandibular ramus), e. obtained bone.

, Seoul, Korea) 를사용하고 10 mm 길이의 pin을적용하여 3 mm tenting 을시행하였다 (Fig. 4b-e, Fig. 5a). 이후염증증상없이치유되었으며 3개월후계획한위치에직경 5 mm, 길이 11 mm의임플란트 (Astra Tech AB, Molndal, Sweden) 두개를식립하였다 (Fig. 5b).

4 Fig. 4. Clinical photographs a. pre-operative view, b. intra-operative view of screw placement for tenting effect, c. flap closure, d. bone graft donor site (mandibular ramus), e. obtained bone. 없었다 (Fig. 4a). 이에임플란트재식립을위한골유도재생술을계획하여하악지에서 6 mm trephine bur로자가골을채득후 bone crusher 로분쇄한후 MBCP 와혼합하여적용하였으며, 차폐막은 Collagide (Oscotec Inc., Seoul, Korea) 를사용하고 10 mm 길이의 pin을적용하여 3 mm tenting 을시행하였다 (Fig. 4b-e, Fig. 5a). 이후염증증상없이치유되었으며 3개월후계획한위치에직경 5 mm, 길이 11 mm의임플란트 (Astra Tech AB, Molndal, Sweden) 두개를식립하였다 (Fig. 5b). 골이식직후방사선사진과비교하여 #16, 17 임플란트근 원심부위에약간의수직적골흡수가발생하였으나, 결과적으로골유도재생술을통해결손부의재건이이루어졌음을확인할수있었다. 식립후 6년까지임상적, 방사선학적특이사항없이잘유지되었다 (Fig. 5c). Ⅲ. Discussion 임플란트가치아결손부위의수복에있어예지성있는치료가되어온것은보편적인실정이지만여전히소수의 Fig. 5. Radiographic images a. post-operative panoramic radiograph after GBR, b. post-operative panoramic radiograph after implant placement, c. 6 years post-operative panoramic radiograph. 38

5 환자에서는임플란트실패가발생하고있다. 임플란트의실패율을감소시키기위해실패원인을규명하고위험인자에대한연구하는노력은현재까지도지속되고있다. 임플란트의실패를유발하는원인으로 Duyck 등 5) 은임플란트주위조직의감염과교합력의과부하, 굽힘모멘트, 비기능적습관과같은교합요소를들었으며 Esposito 등 6) 은감염, 불완전한치유그리고과부하가임플란트상실의주된역학적인요소라고하였다. 치조제증대술 (ridge augmentation) 은임플란트식립시이미손상되어있거나소실이많이된치조제의재건을위해널리사용되고있는술식으로, 그종류에는골유도재생술 (guided bone regeneration), 블록골이식술 (block bone graft), 치조제분할술 (ridge splitting) 그리고견인골신장술 (distraction osteogenesis) 등이있다. 성공적인술식을위해 Wang 등은일차봉합, 재혈관화, 공간의유지그리고혈병의안정화등을중요한요인으로제시하였다 7). 특히수직적, 수평적결손과같은광범위한치조제증대술이필요한부위에서는이식부위의공간을유지하는것이가장중요한요인이라고할수있다. 따라서구치부와같이저작력에견뎌야하는부위나수평적혹은수직적골증강에효과적으로사용할수있는술식으로는자가블록골을사용하는방법이널리사용되며이는자가블록골의구조적안정성과골유도능을효과적으로이용할수있기때문이다 8-10). 자가골은골형성, 골전도, 골유도능력을모두보유하는유일한이식재이며, 많은양의이식이필요한부위에서특히이상적이라고할수있다. 이는자가골이신생혈관의증식, 골생성세포의함유, 성장인자방출등의이점을가지고있어골재생능력이가장뛰어난재료이기때문이다 11). 또한면역거부반응을일으키지않고생체적합력이높아빠른치유를보여주는장점도있다. 그러나채취량이제한적이고공여부에이차결손을야기할수있다는점과, 흡수율 (5 25%) 에대한지식을유념하고있어야한다 12). 자가골은대체로이식후 6개월이내에흡수되기시작하여 18개월에걸쳐지속적으로흡수되는것으로알려져있다 13). 그러나자가골은공여부에따라골흡수량의정도가달라질수있으며여러연구에서구강내의골, 그중에서도하악지나하악골체부와같은막내막성골이식재를사용하는것이이식재의흡수가작아치료의예측가능성이높다고보고된바있다 14,15). 이번증례에서자가골의공여부로선택한하악골체부는구강내에서쉽고빠르게막내막성골을얻을수있는부위이다. 이식한골의형태안정성이우수하며외부반흔이없고, 구강외채취에비해환자의불편감이훨씬적다. 술식적이점으로는공여부와수혜부가인접해있어외과적접근이용이하다는것과, 출혈경향이적고술후압박드레싱이용이한부위이기때문에치유과정이양호하다는점이있다 16,17). 또한골절단술을시행할시피질 골수준을넘어서지않기때문에하치조신경의손상을최소화할수있다. 본증례는 40대후반의남성에서상악동증대술과임플란트식립시행후 4년째에잇몸이붓고고름이나온다는증상을보였으며, 이러한증상은최종보철물을장착한지 2년째에나타났다. 임플란트치주염으로진단후판막을거상해본결과골이식재의불완전한골유착을확인할수있었다. 본환자의 #16, 17 부위임플란트의제거후재식립을고려하였을때제시되었던어려움으로는, 골융해되지못한이식재뿐만아니라소량으로존재했던자가골의소실로인하여광범위한재건이요구되었기때문이다. 낮아진상악치조제의고경을높이기위해선택된이식재는하악지에서채취한자가골과 MBCP의혼합을선택하였으며흡수율을줄이기위해흡수성차단막을사용하였고스크루를이용하여 tenting 효과를주었다. 그결과골이식후양호한골융합을보였고눈에띄는골흡수는없었으며임플란트식립후 6년여기간동안잘유지된것을관찰할수있었다. Ⅳ. Conclusion 본증례에서는상악동거상술과임플란트식립후에발생한임플란트주위염으로인해임플란트와융합되지못한골이식재를제거후광범위한치조골결손과치아상실을보이는환자에서골유도재생술로치조제를재건하여임플란트를식립하였다. 임플란트식립후 6년이지난현재뚜렷한임상증상이나임플란트주위의골소실없이안정적으로기능하고있다. 이러한점을미루어볼때상악동거상술후임플란트의식립에실패후자가골과 MBCP의혼합골이식재로골유도재생술을통해예지성있는결과를얻을수있었고, 장기적인관찰이필요할것으로사료된다. References 1. Albrektsson T, Isidor F. Consensus report of session IV. In: Lang NP, Karring T (eds). Proceedings of the 1st European Workshop on Periodontology. London: Quintessence 1994: von Arx T, Buser D. Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: a clinical study with 42 patients. Clin Oral Implants Res 2006;17: Barbosa DZ, de Assis WF, Shirato FB, Moura CC, 39

6 Silva CJ, Dechichi P. Autogenous bone graft with or without perforation of the receptor bed: histologic study in rabbit calvaria. Int J Oral Maxillofac Implants 2009;24: Duyck J, Naert I. Failure of oral implants: aetiology, symptoms and influencing factors. Clin Oral Invest 1998;2: Esposito M, Hirsch J, Lekholm U, Thomsen P. Differential diagnosis and treatment strategies for biologic complications and failing oral implants : A review of the literature. Int J Oral Maxillofac Implants 1999;14: Khoury F. Augmentation of the sinus floor with mandibular bone block and simultaneous implantation: A 6-year clinical investigation. Int J Oral maxillofac Implant 1999;14: Marx RE. Clinical application of bone biology to mandibular reconstruction. Clin Plast Surg 1994; 21: Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85: McAllister BS, Haghighat K. Bone augmentation techniques. J Periodontol 2007;78: Alberius P, Dahlin C, Linde A. Role of osteopromotion in experimental bone grafting to the skull: a study in adult rats using a membrane technique. J Oral Maxillofac Surg 1992;50: Pikos MA. Mandibular block autografts for alveolar ridge augmentation. Atlas Oral Maxillofac Surg Clin North Am 2005;13: Proussaefs P, Lozada J. The use of intraorally harvested autogenous block grafts for vertical alveolar ridge augmentation: a human study. Int J Periodontics Restorative Dent 2005;25: Raghoebar GM, Brouwer TJ, Reintsema H, Van Oort RP. Augmentation of the maxillary sinus floor with autogenous bone for the placement of endosseous implants: A preliminary report. J Oral Maxillofac Surg 1993;51: Raghoebar GM, Vissink A, Reintsema H, Batenburg RH. Bone grafting of the floor of the maxillary sinus for the placement of endosseous implants. Br J Oral Maxillofac Surg 1997;35: Wang HL, Boyapati L. "PASS" principles for predictable bone regeneration. Implant Dent 2006;15: Roche YA, Schwartz HC. The mandibular body bone (MBB) graft: an alternative source of membranous bone. J Craniomaxillofac Surg 1993;21: Zimmermann R, Jakubietz R, Jakubietz M, Strasser E, Schlegel A, Wiltfang J, et al. Different preparation methods to obtain platelet components as a source of growth factors for local application. Transfusion 2001;41:

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ÀÓÇÁ¶õÆ®26-1È£1010 16 상악동내로전위된임프란트의치험례 서울대학교치과병원구강악안면외과이상우, 송진아, 명훈, 황순정, 서병무, 최진영, 이종호, 정필훈, 김명진 Ⅰ. 서론임프란트의임상적인성공률이상당히높게보고되고있으나상악에서는하악에비해그성공률이낮다고알려져있다. 이것은상악의해부학적특성에기인하며특히상악구치부에서상악동의함기화, 낮은골밀도, 불량한골질등의존재시에더욱그러하다. 1) 상악동구치부의골소주는일반적으로골밀도가낮으며피질골은얇은경우가많다.