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1 ISSN Vol. 36 No. 1, 2017 Vol. 36 No. 1 September 2017

2 Journal of Dental Implant Research AIMS AND SCOPE Journal of Dental Implant Research is the official peer-reviewed, quarterly publication of the Korean Academy of Implant Dentistry (KAID). The Journal publishes original research papers, clinical observations, review articles, viewpoints, commentaries, technical note, case reports, and letters to the editor in subjects relating to clinical practice and related basic research on dental implant including other reconstructive procedures for maxillofacial areas. Eventually, the journal aims to contribute to academic advancement of dentistry and improvement of public oral and general health. BACKGROUND Journal of Dental Implant Research was renamed from Journal of The Korean Academy of Implant Dentistry, which was first published in It was initially published once a year but became a biannual journal from The KAID is the official member of the Korean Academy of Dental Science. OPEN ACCESS JDIR is not for sale. Full text PDF files are also available at the official website. Journal of Dental Implant Research is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( 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. 대한치과이식임플란트학회지 2017 년 9 월, 제 36 권제 1 호 Journal of Dental Implant Research September 2017 Vol. 36 No. 1 발행인김영균 위원장팽준영 편집간사이덕원 Publisher Editor-in-Chief Managing Editor Young-Kyun Kim Jun-Young Paeng Deok-Won Lee 인쇄일 2017 년 9 월 26 일 발행일 2017 년 9 월 30 일 발행처대한치과이식임플란트학회서울특별시종로구대학로 101 ( 연건동 ) 서울대학교치과병원 B168 호전화. (02) 팩스. (02) 편집제작 ( 주 ) 메드랑서울특별시마포구월드컵북로 5 가길 8-17 전화. (02) 팩스. (02) Printing date September 26, 2017 Publication date September 30, 2017 PUBLISHED BY The Korean Academy of Implant Dentistry #B168, 101, Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel Fax PRINTED BY MEDrang Inc WorldCupbuk-ro 5ga-gil, Mapo-gu, Seoul 04001, Korea Tel Fax This paper meets the requirements of KS X ISO 9706, ISO and ANSI/NISO Z (Permanence of Paper)

3 편집위원회 Editorial Boards 편집위원장 (Editor-in-Chief) 팽준영 ( 경북치대 ) Jun-Young Paeng (Kyungpook National Unviersity Hospital) 편집간사 (Managing Editor) 이덕원 ( 강동경희대학교치과병원 ) Deok-Won Lee (Kyunghee University Dental Hospital at Gangdong) 편집위원 (Editorial Board) 권긍록 ( 경희치대 ) 권대근 ( 경북치대 ) 권용대 ( 경희치대 ) 김수관 ( 조선치대 ) 김영균 ( 분당서울대병원 ) 김용호 ( 김용호치과 ) 김은석 ( 위례서울치과 ) 김태영 ( 서울킴스치과 ) 김태인 ( 태원치과 ) 김태일 ( 서울치대 ) 김현철 ( 리빙웰치과병원 ) 문홍석 ( 연세치대 ) 박관수 ( 인제대상계백병원 ) 박영범 ( 연세치대 ) 박원서 ( 연세치대 ) 박원희 ( 한양대구리병원 ) 박준범 ( 가톨릭대서울성모병원 ) 박창주 ( 한양대병원 ) 신승일 ( 경희치대 ) 신재명 ( 인제대일산백병원 ) 안강민 ( 서울아산병원 ) 안진수 ( 서울치대 ) 양병은 ( 한림대학교성심병원 ) 여인성 ( 서울치대 ) 우승철 ( 마포리빙웰치과 ) 이양진 ( 분당서울대병원 ) 전상호 ( 고려대병원 ) 정승미 ( 원주세브란스기독병원 ) 지숙 ( 고려대병원 ) 지유진 ( 강동경희대학교치과병원 ) 최병갑 ( 연세힐링치과 ) 황경균 ( 한양대병원 ) 홍종락 ( 삼성서울병원 ) Kung-Rock Kwon (Kyunghee University) Tae-Geon Kwon (Kyungpook National Unviersity) Yong-Dae Kwon (Kyunghee University) Su-Gwan Kim (Chosun University) Young-Kyun Kim (Seoul National University Bundang Hospital) Yong-Ho Kim (Private Practice, Seoul) Eun-Suk Kim (Private Practice, Seoul) Tae-Young Kim (Private Practice, Seoul) Tae-In Kim (Private Practice, Seoul) Tae-Il Kim (Seoul National University) Hyun-Cheol Kim (Private Practice, Seoul) Hong-Seok Moon (Yonsei University) Kwan-Soo Park (Inje University Sanggye Paik Hospital) Young-Bum Park (Yonsei University) Won-Seo Park (Yonsei University) Won-Hee Park (Hanyang University) Jun-Beom Park (Catholic University Seoul ST. Mary's Hospital) Chang-Joo Park (Hanyang University) Seung-Il Shin (Kyunghee University) Jae-Myung Shin (Inje University Ilsan Paik Hospital) Kang-Min Ahn (Seoul Asan Hospital) Jin-Soo Ahn (Seoul National University) Byoung-Eun Yang (Hallym University Hospital) In-Sung Yeo (Seoul National University) Seung-Cheol Woo (Private Practice, Seoul) Yang-Jin Yi (Seoul National University Bundang Hospital) Sang-Ho Jun (Korea University Medical Center) Seung-Mi Jung (Wonju Severance Christian Hospital) Suk Ji (Korea University Medical Center) Yu-Jin Jee (Kyunghee University Dental Hospital at Gangdong) Byeong-Gap Choi (Private Practice, Seoul) Kyung-Gyun Hwang (Hanyang University) Jong-Rak Hong (Samsung Medical Center) ( 가나다순 )

4 대한치과이식임플란트학회지 Journal of Dental Implant Research 개요 대한치과이식임플란트학회지는 1976 년 5 월 21 일창립된대한치과이식임플란트학회의기관지입니다 년 6 월, 1 권 1 호를발행한이후 2004 년까지는연 1 회, 2005 년 24 권부터연 2 회 (6 월 30 일, 12 월 31 일 ), 2012 년부터연 4 회 (3 월 31 일, 6 월 30 일, 9 월 30 일, 12 월 31 일 ) 발행되고있습니다. 발행목적과범위 대한치과이식임플란트학회지는치과임플란트와관련된과학적, 임상적지식을공유함으로써치과임플란트의이론과술식을발전시키기위한목적으로발행되고있습니다. 본학회지는치과임플란트와관련된모든주제 ( 치료계획, 진단, 재료, 술식, 교합, 심미및관련학문 ) 를다루고있으며과학적연구논문과종설및임상증례를게재합니다. 발행윤리연구의대상이사람인경우, 헬싱키선언에입각하여환자또는보호자에게연구의목적과연구참여중일어날수있는정신적, 신체적위해에대하여충분히설명하여야하고이에대한서면동의서를받았음을명시하는것을원칙으로합니다. 연구의실험대상이동물인경우, 실험동물의고통과불편을줄이기위하여행한처치를기술하여야하고, 그실험과정이당해연구기관의윤리위원회규정이나동물보호법의동물실험에관한원칙에저촉되지않았음을명시하는것을원칙으로합니다. 편집위원회는필요시서면동의서또는기관의윤리위원회나 IRB 승인서의제출을요구할수있습니다. 날조, 위조, 변조, 표절, 자기기만, 중복투고, 논문분할, 부당한저자표시, 타인에대한강요와같은연구부정행위가있어서는안됩니다. 대한치과이식임플란트학회지는연구부정행위와관련하여과학기술부훈령제236호 연구윤리확보를위한지침 을준수합니다. 모든연구윤리와관련된심사및처리절차는대한의학학술지편집인협의회에서제정한의학논문출판윤리가이드라인 ( kamje.or.kr/publishing_ethics.html) 을따릅니다. 발행형태대한치과이식임플란트학회지는비매품이며대한치과이식임플란트학회회원및관련된교육연구기관에무료배포되고있습니다. 주소변경및문의사항은학회사무실 (Tel ) 로연락하시기바랍니다. 대한치과이식임플란트학회지는학회홈페이지 ( 를통해서도무료로다운받으실수있습니다.

5 대한치과이식임플란트학회지 제 36 권제 1 호 2017 년 9 월 목 차 1 콜라겐차폐막을이용한상악동점막거대천공재건술 : 후향적임상연구 강동우, 김영균 6 치조정접근법을이용한상악동점막거상술후골이식을시행하지않고임플란트를식립한증례연구 강동우, 김영균 14 가족치아뼈이식술 : 증례관찰연구 김상윤, 김영균, 엄인웅 19 골유도재생술을동반한임플란트 2 차수술시감염 : 증례보고 구필모, 류동목, 지유진, 이덕원

6 Journal of Dental Implant Research Vol. 36 No. 1 September, 2017 CONTENTS 1 Repair of large maxillary sinus membrane perforation using a collagen membrane: retrospective clinical study Dong-Woo Kang, Young-Kyun Kim 6 Sinus membrane elevation without bone graft through crestal approach and simultaneous implant placement: case series study Dong-Woo Kang, Young-Kyun Kim 14 Family tooth bone graft: case observational study Sang-Yun Kim, Young-Kyun Kim, In-Woong Um 19 The infection after implant 2 nd surgery with GBR: case report Pilmo Koo, Dong-Mok Ryu, Yu-Jin Je, Deok-Won Lee

7 Vol. 36 No. 1, September 2017 Journal of Dental Implant Research 2017, 36(1) 1-5 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

8 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. Journal of Dental Implant Research 2017, 36(1) 1-5

9 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 Journal of Dental Implant Research 2017, 36(1) 1-5

10 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- Journal of Dental Implant Research 2017, 36(1) 1-5

11 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; Journal of Dental Implant Research 2017, 36(1) 1-5

12 Vol. 36 No. 1, September 2017 Journal of Dental Implant Research 2017, 36(1) 6-13 치조정접근법을이용한상악동점막거상술후골이식을시행하지않고임플란트를식립한증례연구 강동우, 김영균 분당서울대학교병원치과구강악안면외과 Sinus membrane elevation without bone graft through crestal approach and simultaneous implant placement: case series study Dong-Woo Kang, Young-Kyun Kim Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, Korea Purpose: This study aims to evaluate the aspects of healing around the implants palced with sinus floor elevation without bone grafts through crestal approach. Materials and Methods: This study included 7 patients who received implant surgery and 9 implants (3 Osstem Implant IS III SA, 6 CA) with crestal approaching sinus elevation at the Seoul National University Bundang Hospital, South Korea, between May 2014 and December We took a CBCT (Kodak 9500 Cone Beam 3D system, Carestream Health, France) and measured the Gray value in right after surgery, 3 months after surgery, prosthesis loading. We measured the Gray value using the OnDemand s softwares made by Cybermed (Korea). We selected the implant which is the same size with the implant placed in implant library made by OnDemand, overlapped both implants, and measured the Grey value around implant 2 mm. Results: Among the 9 implants, 1 implant (CA) has failed. The implant s success rate without bone grafts for 16 months follow-up period was 89%. Although changing patterns are inconsistent, the same patient s implants showed a similar Gray value changing pattern. We confirmed a clear bone gain in 1 patient (CA). Mucosal thickness and haziness seen in the immediate postoperative period were mostly reduced after 3 months. Conclusions: Sinus membrane elevation and simultaneous implant placement without bone grafts through crestal approach technique seem to be good results. (JOURNAL OF DENTAL IMPLANT RESEARCH 2017;36(1):6-13) Key Words: Sinus lift, Without bone graft, Crestal approach, Implant 서론 치아가상실되면치조골의흡수가일어나고종종상악구치부에서는상악동이점차확대되면서함기화가일어난다 1,2). 이처럼임플란트식립시상악동저까지잔존골의높이가부족하여임플란트식립이어려운경우가많이존재한다. 임플란트식립을위해서는상악 동점막을거상하면서빈공간에골이식재를충전하여골높이를확보하는상악동골이식술이필요하다 3,4). 하지만최근에는골이식재충전없이상악동점막거상술및임플란트를식립한증례에도우수한결과가많이보고되고있다 5-8). 상악동점막거상술은잔존골높이 5 mm를기준으로측방접근법혹은치조정접근법을통해이루어진다. 치조정접근법은측방접근법에비해외과적침습도가적기 Received February 3, 2016, Revised March 20, 2016, Accepted April 7, 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

13 Kang DW, Kim YK: Sinus membrane elevation without bone graft through crestal approach and simultaneous implant placement: case series study 7 때문에술후합병증발생율이적고술자와환자에게편안감을제공한다. 기존에는 osteotome을사용하였는데충격으로인한불쾌감, 머리울림, 이비인후과적인합병증, 상악동점막천공위험성이높은것으로알려져있다 9-11). 이단점을보완하기위한다양한방법중수압을이용하여상악동점막을거상하는술식은천공의위험성이매우낮으면서쉽게사용할수있는방법이다. 새롭게개발된 special drilling과 hydraulic pressure를이용한 sinus lifting instrument (Crestal approach sinus lift kt: CAS) 를예로들수있다 12-18). CAS kit (Osstem Implant Co., Busan, Korea) 는빠르고쉽게상악동저피질골을관통하면서상악동점막이찢어지지않게하는특별한구조로된드릴을사용하며, 드릴에삭제된골조직들이부착되어나와이를수집하면골이식재로활용할수도있다. 골이식없이상악동점막거상술이시행되어성공적으로거상량을확보하고골형성이이루어진다면부가적인골이식재비용을경감할수있으면서수술시간단축의효과를얻을수있다. 상악동이천공되지않고잘거상된후그공간으로혈병이차게되면시간이경과하면서신생골이잘형성될수있다. 현재측방접근법을통해골이식없이상악동점막거상술을시행하는술식에관한연구는많이보고되고있으나치조정접근법을통해골이식없이상악동점막을거상하고짧은길이임플란트를동시에식립하는연구들은아직부족한실정이다. 이연구의목적은치조정접근법으로새롭게개발된특별한드릴링시스템과수압을이용하여골이식없이상악동점막을거상하고짧은길이의임플란트를식립한증례들을분석하여임상적예후를평가하는것이다. 대상및방법 2014년 5월부터 2014년 12월사이에분당서울대학교병원치과에서치조정접근법을통해상악동점막을거상시킨후골이식을하지않고임플란트를식립한 7명의환자, 9개의임플란트 (Osstem Implant TS III SA 3개, CA 6개 ) 를대상으로조사하였다 (5명의남성, 2명의여성, 평균연령 53.4±8.0세 ). 치조정절개를통해점막골막피판을거상한후 CAS kit를이용하여드릴링과 hydraulic pressure를이용하여 sinus membrane elevation을시행하였다. 드릴링당시골질을주관적으로평가하였다. 최종식립토크를측정하고식립직후오스텔멘토로초기고정도 (ISQ) 를측정하여기록하였다. 임플란트식립은 1회법으로수술하였고, 임플란트의직경은 Fig. 1. Sinus lifting procedure using hydraulic pressure (Osstem CAS kit). Fig. 2. Implant mock-up was overlapped with real implant fixture. Journal of Dental Implant Research 2017, 36(1) 6-13

14 8 강동우, 김영균 : 치조정접근법을이용한상악동점막거상술후골이식을시행하지않고임플란트를식립한증례연구 4.5 mm 5.0 mm, 길이는 8.5 mm였다.(fig. 1) 식립후창상을봉합하고항생제및소염진통제를처방하고, 수술직후파노라마, 치근단방사선, CBCT 촬영을하고, 수술 10일후발사를시행하고치근단방사선촬영을하였다. 수술 3개월후 CBCT를촬영한후임시보철물을장착하였고, 최종보철물은술후약 6개월전후에장착하였다. 보철물장착직후, 그리고 3개월간격으로치근단방사선사진을촬영하였다. 보철물장착 1년및 2년후엔파노라마방사선을추가로촬영하였다. 수술직후, 수술 3개월후및보철물장착후에 CBCT (Kodak 9500 Cone Beam 3D system, Carestream Health, France) 를촬영하고, Gray value를측정하여상악동점막거상량및상악동골형성정도를평가하였다. 술전 CBCT에서측정한잔존골높이를 baseline으로하여측정하였다. 임플란트식립직후초기고정의정도를오스텔멘토를이용하여측정하였고식립토크를기록하였다. ISQ 측정은근심면, 원심면, 협면, 설면의 4방향모두에서측정하였다. 임플란트이차수술시혹은보철인상채득시오스텔멘토를이용하여이차안정도를측정하였다. Gray value는 Cybermed (Korea) 사의 OnDemand 소프트웨어를이용하였다. OnDemand에서제공하는 implant library에서식립한임플란트와동일한크기의임플란트를선택하여식립한임플란트와중첩시켰다.(fig. 2) 그리고임플란트주변 2 mm 내의 Grey value를측정하였다.(fig. 3) 모든영상분석과정은동일인에의해서시행되었고, 모든측정은시간간격을두고세번씩반복하여측정하였다. CBCT 영상과 OnDemand 소프트웨어를이용하여수술직후와수술 3개월후, 보철수복후의 gray value 값및영상을비교하였다. 결과 7명의환자들의평균관찰기간은약 16개월이었다. 9개 (SA 3개, CA 6개 ) 의임플란트가식립되었으며, 그중 1개의 CA 임플란트가탈락되어재식립하였다. Grey value의술후, 술후 3개월, 보철수복후변화양상은일관된양상을보이진않았으나, 동일인의임플란 Fig. 3. Grey value was measured within 2 mm area around the implant. Table 1. Grey value of Osstem TS III SA implants Gender Age Area Immediate Postoperative Postoperative 3 months Post-prosthetic Pattern of change M1 58 # F1 26 # M2 37 # Average SD Journal of Dental Implant Research 2017, 36(1) 6-13

15 Kang DW, Kim YK: Sinus membrane elevation without bone graft through crestal approach and simultaneous implant placement: case series study 9 트들에서는비슷한 Grey value 변화양상을보였다. CA 임플란트의 Grey value 값은전반적으로감소하거나감소하다가증가하는추세를, SA 임플란트는증가추세를보였다 (Table 1, 2). 술중및술후합병증으로는상악동점막천공 1예, 입술부위감각이상 1예, 나사풀림 1예가있었다술전잔존치조골높이는약 3.66±1.31 mm 였고, 술후 3개월째 CBCT 상에서의잔존골높이증대량은 0.71± 0.52 mm였고, 보철물수복후 CBCT 상에서의잔존골높이증대량은 2.31±1.11 mm였다 (Table 3). 전체적으로보철물수복이후에는잔존치조골이증대된것을확인할수있었으며, 술후상악동방사선불투과상이증가하였다. 수술직후에보였던점막비후및 haziness는 3개월이후에대부분감소하였다. 51세남자환자에서잔존골높이가 3 mm인 #17 부위에상악동점막거상술을시행한후직경 5 mm, 길이 8.5 mm TS III CA 임플란트를식립한증례에서수술직후상악동의방사선불투과상이시간이경과하면서완전히소멸되는것이관찰되었다.(Fig. 4) 55세여자환자에서잔존골높이가 3 mm인 #24 부위에상악동점막거상술을시행한후직경 4.5 mm, 길이 8.5 mm TS III CA 임플란트를식립한증례에서도수술직후상악동내방사선불투과상과점막비후가시간이경과하면서거의소멸되었다.(Fig. 5) 고찰 상악동점막거상술중 osteotome 방법은 1994년에 Summers 에의해소개되었고비교적간편한술식과짧은회복시간을갖는장점이있어널리사용되고있다 19). Osteotome 방법은상악동점막을거상하면서저밀도골질의 cancellous bone이 compaction 되면서골질이향상되는효과가있다. 하지만 osteotome 방법을부적절하게사용할경우 cortical bone의파절이나괴사가일어날수있고술식과정에서환자에게두통이나귀내부에손상을가할수있다. 게다가수술과정에서시야확보가어려워전적으로임상가의실력과감각에의존해야한다 20-23). 게다가 osteotome 방법은상악동점막의천공을유발하거나임플란트가식립될위치에거대한골결손 (bony cavity) 가형성이될수있다. 또한적응증도잔존치조골높이가 5 mm 이상되어야임플란트가적절한초기고정을얻을수있기때문에가능한증례가많지않다. 이러한단점들을보완하기위해본연구에서는수압으로상악동점막을거상하는 CAS kit를사용하여상악동점막의천공을방지하면서빠르고간편하며안전하게상악동거상술및임플란트식립을하였다. 최근에는뼈이식을시행하지않고상악동거상술을시행할 Table 2. Grey value of Osstem TS III CA implants Gender Age Area Immediate Postoperative Postoperative 3 months Post-prosthetic Pattern of change M3 54 # M3 54 # M4 54 # M4 54 # M5 51 # Average SD Table 3. Evaluation of bone augmentation using CBCT Gender/Age Area Preoperative Bone height Bone gain 3 months after bone graft Bone gain after prosthetic delivery M1/58Y # mm 1.31 mm 3.83 mm F1/58Y # mm 1.77 mm 2.29 mm F2/60Y # mm 0.35 mm 2.92 mm M2/54Y # mm 0.63 mm 0.87 mm M2/54Y # mm 0.27 mm 1.16 mm M3/37Y # mm 0.51 mm 1.02 mm M4/54Y # mm 0.54 mm 2.14 mm M4/54Y # mm 0.88 mm 3.64 mm Average 3.66 mm 0.71 mm 2.31 mm Journal of Dental Implant Research 2017, 36(1) 6-13

16 10 강동우, 김영균 : 치조정접근법을이용한상악동점막거상술후골이식을시행하지않고임플란트를식립한증례연구 Fig. 4. Sinus lifting without bone graft case of 51-year male patient. The residual bone height of right maxillary 2 nd molar area was 3 mm and Osstem TS III CA implant (5-mm in diameter, 8.5-mm in length) was installed. 때임플란트식립의성공적인결과가많이보고되고있다. Lundgren 등은뼈이식을하지않고혈액으로상악동을거상한그룹과자가골을이용해뼈이식을한그룹간의통계적으로유의한차이가없다고보고하였다 24). Cricchio 등은뼈이식없이공간을유지하는장치를사용하여상악동거상술을시행할때상악동거상과정에서더많은신생골형성이된다고보고하였다 25). 이것은보통골이식재들이들어가는공간에혈병이위치하면서가능해진다. 혈구 (Blood cell) 는골전구세포 (bone precursor cell) 들이파골세포 (osteoclasts) 로분화를촉진시킴으로써신생골형성이이루어진다. 활성화된파골세포는조골세포 (osteoblasts) 를형성하여골이생성된다고보고된바있다 26). 반면에 Nedir 등의연구에서는뼈이식재의사용이상당한골증대를가져올수있지만신생골형성의전제조건은아니라고보고했다 27). 이처럼뼈이식없이상악동점막거상술을시행할때의임상적예후와임플란트생존율이높게보고되고있기는하지만, 부정적인견해도존재한다. 일부저자들은실제적인최종골증대 효과가제한적이며임플란트끝뷔위가두꺼운상악동결합조직에부착되어결과적으로골유착 (osseointegration) 이되지않는다고하였다 28,29). 그러나뼈이식을하지않고성공적으로상악동점막거상술이시행된다면여러가지장점들이존재한다. 뼈이식을하면서상악동점막거상술을하는경우에는환자들에게많은합병증이따를수있다. 술후출혈, 높은감염의가능성, 급성상악동염, 혈종, 창상회복지연등의합병증이생길수있으며추가적으로많은비용이들게된다 30,31). 뼈이식없이상악동거상술을시행하면환자의불편감을상당히덜어주고전체적인시술시간이단축되며비용면에서도저렴하여환자의부담을덜수있고덜침습적인술식이라는많은장점들이있다. 본연구에서임플란트는직경 mm, 길이 8.5 mm Osstem TS III CA와 SA를식립하였다. 부드러운표면의짧은임플란트의예후를관찰한 90년대초기의연구결과들을보면 10 mm 이하의짧은임플란트는긴임플란트보다더높은실패율을보인다고보고 Journal of Dental Implant Research 2017, 36(1) 6-13

17 Kang DW, Kim YK: Sinus membrane elevation without bone graft through crestal approach and simultaneous implant placement: case series study 11 Fig. 5. Sinus lifting without bone graft case of 55-year female patient. The residual bone height of left maxillary 1 st premolar area was 3 mm and Osstem TS III CA implant (4.5-mm in diameter, 8.5-mm in length) was installed. 되었다. 즉임플란트의길이가짧으면치조골과의접촉면적이적어서초기고정과기능적부하의분산측면에서불리하게작용하기때문이라고생각되었다. 그러나최근에는거친표면짧은임플란트가긴임플란트와유사한생존율을보인다는임상결과가보고되고있다 32-34). Nedir 등은 ITI titanium plasma-sprayed (TPS) and sandblasted and etched (SLA) implants의 7년생존율분석을시행한결과짧은길이임플란트는긴것에비해실패율이높지않았고누적생존율은 99.4% 라고보고한바있다. 특히하악에서는적절한증례들에서사용할경우 6 7 mm 임플란트가매우안정적인결과를보인다고보고되었다. 그러나상악구치부에서짧은임프란트의예후에대해서는아직확실하게기술된논문들이많지않은실정이다. 이번연구에서는상악동까지잔존골높이가 2 6 mm인 7명의환자들에서 CAS kit를이용하여치조정접근법을통해상악동점막 을거상하고골이식을시행하지않은채로 9개의 8.5 mm 길이임플란트를식립하였다. 그중 1개의임플란트만이실패하였다. 짧은기간의연구이지만치조정접근법을통해상악동점막을거상하고골이식을시행하지않은상태에서짧은길이임플란트를식립하는것은상악동거상부위에신생골이잘형성되면서식립된임플란트가잘유지되는양상을보여주었고, 대체로심각한합병증은발생하지않았다. 측방접근법을통해충분한시야를확보한상태에서점막을거상하고골이식을시행하지않고임플란트를식립하는방법은치조정접근법에비해좀더예측가능한좋은결과를보일것으로예상된다. CBCT에서골밀도평가는 medical CT와달리 HU 값으로표현할수없는문제점이있다. Grey value ( 흑화도 ) 는지정된영영의각 voxel의 grey value를계산하여평균값과 SD로표현되고, 최근연구에서 CBCT의 grey value가골밀도와관련이있다는논 Journal of Dental Implant Research 2017, 36(1) 6-13

18 12 강동우, 김영균 : 치조정접근법을이용한상악동점막거상술후골이식을시행하지않고임플란트를식립한증례연구 문들이보고되고있다. 본연구의한계점은 CBCT 를이용한자료분석이라는특성으로 다른시점에서같은촬영기기를이용하여동일한조건으로동일부위를촬영하더라도, grey value 결과에는차이가있을수있다. 또한임플란트에의한 artifact의영향으로인해오차가발생할수있다. 그리고관찰한임플란트개수가적고, 그룹간임플란트개수차이로 (SA 3개, CA 6개 ) 통계적검정은어려웠다. 좀더심도있는연구가필요할것으로보이나, 현재까지진행된연구에따르면상악동점막거상술을시행할때반드시골이식이필요한것은아니며, 적절하게짧은길이의임플란트까지식립되면비용도절감되고환자및술자에게좀더편한치료옵션이될수있을것으로보인다. 결 론 치조정접근법을이용하여상악동점막거상하면서골이식을시행하지않고짧은길이의임플란트를식립하는방법은여러장점들이존재하며, 임상가들에게효과적이고예측가능한치료옵션이될수있다. REFERENCES 1. Sharan A, Madjar D. Maxillary sinus pneumatization following extractions: a radiographic study. Int J Oral Maxillofac Implants 2008;23: Borges FL, Dias RO, Piattelli A, Onuma T, Gouveia Cardoso LA, Salomão M, Scarano A, Ayub E, Shibli JA. Simultaneous sinus membrane elevation and dental implant placement without bone graft: a 6-month follow-up study. J Periodontol 2011;82: Rosen, P.S., Summers, R., Mellado, J.R., Salkin, L. M., Shanaman, R.H., Marks, M.H. & Fugazzotto, P.A. The bone - added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients. International Journal of Oral & Maxillofacial Implants 1999; 14: Toffler, M. Osteotome-mediated sinus floor elevation: a clinical report. The International Journal of Oral & Maxillofacial Implants 2004;19: Lai, H.C., Zhang, Z.Y., Wang, F., Zhuang, L.F. & Liu, X. Resonance frequency analysis of stability on ITI implants with osteotome sinus floor elevation technique without grafting: a 5-month prospective study. Clinical Oral Implants Research 2008;19: Lai, H.C., Zhuang, L.F., Lv, X.F., Zhang, Z.Y., Zhang, Y.X. & Zhang, Z.Y. Osteotome sinus floor elevation with or without grafting: a preliminary clinical trial. Clinical Oral Implants Research 2010;21: Nedir, R., Bischof, M., Vazquez, L., Nurdin, N., Szmukler- Moncler, S. & Bernard, J.-P. Osteotome sinus floor elevation technique without grafting material: 3-year results of a prospective pilot study. Clinical Oral Implants Research 2009;20: Pjetursson, B.E., Ignjatovi, D., Matuliene, G., Bra gger, U., Schmidlin, K. & Lang, N.P. Transalveolar maxillary sinus floor elevation using osteotomes with or without grafting material. Part II: radiographic tissue remodeling. Clinical Oral Implants Research 2009;20: Peñarrocha-Diago M, Rambla-Ferrer J, Perez V, Perez- Garrigues H. Benign paroxysmal vertigo secondary to placement of maxillary implants using the alveolar expansion technique with osteotomes: a study of 4 cases. Int J Oral Maxillofac Implants 2008;23: Saker M, Ogle O. Benign paroxysmal positional vertigo subsequent to sinus lift via closed technique. J Oral Maxillofac Surg 2005;63: Cho SW, Kim SJ, Lee DK, Kim CS. The comparative evaluation using Hatch Reamer technique and osteotome technique in sinus floor elevation. J Korean Assoc Maxillofac Plast Reconstr Surg 2010;32: Davarpanah M, Martinez H, Tecucianu JF, Hage G, Lazzara R. The modified osteotome technique. Int J Peri odontics Restorative Dent 2001;21: Lalo J, Broukris G, Djemil M, Beleh M. Safe technique for sinus floor elevation through alveolar crest with stop sinus osteotomes. Implantodontie 2005;14: Draenert GF, Eisenmenger W. A new technique for the transcrestal sinus floor elevation and alveolar ridge augmentation with press-fit bone cylinders: a technical note. J Craniomaxillofac Surg 2007;35: Tilotta F, Lazaroo B, Gaudy JF. Gradual and safe technique for sinus floor elevation using trephines and osteotomes with stops: a cadaveric anatomic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106: Kfir E, Kfir V, Mijiritsky E, Rafaeloff R, Kaluski E. Minimally invasive antral membrane balloon elevation followed by maxillary bone augmentation and implant fixation. J Oral Implantol 2006;32: Chen L, Cha J. An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the minimally invasive hydraulic sinus condensing technique. J Periodontol 2005;76: Kao DW, DeHaven HA Jr. Controlled hydrostatic sinus elevation: a novel method of elevating the sinus membrane. Implant Dent 2011;20: Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium 1994;15:152, Strietzel FP, Nowak M, Kuchler I, Friedmann A. Peri-implant alveolar bone loss with respect to bone quality after use of the osteotome technique: results of a retrospective study. Clin Oral Implants Res 2002;13: Kolhatkar S, Cabanilla L, Bhola M. Inadequate vertical bone dimension managed by bone-added osteotome sinus floor elevation (BAOSFE): a literature review and case report. J Contemp Dent Pract 2009;10: Leblebicioglu B, Ersanli S, Karabuda C, Tosun T, Gokdeniz H. Radiographic evaluation of dental implants placed using an Journal of Dental Implant Research 2017, 36(1) 6-13

19 Kang DW, Kim YK: Sinus membrane elevation without bone graft through crestal approach and simultaneous implant placement: case series study 13 osteotome technique. J Periodontol 2005;76: Fugazzotto PA, De PS. Sinus floor augmentation at the time of maxillary molar extraction: success and failure rates of 137 implants in function for up to 3 years. J Periodontol 2002;73: Lundgren S, Andersson S, Gualini F, Sennerby L. Bone reformation with sinus membrane elevation: A new surgical technique for maxillary sinus floor augmentation. Clin Implant Dent Relat Res. 2004;6: Cricchio G, Palma VC, Faria PE, de Olivera JA, Lundgren S, Sennerby L, et al. Histological outcomes on the development of new space-making devices for maxillary sinus floor augmentation. Clin Implant Dent Relat Res. 2011;13: Borges FL, Dias RO, Piattelli A, Onuma T, Gouveia Cardoso LA, Salomão M, Scarano A, Ayub E, Shibli JA. Simultaneous sinus membrane elevation and dental implant placement without bone graft: a 6-month follow-up study. J Periodontol 2011;82: Nedir R, Nurdin N, Khoury P, Perneger T, El Hage M, Bernard JP, Bischof M. Osteotome sinus floor elevation with and without grafting material in the severely atrophic maxilla. A 1-year prospective randomized controlled study. Clin Oral Implants Res 2013;24: Lundgren S, Cricchio G, Palma VC, Salata LA, Sennerby L. Sinus membrane elevation and simultaneous insertion of dental implants: A new surgical technique in maxillary sinus floor augmentation. Periodontol ;47: Thor A, Sennerby L, Hirsch JM, Rasmusson L. Bone formation at the maxillary sinus floor following simultaneous elevation of the mucosal lining and implant installation without graft material: An evaluation of 20 patients treated with 44 Astra Tech implants. J Oral Maxillofac Surg 2007;65: Boffano P, Forouzanfar T. Current concepts on complications associated with sinus augmentation procedures. J Craniofac Surg 2014;25: Alkan A, Celebi N, Baş B. Acute maxillary sinusitis associated with internal sinus lifting: report of a case. Eur J Dent 2008;2: Saker M, Ogle O. Benign parosysmal positional vertigo subsequent to sinus lift via closed technique. J Oral Maxillofac Surg 2005;63: Cho SW, Kim SJ, Lee DK, Kim CS. The comparative evaluation using Hatch reamer technique and osteotome technique in sinus floor elevation. J Korean Assoc Plast Reconstr Surg 2010;32: Davarpanah M, Martinez H, Tecucianu JF, Hage G, Lazzara R. The modified osteotome technique. Int J Periodontics Restorative Dent 2001;21: Journal of Dental Implant Research 2017, 36(1) 6-13

20 Vol. 36 No. 1, September 2017 Journal of Dental Implant Research 2017, 36(1) 가족치아뼈이식술 : 증례관찰연구 김상윤 1, 김영균 1,2, 엄인웅 3 분당서울대학교병원치과구강악안면외과 1, 서울대학교치의학대학원치학연구소 2, 한국치아은행연구소 3 Family tooth bone graft: case observational study Sang-Yun Kim 1, Young-Kyun Kim 1,2, In-Woong Um 3 1 Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, 2 Department of Dentistry & Dental Research Institute, School of Dentistry, Seoul National University, Seoul, 3 R&D Institute, Korea Tooth Bank, Seoul, Korea Purpose: The purpose of this study was to evaluate the prognosis of implantation and bone graft using family tooth bone graft material. Materials and Methods: The subject was total 7 patients who received bone graft and implantation using family tooth bone graft material from April 2010 to August To evaluate the prognosis, postoperative complications associated with bone graft materials and complications after implant surgery and prosthetic treatment were investigated based on radiographs and medical records. Results: The mean follow-up period was 40 months from 2 months to 85 months. One patient received alveolar ridge augmentation at Seoul National University Bundang Hospital, and implantation was performed at other local dental clinic. A 13-year-old female patient who has alveolar cleft defect at #12 area received bone graft. A 9-year-old female patient also received bone graft only at #22 area. Total 4 patients received implantation, and 8 implants were implanted in the maxilla and 1 in the mandible. In the case of 52-year-old male patient, circumferential bony defect was observed around the implant in the maxillary right side, and 3.5 mm of marginal bone loss was observed. In all cases except this one case, complications such as wound dehiscence and/or infection did not occur. There was no osseointegration failure in all implantation cases and it was successfully functioned. Conclusions: Bone augmentation, socket preservation, and maxillary bone graft were performed using family tooth bone graft materials and showed good clinical results. (JOURNAL OF DENTAL IMPLANT RESEARCH 2017;36(1):14-18) Key Words: Bone graft, Family tooth 서론 자가골을대체할수있는이상적인재료로자가치아골이식재가개발되었다. 자가치아골이식재는발치한치아를이용하여제작하며, 우수한골전도와골유도능을보유하면서자가골과조직학적치유과정이유사하다. 또한감염의위험성도낮아자가골이식을대체할수있는이상적인골이식재로평가되고있다 1-4). 하지만자가치아골이식재는본인의치아중발치를해야할치아가있어야하기때문에그사용과양이제한적이다. 이러한단점을보완하기위해서직계가 족의치아를이용한가족치아골이식재가도입되었다. 가족치아골이식재는유전자구성이유사하기때문에이식후의면역거부반응혹은감염등의위험성이적다. 또한본인과가족을포함하여유치, 사랑니, 교정을위한발치치아등을모두골이식재로처리할수있기때문에많은양을얻어낼수있다. 또한타골이식재에비하여골재생능력과조직친화력이월등히우수하다 5,6). 본연구에서는직계가족의치아를발취하여제조한가족치아골이식재를골결손부혹은임플란트식립시주변에이식하여만족스런결과를얻은증례들을후향적으로관찰하였으며대표적인증례보 Received March 20, 2016, Revised April 3, 2016, Accepted April 28, 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

21 Kim SY, et al: Family tooth bone graft: case observational study 15 고와임상결과들을정리하여보고하고자한다. Table 1. Bone graft method for each patient Patient number Table 2. Dental implant type and surgical method for each patient Patient number Area Area 대상및방법 2010년 4월부터 2013년 8월까지분당서울대학교병원치과에서직계가족의발치한치아를골이식재로가공하여골이식술을받은 7 명을대상으로하였다. 골이식재가공방법은기존의자가치아골이식재와동일한방법으로수행하였다 1,5). 모든연구는분당서울대학교병원생명윤리심의위원회의승인 (IRB: B ) 을받은후진행하였다. 7명의환자의연령은 9세부터 52세까지평균 37.4세로, 남자 3명, 여자 4명이었다. 모든환자들은특별한내과적질환을보유하고있지않았다. 골이식술의방법에는상악동거상술, 골유도재생술, 치조능증대술, 발치와보존술등이포함되었다 (Table 1). 공여치아들은모두직계가족의사랑니였다. 7명의환자중 3명은골이식술만시행되었다. 나머지 4명의환자는골이식후임플란트식립을진행하였으며, 총 11개의임플란트가식립되었다. 식립된임플란트의종류로는 Zimmer HA, Osstem TS III, US III, MS가있었고, 11개의임플란트중 4개는 1회법으로, 7개는 2회법으로식 Type of surgery 1 #26 Sinus bone graft (lateral approach), GBR 2 #17, 27 BAOSFE #32 Socket preservation 3 #13 23 Horizontal ridge augmentation 4 #25, 27 Sinus bone graft (lateral approach) 5 #12 Bone graft on cleft alveolus 6 #22 Bone graft on cleft alveolus 7 #16 22 Alveolar ridge augmentation GBR: guided bone regeneration, BAOSFE: Bone-added osteotome sinus floor elevation. Implant information (System/diameter/length/installation method) 1 #26 Zimmer HA Submerged 2 #17, 27 TS III 5 10 Submerged #32 MS Non-submerged 3 # #25 TS III Non-submerged #27 TS III Non-submerged 5 #12-6 #22-7 #22 US III Submerged #11 US III Submerged #13 US III 4 13 Submerged #15 US III Submerged #16 US III 4 13 Submerged 립되었다. 식립된악궁별로볼때는상악에 10개, 하악에 1개가식립되었다. 식립위치별로는총 11개중 4개는전치부에, 7개는구치부에식립되었다 (Table 2). 방사선사진및의무기록지를중심으로골이식재와관련된술후합병증및임플란트식립수술및보철치료완료후합병증과같은예후를조사하였다. Table 3. Implant stability Patient number Table 4. Complicationand marginal bone loss Patient number Area 결 4명의환자에서총 11개의임플란트가식립되었다. 술후관찰기간은최소 2개월에서최대 85개월까지평균 40개월이었다. Osstell Mentor (Integration Diagnostics AB, Göteborg, Sweden) 로임플란트의안정성을평가하였으며, 전체임플란트의평균 1차 ISQ Implant 과 Primary stability Secondary stability Area Implant Complication Healing period (months) 1 #26 Zimmer HA 68-6 #17 TS III #27 TS III #32 MS # #25 TS III #27 TS III #12 6 #22 7 #22 US III #11 US III #13 US III #15 US III #16 US III Marginal bone loss 1 #26 Zimmer HA None #17, 27 TS III None 0.2 #32 MS None # #25 TS III None 0.1 #27 TS III None #12 6 #22 7 #22 US III 2 #11 US III Bony dehiscence 1.0 defect #13 US III Bony dehiscence 3.5 defect #15 US III Bony dehiscence 3.5 defect #16 US III Journal of Dental Implant Research 2017, 36(1) 14-18

22 16 김상윤등 : 가족치아뼈이식술 : 증례관찰연구 는 60.4, 2차 ISQ는 68.7로임상적으로양호하였다 (Table 3). 변연골소실양은평행촬영법을이용한치근단방사선사진상에서측정하였다. 최종경과관찰시의변연골소실은최소 0.1 mm에서최대 3.5 mm까지평균 1.1 mm로측정되었다 (Table 4). 52세남환의경우상악우측부위에식립된임플란트 (#13, 15) 가기능후주변으로골열개가발생하였고, 3.5 mm의변연골소실이확인되었다. 이외증례들에서창상열개또는이식재감염과같은합병증은발생하지않았다. 방사선학적평가상에서도모든증례에서임플란트주변으로골이식재의방사선불투과상이점차적으로증가하는경향을보였다. 결과적으로최종내원시까지실패한임플란트없이모두성공적으로유지되었다. 트를통한수복을원하여내원하였다. 직계가족인아들의사랑니를발치하여가족치아골이식재로처리하고, 전신마취하에서상악동거상술및골이식술을시행하였다. 골이식재는가족치아골이식재와하악지에서채취한자가골, 그리고이종골을혼합이식하였다. 골이식 6개월후상악우측중절치, 견치, 제2 소구치, 제1 대구치와상악좌측측절치에임플란트를식립하였다. 수술을위해판막을거상하였을때상악우측골이식을시행한부위에골소실이 3 4 mm 정도관찰되어이종골을추가이식하였다. 6개월후 2차수술을하였으며, 최종적으로보철수복으로마무리하였다. 약 3년간의경과관찰을시행하였으며, 일시적인임플란트주위염외에큰합병증없이양호하게유지되었다.(Fig. 1) 증례보고 1. 증례 년첫내원당시 52세남환으로, 30년전상악낭종적출술을시행한후로치아가소실되어의치를사용하고있었으나, 임플란 2. 증례 년첫내원당시 49세남환으로, 상악좌측구치부소실을주소로내원하였다. 상악좌측제1 대구치, 제2 대구치결손과협소한치조골폭경과높이가관찰되었다. 본인의사랑니와직계가족인아들의사랑니를발치하여골이식재로처리하여상악동거상술을동 A B C D E F G H I Fig. 1. Ridge augmentation using family and autogenous tooth bone graft material was performed in 52-year old male patient. (A) Initial panoramic radiograph. Right maxillary alveolar bone defect is observed. (B) Mucoperiosteal flap was elevated. Severe horizontal and vertical alveolar bone defects were observed. (C) Family tooth bone block was grafted and fixed using titanium screws. Two tenting screws were installed for vertical ridge augmentation. (D) Vertical and horizontal ridge augmentation were performed using autogenous tooth and family tooth bone graft material and autogenous ramus bone. Resorbable collagen membrane was covered. (E) Postoperative panoramic radiograph. (F) Mucoperiosteal flap was elevated for implant installation 4 months after ridge augmentation. (G) Five implants (Osstem US III) were installed. Primary stability was excellent. (H) Postoperative panoramic radiograph after implant placement. (I) Panoramic radiograph 11 months after prosthetic loading. Mean 3.5-mm marginal bone loss was developed around the #13, 15 implants. Journal of Dental Implant Research 2017, 36(1) 14-18

23 Kim SY, et al: Family tooth bone graft: case observational study 17 A B C D E F Fig. 2. Sinus bone graft and ridge augmentation using family and autogenous tooth bone graft material were performed 49-year old male patient. (A) Initial panoramic radiograph. Left maxillary sinus bone graft and delayed implant placement were planned. (B) Panoramic radiograph after bone graft. Sinus bone graft and ridge augmentation were performed using autogenous and family (his son) tooth bone graft material. (C) Panoramic radiograph after implantation. Implants were installed with nonsubmerged technique 3 months after bone graft. (D) Panoramic radiograph at 21 months after prosthetic loading. (E) Periapical radiograph 6 years after prosthetic loading. (F) Panoramic radiograph 6 years after prosthetic loading. 반한임플란트식립술을진행하기로계획하였다. 가족간치아골이식재를이용한상악동거상술시행 3개월후임플란트를 1회법으로식립하였다. 수술후약 7년간경과관찰하였으며, 특별한문제없이임상적으로양호한결과를유지하였다.(Fig. 2) 고찰 치아결손을해결하는임플란트수술중많은증례에서골이식술이필요한경우가많으며, 이에자가골, 동종골, 이종골, 합성골등다양한재료들이사용되어왔다. 앞서언급한자가치아골이식재는무기질함량및구성, 표면구조, 이식후의치유과정이자가골과매우유사하다는것이이미입증되었다. 또한타골이식재와다르게골전도뿐만아니라골유도능을보유하고있어자가골과유사한골형성능을가진다고보고되었고, 생체적합성또한매우우수하다 1-4,7). 자가치아골이식재가이렇게우수한재료임은이미입증되었으나, 발치가필요한본인의치아가있어야하기때문에사용의한계가있다. 또한발치후골이식재로처리하는과정이필요하기때문에발치후즉시골이식술을진행할수없고, 그양또한제한적이다. 따라서이러한한계점을극복하기위하여직계가족의치아를이용한가족치아골이식재가개발된것이다. 직계가족의경우유전자조합이 100% 일치하지는않지만, 골이식재를처리하는과정에서탈회, 동결건조등을통하여면역거부반응을일으킬항원을제거할수있다. 따라서부가적으로 ABO typing과같은조직일치검사를할필요가없다 8). 이렇게가족치아이식재는이미임상적으로널리사용되고있으며, 주로임플란트식립을위한골이식시에이용되고있다. 또한, 구순구개열이나외상으로인한치아및치조골손실등이존재하는어린아이의경우, 재건을위한자가골이식을위하여 장골이나늑골등을채취하는경우에술후통증이심하고공여부반흔등과같은문제점이유발될수있다. 이러한경우자가치아골이식재가좋은방안이될수있으나연령및여건상발치가필요한치아가적기때문에가족치아골이식재가매우유용하게쓰일수있다. 가족치아골이식재는자가치아골이식재와마찬가지로분말형태로제작할경우에는 enamel 부분과 dentin 부분으로구분하여제작할수있다 5). 본증례들에서는대부분분말형태로사용하였으며, 감염과같은골이식재관련합병증은전혀발생하지않았다. 그러나한명의환자에서상악에식립된임플란트주변의골소실이많이발생하였다. 골흡수가발생하는이유로는창상열개, 감염, 임플란트종류, 치유기간중조기하중부여등이있다. 이환자에서수술후감염이나창상열개등은발생하지않았으나골소실이약 3 mm 이상발생되었다. 식립된임플란트의종류가외부육각구조 (external hexa type) 인 US III라는점과다수임플란트를한번에식립하였기때문에치유기간중에장착되었던임시의치로인해임플란트주변에하중이가해진것이골소실의원인으로생각된다. 치조열이존재하는 9세여환에게도가족치아골이식재를이용하여결손부재건을시행하였으며, 술후약 4년까지관찰한결과, 일부골흡수가진행되기는하였으나결손부의 bone bridge 형성은정상적으로이루어졌으며, 성인이된후임플란트식립을통한보철수복을시행할예정이다. 이외에도부족한치조골폭경및높이를회복하기위하여가족치아골이식재를이용해서치조능증대술을시행하기도하였으며, 마지막경과관찰시점까지합병증없이양호한상태를유지하는것이확인되었다. Journal of Dental Implant Research 2017, 36(1) 14-18

24 18 김상윤등 : 가족치아뼈이식술 : 증례관찰연구 결 론 본증례연구를통해가족치아골이식재를이용한골이식의임상 적유용성과안정성이확인되었으나, 증례수가적고관찰기간이 짧다는한계점이존재한다. 그러나임플란트를식립하거나골결손 부의재건을위해골이식술이필요한경우에가족치아골이식재를유용하게사용할수있는가능성이제시되었으며, 자가골혹은자가치아골이식재의대체재료혹은복합이식재료로적절히사용될수있다. REFERENCES 1. Kim YK, Kim SG, Byeon JH, Lee HJ, Um IU, Lim SC, Kim SY. Development of a novel bone grafting material using autogenous teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109: Kim YK, Kim SG, Yun PY, Yeo IS, Jin SC, Oh JS, Kim HJ, Yu SK, Lee SY, Kim JS, Um IW, Jeong MA, Kim GW. Autogenous teeth used for bone grafting: a comparison with traditional grafting materials. Oral Surg Oral Med Oral Pathol Oral Radiol 2014; 117: Kim YK, Kim SG, Oh JS, Jin SC, Son JS, Kim SY, Lim SY. Analysis of the inorganic component of autogenous tooth bone graft material. J Nanosci Nanotechnol 2011;11: Kim YK, Lee HJ, Kim SG, Um IW, Im SC, Kim SG. Analysis of inorganic component and SEM analysis of autogenous teeth bone graft material and histomorphometric analysis after graft. J Korean Acad Implant Dent 2009;28: Lee JY, Kim YK, Um IW, Choi JH. Familial tooth bone graftl Case reports. J Korean Dent Assoc 2013;51: Ma DH, Kim SG, Oh JS, Lee SK, Jeong ME, Kim JS, Kim SH. Guided bone regeneration at bony defect using familial tooth graft material: Case report. Oral Biol Res 2012;36: Jun SH, Ahn JS, Lee JI, Ahn KJ, Yun PY, Kim YK. A prospective study on the effectiveness of newly developed autogenous tooth bone graft material for sinus bone graft procedure. J Adv Prosthodont. 2014;6: Pearson KA, Brubaker SA, Anderson ML. Standards for tissue banking. 12th ed. American Association of Tissue Banks (AATB), McLean, pp , Journal of Dental Implant Research 2017, 36(1) 14-18

25 Vol. 36 No. 1, September 2017 Journal of Dental Implant Research 2017, 36(1) 골유도재생술을동반한임플란트 2 차수술시감염 : 증례보고 구필모, 류동목, 지유진, 이덕원 강동경희대학교치과병원구강악안면외과 The infection after implant 2 nd surgery with GBR: case report Pilmo Koo, Dong-Mok Ryu, Yu-Jin Je, Deok-Won Lee Department of Oral and Maxillofacial Surgery, Kyung Hee University Dental Hospital at Gangdong, Kyung Hee University, Seoul, Korea Dental implant is widely used and has successful results as a method used to restore the masticatory function and esthetics of missing teeth. One of the factors determining long-term prognosis of implants is the presence of a sufficient amount of alveolar bone in the missing tooth area. In cases of alveolar bone defect for various reasons, Guided bone regeneration (GBR) is the most commonly used procedure, and is widely used when there is slightly dehiscence or fenestration wound around the implant. In this case report, we report a case in which the wound dehiscence occurred implantation with GBR. (JOURNAL OF DENTAL IMPLANT RESEARCH 2017;36(1):19-22) Key Words: Infection, Dental implant, GBR 서론 상실된치아의저작기능및심미성을회복하기위해사용되는방법으로치아임플란트식립이널리사용되며성공적인결과를보여주고있다. 임플란트의장기간예후를결정짓는요인중한가지가상실된치아부위에존재하는충분한양의치조골이다 1). 여러가지이유로치조골결손이발생한경우임플란트식립을위해골형성술식이필요하다. 그중골유도재생술은가장많이사용하는술식으로임 플란트주위열개, 천공부위가있을경우에널리사용된다. 본증례보고에서는골유도재생술을통한임플란트 2차수술시봉합부위에생긴감염의치유증례에대해보고하고자한다. 증례보고 고혈압이외에특별한전신병력이없는 69 세남성환자가전반적 Fig. 1. Initial panoramic radiography. Fig. 2. Panoramic radiography 7 months after extraction of #18, 36, 48. Received May 1, 2016, Revised May 15, 2016, Accepted June 12, 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 : 이덕원, 05278, 서울시강동구동남로 892, 강동경희대학교치과병원구강악안면외과 Correspondence to: Deok-Won Lee, Department of Oral and Maxillofacial Surgery, Kyung Hee University Dental Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea. Tel: , Fax: , verycutebear@hanmail.net / verycutebear@khu.ac.kr JOURNAL OF DENTAL IMPLANT RESEARCH

26 20 구필모등 : 골유도재생술을동반한임플란트 2 차수술시감염 : 증례보고 인치아의불편감을주소로내원하였다. 임상적, 방사선학적검사상전반적인치주염, 특히 #36의치근단병소가관찰되었다. 치료계획으로 #36 발치후임플란트식립및치주치료와 #18, 48발치를계획하였다.(Fig. 1) 2015년 4월 14일 #18, 36, 48발치를시행하였으 며, 7개월후촬영한파노라마방사선상에서발치와의완전한치유를보이지는않았다.(Fig. 2) 2015년 12월 11일 #36부위임플란트 (IS-II active, Neobiotech CO., Ltd., Seoul, Korea., 직경 4.5 mm, 길이 11.5 mm) 식립을 A B C Fig. 3. (A) Delayed healing on extraction site 8 months after extraction of #36. (B) Implantation & bone graft by allogenic bone material on #36i distal. (C) Panoramic radiography after implantation on #36i. A B C Fig. 4. (A) Re-bonegraft on #36i buccal side at second surgery. (B) Stitch out was performed but wound dehiscence on #36i buccal & distal side. (C) Removal of inflammatory bone material. Journal of Dental Implant Research 2017, 36(1) 19-22

27 Koo P, et al: The infection after implant 2 nd surgery with GBR : case report 21 A B Fig. 5. (A) Finally good healing state. (B) Complete prosthetic treatment. 시행하였다. 피판을거상하고확인해보니 #36 발치와의지연된치유양상을보이고있었다. 이에임플란트식립과동시에주변부위에동종골 (Irradiated Allogenic Cortical Bone&Marrow 0.5 g, ( 주 ) 푸르고바이오로직스, Sungnam, Korea) 를이용한골이식을시행하였다. 임플란트의초기고정력은 40 N로측정되었다.(Fig. 3) 약 5개월뒤 2016년 5월 6일 2차수술을위하여피판을거상하였을때임플란트의협측나사산이나사산 1개가노출된것을확인하여 healing abutment를채결하고해당부위에동종골 (Irradiated Allogenic Cortical Bone&Marrow 0.25 g, ( 주 ) 푸르고바이오로직스, Sungnam, Korea) 을이용하여골이식을재시행하였다. 약 2주후 2016년 5월 20일발사를시행하였으며발사당시 #36i 원심부에일차폐쇄가되지않았음을확인하고감염을예방하고 2차치유를유도하기기다리며클로르헥시딘가글을하도록지시하였다. 2016년 7월 5일환자는통증을호소하였고일차폐쇄가되지않은부위에감염된골이식재를관찰할수있었다. 임플란트주위의피판을거상하여감염된과도한골이식재를제거하여주었다.(Fig. 4) 이후환자의증상은호전되었으며, 임플란트주위의점막의치유도안정화되어보철치료를완료하였다.(Fig. 5) 고찰 골유도재생술시부적절한창상폐쇄는감염의위험성이커지고, 임플란트주위에서재생조직의양이감소하게되어치유기간이연장되고결과가저하된다 2-4). 적절한일차폐쇄가이루어지도록하기위해서는근육장력제거, 적절한피판설계및비외상성피판거상, 골막이완절개에의한피판의무장력화등이있다. 이중골막이완절개를통한무장력폐쇄 (tension-free closure) 가가장중요한요소이다 5,6). 골유도재생술을시행하면해당부위의부피가증가하여봉합과정중피판에장력이가해질가능성이높다. 장력이있는상태에서무리하게피판을봉합하면피판변연의혈류량이감소하여피판의부분적괴사와창상열개가생기게된다 7). 절개시수직절개를동반하거나, 골막이완절개를하여피판의장력을없애줄수있다. 피판의장력을최소화하여봉합을하여도일차폐쇄의실패가일어날수있다. 일차폐쇄실패는골유도재생술에서나타날수있는술후합병증중하나로써일차폐쇄실패가일어나면세균이급속히증식하고감염이발생할수있다 4). 골유도재생술후일차폐쇄실패시감염의위험성을최소화하기위하여하루에클로르헥시딘으로 2 3 번구강을세정하도록하거나면봉에클로르헥시딘을묻혀서수술부위를가볍게문질러닦아주도록한다. 또한환자를 2 3일에한번씩내원하도록하여드레싱하면서경과관찰을한다 8). 결론적으로본증례에서골유도재생술후일차폐쇄의실패요인은과도한골이식후봉합시피판의장력을줄여주지않고봉합을한것이다. 이로인하여일차폐쇄가이루어지지않은부분의골이식재에감염이일어났고, 연조직의치유가이루어지지않았다. 무장력폐쇄나수직절개를통하여장력을줄여봉합을했다면일차폐쇄의실패가능성을줄였을것이다. REFERENCES 1. Bra-nemark P-I, Zarb GA, Albrektsson T, Rosen HM. Tissue- Integrated Prostheses. Osseointegration in Clinical Dentistry. LWW, Simion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. International Journal of Periodontics & Restorative Dentistry 1992; Machtei EE. The effect of membrane exposure on the outcome of regenerative procedures in humans: a meta-analysis. Journal of periodontology 2001;72: Sanctis M, Zucchelli G, Clauser C. Bacterial colonization of barrier material and periodontal regeneration. Journal of clinical periodontology 1996;23: Wang H-L, Boyapati L. PASS principles for predictable bone regeneration. Implant dentistry 2006;15: Greenstein G, Greenstein B, Cavallaro J, Elian N, Tarnow D. Flap advancement: practical techniques to attain tension-free primary closure. Journal of periodontology 2009;80:4-15. Journal of Dental Implant Research 2017, 36(1) 19-22