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1 Vol. 36 No. 1, September 2017 콜라겐차폐막을이용한상악동점막거대천공재건술 : 후향적임상연구 강동우, 김영균 분당서울대학교병원치과구강악안면외과 Repair of large maxillary sinus membrane perforation using a collagen membrane: retrospective clinical study Dong-Woo Kang, Young-Kyun Kim Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, Korea Purpose: To evaluate the clinical outcomes of reconstruction using a collagen membrane, when a large perforation occurs during sinus lifting proceudure. Materials and Methods: This study included 18 patients who occurred a large perforation in the course of a sinus lifting at Seoul National University Bundang Hospital between September 2011 and March The cases have a variety of 5 10 mm perforating size. We sealed the perforation using collagen membrane and bone graft was performed simultaneously. Thirteen patients had completed all treatments in the Seoul National University Bundang Hospital and the remaining 5 patients received the implant surgery from other dental clinics. We checked the information of implants, primary and secondary stability, types of complications, marginal bone loss, and resorptions of bone graft materials. Results: The average resorption was 2.46±1.17 mm 1 year after sinus bone graft, 3.99±1.96 mm 2 years after bone graft. The total average followup period of the patients was months and the final average absorption was 4.10±2.03 mm. Intraoperative and postoperative complications included bleeding, hematoma, sinusitis, severe pain, peri-implantitis, and prosthesis dislodgement. Implant survival rate was 100% until the final follow-up period. The final alveolar bone resorption was 0.88±0.87 mm around the implant. Conclusions: The reconstruction using collagen membrane of large maxillary sinus perforation is very effective and successful treatment. When the maxillary sinus elevation and bone grafting are performed properly using a collagen membrane, there are many advantages about stability of bone graft materials for a long time and good retention and fuction of maintaining implants. (JOURNAL OF DENTAL IMPLANT RESEARCH 2017;36(1):1-5) Key Words: Implant, Perforation of sinus membrane, Collagen membrane 서론 상악동거상술 (Sinus lift) 은상악동함기화 (pneumatization), 치조골퇴축혹은외상등으로인해심각한치조골소실이존재하는상악골후방부위에서수직적골체적을증가시키기위해자주시행하는술식이다. 상악동거상술시행중가장많이발생하는합병증은 상악동점막의천공이며, 천공빈도는문헌에따라 14 56% 까지매우다양하게보고되고있다 1-3). 상악동점막의천공은주로절삭기구나점막거상기구를부적절하게사용할때혹은점막자체가얇다든지상악동격벽 (sinus septa) 이존재하는경우에발생할수있다. 상악동점막천공이발생한상태에서골이식술을시행하면천공부를통해입자형골이식재가소실되고상악동의자연공 (natural os- Received February 1, 2016, Revised March 2, 2016, Accepted March 20, cc This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( commons.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. 교신저자 : 김영균, 13620, 경기도성남시분당구구미로 173번길, 분당서울대학교병원치과구강악안면외과 Correspondence to: Young-Kyun Kim, Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, 82 Gumi-ro, 173beon-gil, Bundang-gu, Seongnam 13620, Korea. Tel: , Fax: , kyk0505@snubh.org JOURNAL OF DENTAL IMPLANT RESEARCH

2 강동우, 김영균 : 콜라겐차폐막을이용한상악동점막거대천공재건술 : 후향적임상연구 tium) 을폐쇄하면서상악동염이나술후감염혹은낭종같은합병증을유발할가능성이커진다. 그러나천공자체가골이식이나임플란트생존율에악영향을미친다는것에대해서는아직논란이많다 4-6). 상악동점막의천공은크기에따라처치가달라질수있다.

2 2 강동우, 김영균 : 콜라겐차폐막을이용한상악동점막거대천공재건술 : 후향적임상연구 tium) 을폐쇄하면서상악동염이나술후감염혹은낭종같은합병증을유발할가능성이커진다. 그러나천공자체가골이식이나임플란트생존율에악영향을미친다는것에대해서는아직논란이많다 4-6). 상악동점막의천공은크기에따라처치가달라질수있다. 보통크기가 5 mm 이상인경우에는적절한술식을통해천공부를폐쇄하고이식재료들의유동성을최소화하는술식을구사하는것이매우중요하며, 10 mm 이상의거대천공이발생한경우더세심하게조치를취해야만한다. 상악동점막천공치료에대한다양한방법과재료들이소개된바있으며대표적으로 fibrin glue와같은조직접착제, 콜라겐차폐막 (collagen membrane), 국소지혈제, 협지방대이식 (buccal fat pad graft), 자가블록골이식등을들수있다 7). 본연구의목적은상악동점막에거대천공이발생할경우콜라겐차폐막을사용하여폐쇄하고골이식을진행하여임플란트를식립한증례들을후향적으로분석하여그예후를평가하는것이다. 흡수량을평가했다.(Fig. 2, 3) 변연골흡수량평가방법은임플란트 fixture의 platform을기준으로근심과원심의치조정까지의높이변화량을측정하여평균값을구하였다.(fig. 4, 5) ISQ 측정은임플란트식립시초기안정도를측정했고, 2차수술혹은인상채득하면서이차안정도를측정했다. 최종관찰시점에서의임플란트성공율도조사했다. 통계처리는 SPSS ver.17.0 프로그램 (SPSS Inc., Chicago, IL, USA) 을이용했다. ISQ의초기안정도와이차안정도간의차이는 Independent-samples T-test를사용했다. 상악동골이식재의흡수량은 Shapiro-Wilk 정규성검정을거쳐 One-way ANOVA를사용하여검정했다. 대상및방법 2011년 9월부터 2014년 3월까지분당서울대학교병원구강악안면외과에서상악동점막거상술시행도중에거대천공이발생하여콜라겐차폐막으로폐쇄했던 18명의환자들을대상으로조사하였다 (11명의남성, 7명의여성, 평균연령 55.1±12.3세 ). 이중 5명의환자는다른치과의원에서임플란트식립수술및보철치료를받았다. 따라서총 13명의환자들에게식립된 21개의임플란트를평가하였다. 상악동점막천공크기는 5 10 mm로다양했으며, 콜라겐차폐막과조직접착제를이용하여천공부위를폐쇄하면서골이식을동시에시행하였다.(Fig. 1) 골이식재는단독혹은 2가지재료가혼합되어사용되었다. 사용한임플란트, 조직접착제, 콜라겐차폐막의종류, 골이식재의종류는 Table 1과같다. 임플란트의정보와식립방법, 초기및이차안정도 (ISQ), 합병증의종류, 변연골소실, 상악동골이식재의흡수량등을조사하였다. 상악동골이식재의흡수량은이식재의최상방에서임플란트 fixture의첫번째나사산까지의거리를파노라마방사선사진또는 CBCT를이용하여측정하였고수술직후방사선사진을기준으로 1년, 2년, 및최종관찰시점의 Table 1. Biomaterials which were used in the study Biomaterials Types Numbers Implant Superline 7 Osstem 6 CMI 4 Zimmer 4 Additives Tissel 5 surgicel 2 PRP 1 Collagen membrane Bio-Arm 13 HA collagen membrane 3 Cytoplast RTM 2 Bioguide 2 Ossix 1 Bone graft materials Autogenous 10 NOVOSIS-Dent 2 Exfuse 5 Bio-Oss 6 InduCera 8 Osteon 1 Por-Oss 3 Allomatrix 2 Fig. 1. Large sinus membrane was sealed with resorbable collagen membrane. The perforated site and sinus walls were covered with collagen membrane completely.

Kang DW, Kim YK: Repair of large maxillary sinus membrane perforation using a collagen membrane: retrospective clinical study 3 Fig. 2.

Fig. 5. 3 years after postoperative periapical radiograph of 50- year old female patient. 결 과 Table 2. The amounts of sinus bone graft resorption 최종선정된 13명의연구대상환자들의평균관찰기간은 38.13±17.

평가시점에따라통계적으로유의한차이를보였다 (P=0.001) (Table 2). 최종재진시점에서임플란트주변의치조정골흡수량은평균 0.88±0.87 mm였다. 술중이나술후발생한합병증은상악동염 4 증례, 혈종 2 증례, 출혈 1 증례, 임플란트주위염 2 증례, 술후심한통증 1 증례, 보철물탈락은 2 증례에서발생하였다.

임플란트주위염은소파술, chlorhexidine 세정및국소항생제투여를통해잘관리되었으며보철물탈락은임시접착후일정기간경과를관찰하다가영구접착하였다 (Table 3). 임플란트식립시측 Period Resorption (mm) P-value 1 year 2.46±1.17 0.001 2 year 3.99±1.96 Final F/U 4.

3 Kang DW, Kim YK: Repair of large maxillary sinus membrane perforation using a collagen membrane: retrospective clinical study 3 Fig. 2. Postoperative panoramic radiograph of 50-year old female patient. Fig months after postoperative periapical radiograph of 50- year old female patient. Fig years after postoperative panoramic radiograph of 50-year old female patient. Fig years after postoperative periapical radiograph of 50- year old female patient. 결 과 Table 2. The amounts of sinus bone graft resorption 최종선정된 13명의연구대상환자들의평균관찰기간은 38.13±17.53개월이었다. 21개의임플란트중 1회법으로식립한증례는 13개, 2회법으로식립한증례는 8개였다. 상악동골이식재의평균흡수량은 1년후평가가능한 21개의증례에서는 2.46±1.17 mm, 2년후평가가능한 17개의증례에서는평균흡수량 3.99± 1.96 mm, 최종재진시점에서골이식재의흡수량은평균 4.10±2.03 mm였다. 평가시점에따라통계적으로유의한차이를보였다 (P=0.001) (Table 2). 최종재진시점에서임플란트주변의치조정골흡수량은평균 0.88±0.87 mm였다. 술중이나술후발생한합병증은상악동염 4 증례, 혈종 2 증례, 출혈 1 증례, 임플란트주위염 2 증례, 술후심한통증 1 증례, 보철물탈락은 2 증례에서발생하였다. 술중후상치조동맥에발생한출혈은국소지혈제 (Surgical) 로조절하였다. 상악동염은항생제를 3 4주투여하여해결하였고혈종은흡인과항생제투여및온찜질을시행하였다. 술후극심한통증이오래지속된환자는마약성진통제를처방하여통증을조절하였다. 임플란트주위염은소파술, chlorhexidine 세정및국소항생제투여를통해잘관리되었으며보철물탈락은임시접착후일정기간경과를관찰하다가영구접착하였다 (Table 3). 임플란트식립시측 Period Resorption (mm) P-value 1 year 2.46± year 3.99±1.96 Final F/U 4.10±2.03 Table 3. Types of complications Types Table 4. Implant stability Number Sinusitis 4 Hematoma 2 Bleeding 1 Peri-implantitis 2 Pain 1 Prosthesis falling-off 2 Types ISQ P-value Primary stability 72.33± Secondary stability 73.10±8.19

4 4 강동우, 김영균 : 콜라겐차폐막을이용한상악동점막거대천공재건술 : 후향적임상연구 정된초기안정도는 72.33±8.22 ISQ, 이차수술혹은인상채득일날측정한이차안정도는 73.10±8.19 ISQ였으며통계적으로유의성있는차이를보이지않았다 (P=0.765) (Table 4). 최종경과관찰시임플란트생존율은 100% 였다. 고찰 상악동점막의천공은상악동거상술과정에서가장많이발생하는합병증이다. 천공의크기가경미한경우엔점막을거상하면서중첩되는과정을통해자연적으로폐쇄되기때문에특별한처치가필요하지않지만육안으로천공이관찰되는거대천공시에는적절한술식으로천공부위를폐쇄하여재건하고이식재료들의유동성을최소화하는치료가필요하다. 폐쇄효과를높이기위해서 Surgicel 같은국소지혈제나 fibrin glue 등의조직접착제도유용하게사용될수있다. 상악동점막천공이발생한경우의치료법들은크게 5가지로요약해볼수있다. 1. 수술중단 2. 봉합술 3. 자가블록골이식 4. 유경협지방대 (pedicled buccal fat pad) 를이용한천공부폐쇄 5. 흡수성차폐막을이용한천공부폐쇄등이있다. 수술을중단하는경우에는최소 6 8주의자연치유기간을부여한후재수술을시행하는것을고려해볼수있으나, 임상에서수술을시도하다가포기하는것이현실적으로불가능한경우가많다. 봉합술은일부문헌들에서많이소개되고있으나접근성이어렵고, 점막자체의잘찢어지는성질등으로인해임상에적용하기는매우어렵다. 자가블록골이식은입자형골이식재에비해거대천공이발생한상악동내에서잘안정될수있는장점이있다. 유경협지방대 (pedicled buccal fat pad) 를이용한방법은 Kim 등의연구에서성공적인결과를보여주었다. 유경협지방대를이용한술식은빠른상피화및풍부한혈행공급등의장점을살려성공율을높힐수있다 8-10). Pikos는 5 10 mm 정도의천공발생시콜라겐차폐막의사용을, 10 mm 이상의천공에서는수술을연기할것을추천했다 11). 콜라겐차폐막으로거대천공을피개하는대표적인방법으로 Loma Linda pouch 술식이있다 12). 측방창을통해흡수성콜라겐차폐막을삽입하여상악동벽및천공부를 pouch 모양으로완벽히피개하고골이식을시행하는방법이다. 이방법은상악동점막천공부로콜라겐차폐막이함몰되는것을최소화하면서골이식재를완전히감싸고동일재료로상악동측방창을폐쇄하는장점이있지만, 상악동골벽을차단함으로인해혈행이잘이루어지지않으면서골치유가지연될가능성이있다. 콜라겐차폐막으로거대천공부를폐쇄할경우에차폐막의안정도를높이기위하여측방으로차폐막의일부를꺼낸후핀이나나사로고정하는방법을소개한보고도있다 13,14). Jeong 등의연구에서상악동골이식후에 6개월후골이식재의흡수량을평가한결과자가치아골이식재 (AutoBT) 군은 1.27±1.06 mm (13.57%), DFDBA (demineralized freeze-dried bone allograft) 군은 1.53±0.71 mm (14.30%), DBBM (deproteinized bovine bone mineral) 군은 1.37±1.09 mm (11.92%) 로나타났다 15). Guarnieri 등의연구에서는상악동골이식후에최종골이식재의흡수량이 0.91±0.25 mm로나타났다 16). Berberi 등의연구에서 CBCT를이용하여 3차원적인부피변화량을 3개의시점에서평가하였다 17). 상악동골이식 2주이내 (T0), 골이식 4개월후임플란트를식립하기직전 (T1), 그리고보철적하중 1년후 (T2) 골이식량을측정하였다. 평균부피감소량은 T0 T1 시점에서는 1.76±0.34 cm 3, T1 T2 시점에서는 1.42±0.40 cm 3 이었으며각각감소비율은 10.83%, 9.8% 로나타났다. 본연구에서는상악동골이식재의평균흡수량은 1년후평가가능한 21개의증례에서는평균 2.46± 1.17 mm, 2년후평가가능한 17개의증례에서평균 3.99±1.96 mm, 최종재진시점에서골이식재의흡수된총평균량은 4.10± 2.03 mm을보였는데, Jeong 등의연구나 Guarnieri 등의연구와비교했을때조금더큰값을나타냈다. 즉상악동점막거대천공이발생한경우엔차폐막으로천공부를잘폐쇄하더라도골이식재의흡수량이많아지는것으로생각된다. 동시에식립한임플란트의초기안정도는평균 72.33±8.22 ISQ로서매우안정적이었으며이차수술혹은인상채득일날측정한이차안정도의평균 ISQ 값은 73.10±8.19로초기안정도와통계적으로유의성있는차이를보이지않았고골유착이성공적으로잘이루어진것이확인되었다. 최종재진시점에서측정된임플란트주변의치조정골흡수량은평균 0.88±0.87 mm로서매우안정적으로유지되었다. 술중및술후다양한합병증들이발생하였으나적절히잘처치되었고심각한후유증이발생한경우는전혀없었다. 따라서상악동거상술을시행할때수술하는치과의사가최대한조심하여상악동점막천공같은합병증을예방하는것이가장중요하지만, 여러가지이유로상악동점막천공이발생한경우에필요한외과적인처치, 약물투여, 물리치료등을적절히활용하여상악동염과같은술후합병증이발생하지않도록하는것이매우중요하다 15). 결 론 상악동거상술과정에서점막에거대천공이발생한경우콜라겐차폐막을이용하여천공부를폐쇄하고골이식을시행하는술식은안정적이며심각한합병증을유발하지않는유용한방법이라고생각된다. 상악동골이식재흡수량이약간많은양상을보이지만임플란트의생존율과변연골이안정적으로유지되는것이확인되었다. REFERENCES 1. Misch CE. The maxillary sinus lift and sinus graft surgery. In: Misch CE, ed. Contemporary Implant Dentistry. Chicago, IL: Mosby;1999: Pikos MA. Maxillary sinus membrane repair: Report of a techni-

5 Kang DW, Kim YK: Repair of large maxillary sinus membrane perforation using a collagen membrane: retrospective clinical study 5 que for large perforations. Implant Dent 1999;8: Pikos MA. Complications of maxillary sinus augmentation. In: The Sinus Bone Graft, 2nd Ed, Vol.9. Hanover Park,IL: Quintessence Publishing Co, Inc; 2006: Khoury F. Augmentation of the sinus floor with mandibular bone block and simultaneous implantation: A 6-year clinical investigation. Int J Oral Maxillofac Implants 1999;14: Raghoebar GM, Timmenga NM, Reinstema H, et al. Maxillary bone grafting for the insertion of endosseous implants: Results after months. Clin Oral Implants Res 2001;12: Raghoebar GM, Vissink A, Reinstema 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: Proussaefs P, Lozada J. The Loma Linda pouch; A technique for reparing the perforated sinus membrane. Int J Periodontics Restorative Dent 2003;23: Choi BH, Zhu SJ, Jung JH, Lee SH, Huh JY. The use of autologous fibrin glue for closing sinus membrane perforations during sinus lifts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101: Kim YK. The use of a pedicled buccal fat pad graft for bone coverage in primary palatorrhaphy: a case report. J Oral Maxillofac Surg 2001;59: Kim YK. Closure of large perforation of sinus membrane using pedicled buccal fat pad graft: a case report. Int J Oral Maxillofac Implants 2008;23: Pikos MA. Maxillary sinus membrane repair: Report of a technique for large perforations. Implant Dent 1999;8: Proussaefs P, Lozada J. The Loma Linda Pouch : A technique for reparing the perforated sinus membrane. Int J Periodontics Restorative Dent 2003;23: Michael A. Maxillary Sinus Membrane Repair: Update on Technique for Large and Complete Perforations. Implant Dent 2008;17: Testori T, Wallace SS, Del Fabbro M, et al. Repair of large sinus membrane perforations using stailized collagen barrier membranes: Surgical techniques with histologic and radiographic evidence of success. Int j Periodontics Restorative Dent 2008; 28: Jeong TM, Lee JK. The Efficacy of the Graft Materials after Sinus Elevation: Retrospective Comparative Study Using Panoramic Radiography. Maxillofac Plast Reconstr Surg 2014;36: Guarnieri R, Belleggia F, Ippoliti S, DeVilliers P, Stefanelli LV, Di Carlo S, Pompa G. Clinical, Radiographic, and Histologic Evaluation of Maxillary Sinus Lift Procedure Using a Highly Purified Xenogenic Graft (LaddecR). J Oral Maxillofac Res 2016;7(1):e Jensen OT. The Sinus Bone Graft. Quintessence book. 2nd edi. 2006;

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untitled ISSN 1229-7038 Vol. 36 No. 1, 2017 Vol. 36 No. 1 September 2017 Journal of Dental Implant Research AIMS AND SCOPE Journal of Dental Implant Research is the official peer-reviewed, quarterly publication