ISSN Vol. 34 No. 1, 2015 대한치과이식임플란트학회지 VOL. 34 NO. 1 June 2015

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1 ISSN Vol. 34 No. 1, 2015 대한치과이식임플란트학회지 VOL. 34 NO. 1 June 2015

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/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 대한치과이식임플란트학회지 2015 년 6 월, 제 34 권제 1 호 Journal of Dental Implant Research June 2015 Vol. 34 No. 1 발행인김현철 위원장팽준영 편집간사이덕원 Publisher Editor-in-Chief Managing Editor Hyoun-Chull Kim Jun-Young Paeng Deok-Won Lee 인쇄일 2015 년 6 월 26 일 발행일 2015 년 6 월 30 일 발행처대한치과이식임플란트학회서울특별시종로구대학로 101 ( 연건동 ) 서울대학교치과병원 B168 호전화. (02) 팩스. (02) 인쇄 ( 주 ) 메드랑서울특별시마포구월드컵북로 5 가길 8-17 전화. (02) 팩스. (02) Printing date June 26, 2015 Publication date June 30, 2015 PUBLISHED BY The Korean Academy of Implant Dentistry #B168, 101, Daehak-ro, Jongno-gu, Seoul , Korea Tel Fax PRINTED BY MEDrang Inc WorldCupbuk-ro 5ga-gil, Mapo-gu, Seoul , 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 ( 강동경희대병원 ) Deok-Won Lee (Kyunghee University 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 ) 박원서 ( 연세치대 ) 박원희 ( 한양대구리병원 ) 박준범 ( 가톨릭대서울성모병원 ) 신승일 ( 경희치대 ) 신재명 ( 인제대일산백병원 ) 안강민 ( 서울아산병원 ) 양병은 ( 한림대학교성심병원 ) 여인성 ( 서울치대 ) 우승철 ( 마포리빙웰치과 ) 이양진 ( 분당서울대병원 ) 전상호 ( 고려대병원 ) 정승미 ( 원주세브란스기독병원 ) 지숙 ( 고려대병원 ) 지유진 ( 강동경희대병원 ) 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) Won-Seo Park (Yonsei University) Won-Hee Park (Hanyang University) Jun-Beom Park (Catholic University Seoul ST. Mary's Hospital) Seung-Il Shin (Kyunghee University) Jae-Myung Shin (Inje University Ilsan Paik Hospital) Kang-Min Ahn (Seoul Asan Hospital) 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 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 34 권제 1 호 2015 년 6 월 목 차 1 임플란트수술전후의통증조절을위한합리적인경구진통제선택법 류대승, 이덕원 7 자가치아뼈이식재의공여치아상태에따른예후평가 안교진, 김영균, 엄인웅, 김지윤 12 인접자연치를침범한임플란트와침범받은자연치의임상적예후 구정귀, 윤필영, 최용훈, 이양진, 안교진, 이희진, 김영균 22 A retrospective study of Snucone implants: Clinical and radiographic results Sunam Yang, Hyunsu Lee, Hyeongi Yi, Dongwoo Lee, Heesang Lee, Hongjae Kwak, Panjun Kim, Kiwook Song, Woonheuk Jung 27 자가치아블록을이용한골이식술 : 후향적증례관찰연구 구정귀, 김영균, 엄인웅

6 Journal of Dental Implant Research Vol. 34 No. 1 June, 2015 CONTENTS 1 The reasonable selection of oral analgesics for perioperative pain control in oral implant surgery Dae-Seung Ryu, Deok-Won Lee 7 Evaluation of prognosis of autogenous tooth bone graft material according to the condition of donor tooth Gyo-Jin Ahn, Young-Kyun Kim, In-Woong Um, Ji-Yun Kim 12 The clinical prognosis of implants invading the adjacent natural tooth and invaded teeth Jeong-Kui Ku, Pil-Young Yun, Yong-Hoon Choi, Yang-Jin Yi, Kyo-Jin Ahn, Heejin Lee, Young-Kyun Kim 22 A retrospective study of Snucone implants: Clinical and radiographic results Sunam Yang, Hyunsu Lee, Hyeongi Yi, Dongwoo Lee, Heesang Lee, Hongjae Kwak, Panjun Kim, Kiwook Song, Woonheuk Jung 27 The retrospective clinical study of the autogenous tooth block bone graft Jeong Kui Ku, Young-Kyun Kim, In-Woong Um

7 Vol. 34 No. 1, June 2015 Journal of Dental Implant Research 2015, 34(1) 1-6 임플란트수술전후의통증조절을위한합리적인경구진통제선택법 류대승, 이덕원 경희대학교강동경희대치과병원구강악안면외과 The reasonable selection of oral analgesics for perioperative pain control in oral implant surgery Dae-Seung Ryu, Deok-Won Lee Department of Oral and Maxillofacial Surgery, Kyung Hee University Dental Hospital at Gangdong, Kyung Hee University, Seoul, Korea Pain control in oral implant surgery is important to both surgeon and patient. Ineffective control of perioperative pain in implant surgery increase patient s discomfort, morbidity, anxiety and complication. Pharmacological intervention using non-steroidal anti-inflammatory drugs (NSAIDs) and weak opioids are effective methods for perioperative pain control. In particular, oral administration is safe and convenient. However, variety of NSAIDs are confusing dentist which analgesic is the best selection. Insufficient dose and improper usage of NSAIDs and opioids failed to control perioperative pain due to increasing side effects. To achieve optimal medication with NSAIDs and weak opioids, dentists need to know which oral analgesics are reasonable and effective. WHO pain ladder is a guideline of pain management and Oxford league table of analgesic efficacy reveal intrinsic activity of common oral analgesics. Based on these previous studies, dentists can prescribe optimal oral analgesics for perioperative pain control in implant surgery. (JOURNAL OF DENTAL IMPLANT RESEARCH 2015;34(1):1-6) Key Words: Pain, Analgesics, Surgery, Implant 서론 임플란트시술은치과영역에서흔하게시행되는수술중의하나이며술후통증은환자들의주요한불만사항중의하나이다. 대부분의환자들은수술전에통증에관련된질문을하며, 외과적시술에대한불안과공포를보인다. 수술후적절하지못한통증조절은임플란트수술후출혈및부종, 수면장애, 음식물섭취의저하등을야기할수있다 1). 건강한일반인의경우정상적인과정의임플란트시술후경도에서중등도의통증과염증반응을겪게되며, 이경우금기사항이없는한비스테로이드성소염진통제 (NSAIDs) 를사용하여통증을조절하게된다 2,3). 이러한경구진통제를선택하는과정에서진통제의선택은용법과효과에대한고려보다는술자의선호도에의존하는경향이많다. 대부분의 NSAIDs는진통, 소염, 해열 작용이있는데, 진통작용은천장효과 (Ceiling effect) 가존재하기때문에증량하여도통증완화효과가없다. 이때문에중등도이상의통증을호소하는급성통증기에는약한아편유사제와 NSAIDs를혼용하여통증조절하는것이좋다 4). 마약성진통제는중등도이상의통증에효과적이나, 치과영역에서의처방은용량조절의어려움과탐닉성과내성, 의존성등의부작용에대한우려때문에적극적으로사용되고있지않고있다 5). 하지만, 약한아편유사제로인한중독성을나타내는경우는드물기때문에중증도이상의통증을호소하는경우금기사항이없는한약한경구아편유사제의혼용이환자의술후만족감을보다높일수있으며, NSAIDs의천장효과를피하고, NSAIDs의양을줄임으로써과량복용시나타날수있는독성을방지할수있다 6). 또한, 선행진통 (Preemptive analgesia) 을적용한경우술후에동량을투여하는경우보다효과적으로술후통증 Received April 15, 2014, Revised April 10, 2014, Accepted May 30, 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, , 서울시강동구동남로 892, 강동경희대치과병원구강악안면외과 Correspondence to: Deok-Won Lee, Department of Oral and Maxillofacial Surgery, Kyung Hee University Dental Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul , Korea. Tel: , Fax: , verycutebear@hanmail.net, verycutebear@khu.ac.kr This work was supported by a grant from National Research Foundation of Korea (NRF-2014R1A1A ). JOURNAL OF DENTAL IMPLANT RESEARCH

8 2 류대승, 이덕원 : 임플란트수술전후의통증조절을위한합리적인경구진통제선택법 을조절할수있다 7-9). 수술후통증을조절하기위한진통제의투여방법은 WHO pain ladder 의지침에따라투여하는것이바람직하며, 진통제의선택은특별한금기사항이없는한 Oxford league table of analgesic efficacy 에서투여횟수가적고, 진통효과가좋은진통제를선택하는것이유리하다. 또한, NSAIDs 및 Opioids의부작용과비적응증에대하여숙지하여이로인하여나타나는부작용을최소화하여야한다. 통증 통증은 실질적인또는잠재적인조직손상과관련된불유쾌한감각적정서적경험 으로정의되며통증의특성과세기는조직손상과연관된감각과감정적이고인지적인기전두가지모두의결과이다. 불안과스트레스정도가통증정도와술후상처치유와연관되어있다. 임플란트시술후나타나는통증은조직손상이치유되는데걸리는약 1주일간의시간이지나면사라지는급성통증이다. 통증의발생 임플란트식립을위한절개및조직의박리는염증과정을활성화시킨다. 이로인해프로스타글란딘 (prostaglandins), Substance P, Bradykinins 같은통증매개물 (Pain mediator) 의분비가말초통증수용기의감수성을증가시켜, 일차구심성섬유 (primary afferent fiber, A-, C fiber) 를통하여척수뉴런의탈분극 (depolarization) 이일어난다 10). 이러한일련의과정은자발성구심성활동 (spontaneous afferent activity) 을유발하고, 자극에대한반응을증진시키며, 국소적발적 (local arterial dilatation), 부종 (capillary permeability) 및통각과민 (hyperalgesia) 을일으킨다. 그후통증의부위가주위로확대되는데, 이는말초로부터지속적인통증신호전달에따른이차성통각과민 (secondary hyperalgesia) 에의해나타난다. 조직손상에의한직접적인침해수용체의활성화는일차통각과민 (primary hyperalgesia), 조직손상과관련없는손상부위주변에발생하는이차통각과민 (secondary hyperalgesia) 로나눌수있으며, 침해수용체의역치가감소되어나타나는데, 통증의역치감소는말초와중추의감작 (sensitization) 때문이다. 통각과민으로인한 C-fiber 침해수용체의지속적인활성화는척수후각 (dorsal horn) 의 N-methyl-D-aspartate (NMDA) 수용체의활성을증가시켜중추를감작되게하며, 이때문에임플란트수술후지속적인통증이나타나게된다. 일반적인임플란트시술후중등도이상의통증은술후 6 24시간이내에나타난다고알려져있으며약 2 8시간사이에최고조의통증이나타난다고한다 11). 통증의조절 진통제란통증의전달경로를일부차단함으로써통증을억제하는약물을말한다. 통증의조절은약물을투여함으로써달성할수있는데, 임플란트수술후급성통증기의조절은비아편유사제, 아편유사제, 스테로이드, 항경련제및항우울제를통해조절할수있다. 통증조절을위한진통제의사용은세계보건기구의 WHO's cancer pain ladder for adults 의원칙에따른다.(Fig. 1) 이는과거암환자의통증조절을위해사용되었으나지금은다양한통증조절을위해널리쓰이고있는원칙이다. 구강내소수술은환자개인이느끼는통증의정도가암성통증에비교할만큼예민하고대부분염증과부종이동반되기때문에이원칙을유용하게적용할수있다 12,13). 약물은가능한경구 (By mouth) 로투여하여환자스스로가관리하 Fig. 1. WHO pain ladder with pain management. Journal of Dental Implant Research 2015, 34(1) 1-6

9 Ryu DS, Lee DW: The reasonable selection of oral analgesics for perioperative pain control in oral implant surgery 3 기쉽고안정된방법으로정기적으로 (By clock) 투여하여약제의 효과가감소되지않게하며, 통증조절이잘되지않을경우 WHO 의 기준에따라 (By ladder) 약을추가하거나바꾼다. 수술후느끼는 통증은환자개인마다다르므로과거치과치료에대한통증경험을문진한후약을처방하는것이필요하다 (By the individual). 가능하다면환자를다음날재내원하게하여약물투여에따른통증변화와부작용을평가 (By attention to detail) 하도록한다 14). 선행진통 급성통증자극이인체에주어지기전에미리진통제를사용하여차단하여손상된조직의통증매개체의형성을억제하여말초신경계를억제하고중추신경계가감작되는것을막는개념이다. 넓게보면국소마취제를이용한전달마취및침윤마취역시선행진통의범주에들어가며투약을통한선행진통으로유용한약물로는 Ibuprofen 800 mg PO, Gabapentin 600 mg PO, Ketorolac 30 mg IV 등이술후통증을감소시키는데유용한것으로알려져있다. 비스테로이드성소염진통제 (NSAIDs) 와 Acetaminophen (Paracetamol) 비아편유사제로소염, 진통, 해열작용이있는 NSAIDs와소염작용이거의없는 Acetaminophen (Paracetamol) 이존재한다. NSAIDs 는 Cyclooxygenase (COX) 의 Acetylation 화하여 Arachidonic acid가 COX에의해 Prostaglandin으로전환되는것을억제하는기전으로통증매개물의생성을방해한다. COX는 COX-1과 COX-2로존재하며 COX-1은혈소판응집과위점막보호작용을하며, COX-2는통증매개물을생성하여통각과민을일으키는역할을하는데, 대부분의 NSAIDs는 COX-1과 COX-2를모두억제하기때문에이로인해출혈경향이나위궤양등을유발할수있다 15). NSAIDs로널리사용되고있는 Aspirin은다른비스테로이드성소염진통제와비교대상이되는기준약물이다. 다른 NSAIDs는 COX를경쟁적으로억제하는데반해아스피린은혈소판에서 COX 를비가역적으로억제하는데, 이때핵이없는혈소판은추가적인 COX 생산능력이없기때문에출혈시간을현저히증가시킨다. 진통목적을위한고용량의아스피린 (1.5 2 g/day) 투여는오히려혈전생성효과를일으킨다고알려져있어심혈관계부작용을일으킬위험이크다. 따라서, 임플란트시술후진통목적으로는부적절하며마찬가지의이유로시술전 5 7일정도의복약중지가필요하다. 치과치료후소아청소년에게 Aspirin 투여는 Reye syndrome을유발할수있으므로금기이며 Ibuprofen이나 Tramadol, Acetaminophen을투약하는것이추천된다. Ibuprofen은수술전또는수술후즉시투여한경우통증의발현과정도를감소시킬수있는약물로 1,200 2,400 mg/day의 용량에서우수한진통효과를보이며다른약물에비해위장관효과가적고독성이낮다. 단, 반감기가짧아지속적인진통효과를위해 4 6시간간격으로 400 mg의투여가필요하다. Acetaminophen 이소아에서심한간독성을보일수있는것과달리 Ibuprofen은안전하므로소아환자의통증조절에도유용하다. Naproxen은 Ibuprofen과비슷한진통효과를가지며그에비해 14시간의긴반감기를가지고있어복약횟수를줄일수있다. Diclofenac은중등도이상의술후통증에서효과적인진통효과를보인다고알려져있다. Etodolac도상대적으로 COX-2 선택성을가지며진통효과는사용용량 ( mg) 에서상대적으로긴 8시간정도지속되기때문에유용하다. Aceclofenac은 Etodolac 보다더 COX-2 선택적이며효과와반감기가비슷하여위장관계부작용을줄일수있다. Ketorolac은강한진통효과를보이나다른 NSAIDs에비해상대적으로높은출혈경향과위장관계부작용을갖기때문에 5일이상사용할수없다. Ketorolac 10 mg의경구제는 Asprin 650 mg, Acetaminophen 600 mg, Codeine 60 mg/acetaminophen 600 mg 복합제보다효과가뛰어나다. 하지만위장관출혈위험및신독성위험때문에다른 NSAIDs와병용할수없다. Aspirin을제외한Ketololac 및 NSAIDs가수술시출혈의심한증가를일으키지는않으므로전후통증조절에사용될수있다. COX-2 억제제로는 Celecoxib, Etoricoxib가있다. 선택적으로 COX-2만억제하기때문에기존의 NASIDs에대한부작용없이소염, 진통, 해열작용을얻을수있다. Celecoxib의 COX-2 선택적억제는 COX-1에비해약 7.6배의선택성을갖는반면, Etoricoxib 는 106배강력한선택성을보인다. Celecoxib가약 6 12시간의반감기, Etoricoxib는약 20 26시간의반감기를갖는다. COX-2 억제제는만성신부전, 심장질환, 간부전이있는환자에게는금기이다. NSAIDs의출혈경향때문에위장관계질환이있는환자에게는주의하여야한다. 위장관계위험성은 Ibuprofen<diclofenac, naproxen<ketorolac 순서로증가한다. 하지만이런위장관위험성이낮은약물들도용량의존적으로증가시위험성도커지기때문에주의가필요하다. 위장관보호를위해 Misoprostol, H 2-antihistamine, Proton pump inhibitors를투여해주는것이좋다. 신장에서 Prostanglandin의합성저하로신장혈류감소와신장수질의허혈로인한급성신부전을일으킬수있으므로신장질환자는가급적 Acetaminophen, Tramadol 등의대체약물을투여하는것이좋다. 기관지천식 (Asthema) 환자에게 NSAIDs의투여는천식발작과두드러기및혈관부종을일으켜천식을더욱악화시킬수있으므로 COX-2 선택적 NSAIDs를투여하는것이안전하다. 특히, Aspirin은금기이다. Acetaminophen은기존의 NSAIDs와는몇가지다른특징이있다. 중추와말초모두에서 Prostaglandin의합성을저해하나주 Journal of Dental Implant Research 2015, 34(1) 1-6

10 4 류대승, 이덕원 : 임플란트수술전후의통증조절을위한합리적인경구진통제선택법 로중추에서억제효과를보인다. 그렇기때문에해열과진통효과를보이나기존의 NSAIDs와는달리항염작용은거의없으며, 마찬가지의이유로혈소판응집을저해하지않으며, 위장관자극도유발하지않는다. 염증감소의목적으로는사용할수없으나염증으로인한통증조절에는효과적이며, 치료용량의 Acetaminophen 투여는위장관계, 혈소판응집저해, 신독성을나타나지않기때문에그안정성때문에노인에게유용하며하루최대 4 g까지사용가능하다. 전통적인 NSAIDs는간독성이드물지만대조적으로 Acetaminophen 은간독성이크며급성간부전의원인이될수있어, 간질환이있는환자에게는신중한투여가필요하다. 간독성을나타내는용량은성인 g, 소아에서는 150 mg/kg으로알려져있다. 정주 (IV) 용제제로는 Propacetamol이존재한다. Codeine 과 Tramadol 일반적으로수술후중등도이상의통증조절시아편유사제와 NSAIDs를동시에사용하여통증을조절하는방법을사용한다. 아편유사제의단독경구투여는 NSAIDs에비해서효과가적고부작용이크다. NSAIDs로는중추와말초에서 COX에의해생성되는통증매개물을억제하고, 아편유사제는중추에서작용하는아편유사제수용체인 (mu) 에주로작용하여진통효과를나타낸다. 서로다른경로의통증경로를차단하기때문에이러한복합사용은통증조절에필요한 NSAIDs 및아편유사제의용량을경감시킬수있으며, 각약물로인해나타날수있는부작용을줄일수있다. Codeine은약한마약성진통제이며천연알칼로이드로간에서대사되어 Morphine으로전환된다. Codeine 자체는아편유사제수용체에친화도가매우낮으며, Morphine으로전환된양만큼진통작용을나타내는데, 경구복용량의 10% 만이대사된다. 진해작용도가지고있는데, 진해작용자체는 Codeine 자체에서기인한다. Morphine보다남용가능성이낮고, 약물의존성을거의유발하지않는다. 단독사용보다는 NSAIDs 및 Acetanminophen과혼합 된상태로사용되며 Mypol R (Mypol Cap, SUNGWON ADCOCK PHARM, Seoul, South Korea) 은 Codeine 10 mg/acetaminophen 250 mg/ibuprofen 200 mg이들어있다. Tramadol은비아편중추작용합성진통제로 수용체에대한친화성이약하고, Norepinephrine과 serotonin retake를약하게억제한다. 중등도의통증조절을위해투약하는데, 진통작용은두약한효과의상승작용이다. Morphine에비해 10배정도약하며 codeine과비슷한효과를보인다. 400 mg/day 이상의경구투여시진통작용보다는부작용이더크기때문에권장되지않으며, 항우울증약으로 MAOI (Monoamine oxidase inhibitor) 를먹는환자에게는금기이다. 임플란트식립및치주치조수술후진통효과에서 Mypol R 2캡슐은 Acetanminophen 600 mg보다효과적이며, 임플란트시술전선행진통으로 Mypol R 투약및술후 2일째까지투여한결과환자의통증감소와높은만족도를보였다 7,16). The 2007 Oxford League Table of Analgesic Efficacy NSAIDs를포함한진통제가다양하기때문에어떤진통제를어떻게처방해야좋은지에대한고민을해결하기위해서유용한것이 Oxford League Table 이다. 이표는중등도이상의술후급성통증을보이는환자에게이중맹검법일회용량연구를통해서만든것으로진통제의효능 (Efficacy) 을평가한다. 진통효과가클수록낮은 NNT (Number-needed-to-treat) 를갖게되며가장낮은값은 1로표현된다. 단일진통제복약으로통증이 4 6시간동안 50% 이상이감소되는데필요한치료횟수가 NNT이므로 NNT가낮은약일수록효능이높아효과적인통증조절이가능하다.(Fig. 2) Oxford league table에서국내에서일반적으로쓰이는경구 NSAIDs를편집한표 (Table 1) 에따르면 NSAIDs의증량에따른 Fig. 2. Common oral analgesics efficacy. 95% CI of Number needed to treat (NNT) for at least 50% pain relief over 4-6 hours compared with placebo. Journal of Dental Implant Research 2015, 34(1) 1-6

11 Ryu DS, Lee DW: The reasonable selection of oral analgesics for perioperative pain control in oral implant surgery 5 Table 1. The 2007 Oxford league table of analgesic efficacy Analgesic (mg, single dose) Number of patients in comparison Percent with at least 50% pain relief NNT* Lower confidence interval Higher confidence interval Etoricoxib 180/240 Etoricoxib 120 Celecoxib 400 Celecoxib 200 Ibuprofen 600/800 Ibuprofen 400 Ibuprofen 200 Aspirin 600/650 Ketorolac 20 Ketorolac 10 Diclofenac 50 Diclofenac 25 Naproxen 500/550 Naproxen 400/440 Naproxen 200/220 Paracetamol 1000 Paracetamol 600/650 Tramadol 100 Tramadol 50 Paracetamol 650+tramadol ,456 3,248 5, , ,759 1, *NNT (Numbers needed to Treat), (Adapted from Fig. 3. Pain control guideline after implant surgery. Acetaminophen is the first choice analgesic of common implant surgery. (Adapted from 대한치과마취과학회, 치과마취과학, 둘째판, 서울, 군자출판사, 2010; 657). 천장효과 (Ceiling effect) 를볼수있다. Acetaminophen 600/650 mg에서 1,000 mg으로증량한다고해도 NNT는크게변하지않는다. Naproxen의경우도 200/220 mg에서 400/440 mg으로증량할경우 NNT는감소하지만 500/550 mg으로증량해도크게변하지않는다. Diclofenac도비슷한경향을보인다. Acetaminophen과 Tramadol에서도각약의단독복용보다는혼합약제의복용이 NNT를크게감소시켜주는것을보여준다. 이는서로다른경로의통증전달기전을억제하기때문이다. 또한 COX-2 억제제의경우전통적인 NSAIDs에비해효과적인진통효과를보이고반감기가길어서투약횟수를줄일수있는장점이있다. 결론 일반적으로외과적시술에대한심리적자극만으로도환자는공포와불안감을느끼고, 이것은술후환자가느끼는통증을증가시키고민감하게받아들인다고알려져있다 17). 임플란트수술이환자에 Journal of Dental Implant Research 2015, 34(1) 1-6

12 6 류대승, 이덕원 : 임플란트수술전후의통증조절을위한합리적인경구진통제선택법 게가장불안감을유발시킨다는보고도있다. 환자는수면중에주위 의물리적자극이나심리적인요소의영향이최소화되기때문에, 임플란트수술전부터환자에게정서적안정감을주는것이수술전, 중, 후의통증조절에중요하며필요하다면의식하진정법을사용하는것도고려할수있다 18). 임플란트수술후통증조절을위해서는적절한약물적중재가필요하다. Ibuprofen이나 Mypol R 을이용한선행진통요법의사용은술후통증감소에유익하다. NSAIDs의선택시환자의전신상태에대한고려가필요하며가급적효력이좋고반감기가긴약물을선택하는것이좋으며, Opioids의경우치과임상적으로 Codeine 과 Tramadol을유용하게사용할수있는데단독사용은장점보다는단점이더많기때문에 NSAIDs와혼합된약물사용이서로다른통증경로를억제하기때문에추천된다. Acetaminophen은일차적으로선택할수있는비교적안전한진통제이며소염작용은없다. Ibuprofen은충분한진통효과를보이며부작용도적어소아에게처방하여도안전한진통제이다. 위장관계, 신장질환, 천식등을가지고있는환자에게는가급적 NSAIDs 는피하고 Acetaminophen이나 Tramadol을이용하여통증을조절하며, 간질환을가지고있는환자는가급적 Acetaminophen을피하는것이간독성을막을수있다.(Fig. 3) 항우울제를먹는환자에게는 Tramadol을사용하면안된다. 금기가없는한가급적 NNT가작은약물, 반감기가긴약물을사용하는것이좋으며, 전통적인 NSAIDs에부작용을보이는환자들은 COX-2억제제를사용하는것이좋다. 임플란트수술후조절되지않는급성기통증은수술에대한환자의만족도를감소시키고예후를불량하게할수있으므로 NSAIDs 및 Opioids를비롯한적절한진통제를선택하여적극적인약물적중재를시행하도록해야한다. REFERENCES 1. Bryce G, Bomfim DI, Bassi GS. Pre- and post-operative management of dental implant placement. Part 1: management of post-operative pain. Br Dent J 2014;217: Turan A, Sessler DI. Steroids to ameliorate postoperative pain. Anesthesiology 2011;115: Brodala N. Flapless surgery and its effect on dental implant outcomes. Int J Oral Maxillofac Implants 2008;24: Becker DE. Pain management: Part 1: Managing acute and postoperative dental pain. Anesth Prog 2010;57:67-78; quiz Denisco RC, Kenna GA, O'Neil MG, Kulich RJ, Moore PA, Kane WT, et al. Prevention of prescription opioid abuse: the role of the dentist. J Am Dent Assoc 2011;142: de Craen AJ, Di Giulio G, Lampe-Schoenmaeckers JE, Kessels AG, Kleijnen J. Analgesic efficacy and safety of paracetamol-codeine combinations versus paracetamol alone: a systematic review. BMJ 1996;313: Cho KS, Lee JH, Kim HY, Suh JG, Choi SH, Chai JK, et al. Pain Control Effects of Myprodol (R) after Periodontal Surgery and Dental Implant Surgery. J Korean Periodontol 2000;30: Katz J, McCartney CJ. Current status of pre-emptive analgesia. Curr Opin Anesth 2002;15: Steffens JP, Santos FA, Sartori R, Pilatti GL. Preemptive dexamethasone and etoricoxib for pain and discomfort prevention after periodontal surgery: a double-masked, crossover, controlled clinical trial. J Periodontol 2010;81: Sacerdote P, Levrini L. Peripheral mechanisms of dental pain: the role of substance P. Mediators Inflamm 2012;2012: Gonzalez-Santana H, Penarrocha-Diago M, Guarinos-Carbo J, Balaguer-Martinez J. Pain and inflammation in 41 patients following the placement of 131 dental implants. Med Oral Patol Oral Cir Bucal 2005;10: Cooper S. SINGLE-DOSE ANALGESIC STUDIES-THE UPSIDE AND DOWNSIDE OF ASSAY SENSITIVITY. LIPPINCOTT-RAVEN PUBL 227 EAST WASHINGTON SQ, PHILADELPHIA, PA Forbes J. ORAL-SURGERY. Advances in pain research and therapy. 1991;18: 박수석. 암성통증관리 - 아편유사제. J Korean Med Assoc 2010; 53: Datta R, Grewal Y, Singh A, Batth J. A survey of analgesic and anti-inflammatory drug prescription for oral implant surgery. Plast Aesthet Res 2015;2: 김용태, 박정철, 윤정호, 정의원, 김창성, 조규성, et al. 임플란트수술시통증에영향을주는요인에관한평가. 대한치과의사협회지 2011;49: Berggren U, Meynert G. Dental fear and avoidance: causes, symptoms, and consequences. J Am Dent Assoc 1984;109: Aurell J, Elmqvist D. Sleep in the surgical intensive care unit: continuous polygraphic recording of sleep in nine patients receiving postoperative care. Br Med J (Clin Res Ed) 1985;290: 대한치과마취과학회, 치과마취과학, 둘째판, 서울, 군자출판사, 대한통증학회, 통증의학, 넷째판, 서울, 군자출판사, Journal of Dental Implant Research 2015, 34(1) 1-6

13 Vol. 34 No. 1, June 2015 Journal of Dental Implant Research 2015, 34(1) 7-11 자가치아뼈이식재의공여치아상태에따른예후평가 안교진, 김영균, 엄인웅 1, 김지윤 2 분당서울대학교병원치과구강악안면외과, 한국치아은행연구소 1, 단국대학교사범대학과학교육과 2 Evaluation of prognosis of autogenous tooth bone graft material according to the condition of donor tooth Gyo-Jin Ahn, Young-Kyun Kim, In-Woong Um 1, Ji-Yun Kim 2 Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, 1 R&D Institute, Korea Tooth Bank, Seoul, 2 Department of Science Education, College of Education, Dankook University, Yongin, Korea Purpose: There have been many positive clinical results of autogenous tooth bone graft materials (AutoBT) since it developed in The purpose of this study is to evaluate the prognosis of graft materials according to the condition of the donor tooth. Materials and Methods: Ninety seven patients (187 implants) who treated implant installation with a variety of bone graft using AutoBT in Seoul national university Bundang hospital from 2009 to Total 191 extracted teeth were processed to graft materials. AutoBT was calssified into 4 groups according to donor tooth condition (fresh, caries, nonvital, periodontitis). AutoBT was used in guided bone regeneration, sinus graft, socket preservation, and ridge augmentation. The delayed or simultaneous implant installation was done. We measured primary and secondary stability. Postoperative complication and implant survival rate were evaluated. Organic component of AutoBT was analyzed. Results: Most complications were wound dehiscence. There were no infections. Wound dehiscence showed favorable secondary healing. Good implant survival rate and secondary stability were obtained in all groups. Small amount of protein and type I collagen were detected in group 1 (fresh tooth) and group 2 (caries). Conclusions: There were no complications related with bone material itself and donor tooth conditions didn t affect the implant stability and survival rate. (JOURNAL OF DENTAL IMPLANT RESEARCH 2015;34(1):7-11) Key Words: Donor, Bone graft, Tooth 서론 현재치과임상에서는골결손부수복을위해다양한골이식재가사용되고있다. 그중자가골이식이가장이상적인재료라는것에는이견이없다. 하지만적은채취량, 추가적인수술에대한부담, 불가피한공여부에서의이차결손등단점이존재하는것도사실이다. 따라서오래전부터자가골을대체하기위한골이식재료의개발 및연구가시행되어왔고다양한종류의동종골, 이종골, 합성골이현재임상에서사용되고있으나각각의장단점이존재하며자가골을완전히대체하기에는부족한것이사실이다. 1993년부터사람과동물의치아를이용한실험적연구가진행되어치아를이용한 toothash라명명한골이식재가개발되었으나실용화되지는못하였다 1-6). 그런연구를기반으로 2008년 AutoBT (Korea Tooth Bank, Seoul, Korea) 라는상품명으로실용화되어자가치아골이식재가 Received February 15, 2014, Revised March 3, 2014, Accepted March 29, 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, , 경기도성남시분당구구미로 82, 173번길, 분당서울대학교병원치과구강악안면외과 Correspondence to: Young-Kyun Kim, Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, 82 Gumi-ro 173 beon-gil, Bundang-gu, Seongnam , Korea. Tel: , Fax: , kyk0505@snubh.org This study was supported by graft no from Korea Tooth Bank Research Fund. JOURNAL OF DENTAL IMPLANT RESEARCH

14 8 안교진등 : 자가치아뼈이식재의공여치아상태에따른예후평가 임상에서사용되기시작했다. 환자자신의발치된치아를이용하여최첨단의료공법을통해자가치아골이식재로제조한후동일환자의골이식술에이용할수있게되었다. 임상적용이후의많은실험적, 임상적인연구를통해매우우수한골유도및골전도에의한골치유를보인다는것이입증되었고감염에대한저항성이뛰어나며생체적합성이매우뛰어나다고판명되었다 7-12). 자가치아골이식재는환자본인의발치된치아가없이는제조가불가능하다. 따라서발치할수있는치아가존재하는환자에서만사용할수있고발치대상치아들의선택도골이식재의제조과정에서중요한부분의하나이다. 발치대상치아들은건전한사랑니, 심한우식증으로인해근관치료및수복이불가능한치아, 진행성치주염에이환된치아, 과거에근관치료되었던치아들로서치주및근단부염증이진행된것들이포함된다. 자가치아골이식재와관련된실험및임상연구를통해그효능과안정성은증명되었지만공여치아들의상태에따라가공처리된골이식재의성능에차이가있지않을 까하는의문에서이번연구가계획되었다. 본연구에서는발치된치아들의상태에따라자가치아골이식재를분류하여골이식술이후의합병증과그부위에식립된임플란트의안정성을평가하고각각의공여치들의유기성분을분석하여차이가있는지평가하고자하였다. 대상및방법 본연구는분당서울대학교병원생명윤리심의위원회의승인 (IRB ) 하에시행되었다. 2009년부터 2010년까지분당서울대학교병원에서임플란트를식립하면서골결손부위에자가치아골이식재를사용한환자들을대상으로하였다. 총 97명의환자에서 191개의치아가발치되어자가치아골이식재 (AutoBT, Korea Tooth Bank, Seoul, Korea) 로제조되었고, 187개의임플란트가식립되었다. 자가치아골이식재는골유도재생술, 상악동골이식술, 발 Table 1. Types of bone grafts using AutoBT Group Sinus graft GBR Socket preservation Ridge augmentation Total Total GBR: guided bone regeneration. Fig. 1. Group 1. Fresh impacted tooth. Fig. 3. Group 3. Hopeless nonvital tooth. Fig. 2. Group 2. Unrestorable severe caries. Fig. 4. Group 4. Severe advanced periodontitis. Journal of Dental Implant Research 2015, 34(1) 7-11

15 Ahn GJ, et al: Evaluation of prognosis of autogenous tooth bone graft material according to the condition of donor tooth 9 치창보존술, 치조능증대술에사용되었으며임플란트의지연식립혹은동시식립이함께시행되었다 (Table 1). 자가치아골이식재는대부분분말형태로제조되었으나블록형태로제조된것도일부있었으며자가골, 동종골, 이종골, 혹은합성골과혼합하여사용하기도하였다. 4 증례에서는자가골, 24 증례에서동종골, 23 증례에서이종골을그리고 4 증례에서는합성골을자가치아골이식재와혼합하여사용하였다. 이번연구에서는공여치아상태에따른비교를위해 4 group으로자가치아골이식재를분류하였다. Group 1은병적인상태에전혀이환되지않은신선한치아로가공된자가치아골이식재로분류하였고이는대부분사랑니였다. Group 2는심하게치아우식증에이환되어발치된치아로가공된것, Group 3는이전에근관치료를시행한후발치하게된실활치 (nonvital tooth) 로가공된것, Group 4는심한치주질환에이환되어발치를하게된치아로가공된자가치아골이식재로분류하였다.(Fig. 1-4) Group 1에서는총 14개의치아가발치되어자가치아골이식재로제조되었고 17개의임플란트식립부위에서골이식술시사용되었다. Group 2에서는 25개의치아가발치되어 21개의임플란트식립부위에서사용되었고, Group 3에서는 35개의치아들이발치되어 36개의임플란트식립부위에서골이식술에사용되었으며 Group 4에서는 117 개의치아가발치되어 112개의임플란트식립부위에서사용되었다. 각집단에서의골이식술후합병증과임플란트생존율을평가하였다. Osstell TM Mentor (Gothenborg, Sweden) 를이용하여임플란트식립직후일차안정도 (primary stability) 와이차수술혹은첫인상채득시점에이차안정도 (secondary stability) 를측정하였으며 ISQ (Implant stability quotient) value의변화를비교하였다. 골이식술후평균경과관찰기간은 22.9개월이었다. 공여치아상태에따른유기질의변성여부를평가하기위해 4가지그룹의발치된치아들을각각 2개씩선택하여자가치아골이식재로제조한후분석을시행하였다. Group 1은건전한매복치, Group 2는진행성우식증으로발치한치아들, Group 3는근관치료를받았던비활성치아, Group 4는진행성치주질환으로발치한치아들이었다 (Table 2). 제조된치아골이식재시편들을대상으로 SDS-PAGE (20 25 o C), Silver staining, Western-blotting (antibody, R&D corp., USA) 을시행하였다. Table 3. Kinds of complications Group Wound dehiscence Hematoma Total Total 결 과 1. 술후합병증및임플란트생존율 총 187개임플란트식립부위중 23개부위 (12.3%) 에서술후합병증이발생하였다. 심한치아우식군 (Group 2) 에서 18.18% 로가장높은비율로관찰되었고, 심한치주질환군 (Group 4) 에서도 13.39% 로비교적높게나타났다. Fresh tooth (Group 1) 와 Non-vital tooth (Group 3) 에서는각각 5.88%, 5.56% 로비교적낮은비율의합병증이관찰되었다 (Table 2). 술후합병증은총 23 개중 21개가창상열개로대부분을차지하였고혈종이 2 증례에서발생하였다 (Table 3). 술후합병증은특별한처치없이보존적인처치만으로모두좋은 2차치유를보였다. 또한술후감염증상을보인증례는한건도관찰되지않았다. 최종경과관찰시점까지의임플란트생존율은 Group 1, 2, 3, 4에서각각 94.12%, 95.46%, 97.22%, 96.43% 였다 (Table 2). 2. ISQ (Implant stability quotient) value 2차수술혹은첫인상채득시측정한 ISQ value는 Group 1, 2, 3, 4에서각각 76.07, 72.90, 74.82, 73.84로충분히높은이차안정도를지니고있는것으로관찰되었으며, 모든집단에서식립시에비해증가된 ISQ value를보였다. Group 2에서 3.66으로가장낮은증가량을보였으나 ISQ value는 72.90으로다른집단과큰차이없이충분히높은안정도를지닌것으로관찰되었다 (Table 4). 3. 유기성분분석 Group 1 (fresh tooth), 2 (caries) 에서 60 kda의 osteopontin, 110 kda, 120 kda에서 2 chain, 1 chain의 type I collagen과소량의단백질들이검출되었으나 Group 3, 4에서는검출되지않았다.(Fig. 5) Table 2. Complications and survival rate* Group Complication rate Survival rate Average 5.88% 18.18% 5.56% 13.39% 12.30% 94.12% 95.46% 97.22% 96.43% 96.26% Table 4. ISQ value Group Primary stability Secondary stability Increase Journal of Dental Implant Research 2015, 34(1) 7-11

16 10 안교진등 : 자가치아뼈이식재의공여치아상태에따른예후평가 Fig. 5. Small amount of protein and type I collagen were detected in group 1 and 2. 고 찰 치아골이식재의학술적근거는 1993 년이후발표된치아회분말 실험및논문을통해고온에서회화시킨동종및이종치아회분말의안전성및골전도성치유능력이밝혀진바있다 1-6). 치아회분말은 o C의고온에서 분간회화한후분쇄하여불순물을제거하여치아회분을제작하였고이는세포독성및과민성실험결과세포독성및특이한과민반응이없었다고보고되었다 13). 치아는 calcium phosphate inorganic component 와 collagen 및 other organic component로이루어진유무기복합체로알려져있다. calcium phosphate는주로 (hydroxyapatite (HA, Ca 10(PO 4)6(OH) 2) 로이루어진것으로알려져있고그외에 TCP (tricalcium phosphate, Ca 3(PO 4) 2), ACP (amorphous calcium phosphate), OCP (octacalciucm phosphate) 등이미량이지만균질하게분포되어있을것으로추측된다. 김등이발표한자가치아골이식재의무기성분에대한연구에의하면치아의열처리후법랑질의 4.7%, 상아질의약30% 의무게감량이있었다고한다. 이는열처리를통해대부분의 collagen 등유기물과물등이분해, 휘발되고 HA, TCP, OCP, ACP 등의광물만이남았음을의미한다 10). 자가치아골이식재는탈회과정을통해유기질과적절한강도의무기질을함께유지되도록만들어졌다. 또한탈회과정은세균오염을감소시킬수있으며이식후에도감염의위험성없이골유도성치유를발휘할수있다 14,15). 김등의보고에의하면골이식술후창상이일부벌어지며노출되는합병증이발생하더라도자가치아골이식재는감염에대한저항성이우수하고자가골이식에서기대할수있는 2차치유가잘이루어진다고하였다 7). 이번연구에서는 12.3% 에서술후합병증이발생하였고상대적으로심한우식이나치주질환을가지고있던치아로처리한이식재에서높은비율의합병증이 관찰되었다. 그러나발생한합병증은골이식재와직접적인연관성은없었으며수술과정과연관된합병증들이었다. 모든증례들에서술후감염이발생하여실패로이어진경우는없었고대부분의합병증은창상열개였으나모두보존적인처치만으로성공적인 2차치유가잘이루어졌다. 임플란트생존율은모든그룹에서유사하게높은결과를보였고이차안정도역시높게나타난것을볼때모든유형의자가치아골이식재는양호한치유를보이면서임플란트주변결손부수복에좋은결과를보였음을의미한다. 탈회시킨치아의상아질기질내에골유도성단백질이존재한다는것은많은학자들의연구를통해밝혀졌다 16-26). SDS-PAGE and western blotting test를시행한결과자가치아골이식재분말에서 BMP-2를검출하진못하였다. 그러나 kda에서미세한밴드가존재하는것이관찰되었는데정제과정중에 BMP가일부변성된흔적으로추정된다고하였다. 단백질검출에실패한원인은 10% H2O2로처리하는과정중에상아질콜라겐과단백질의변성, 근관치료된치아들의경우 sodium hypochlorite에의한단백질의변성, 검사대상시료의양이너무적었던것으로추정하였다. 그러나동물실험을통한조직학적연구에서골유도성치유소견이관찰된것으로보아치아골이식재내부에골형성을유도하는단백질과 type I collagen이존재하는것은분명하다고하였다 27). 본연구에서건전한치아, 진행성치아우식증, 치주질환, 실활치들로제조한자가치아골이식재의유기성분의차이를알아보기위한분석을시행하였지만시편의수와양이너무적어서세부적인단백질추출이실패한것으로생각된다. 특히치주질환에이환된것과실활치아들에서단백질들이검출되지않았음에도불구하고임상적으로 4가지종류의자가치아골이식재모두양호한골치유가이루어졌던것을볼때우수한골유도및골전도능력이존재하고있음을추정할수있다. 그러나추후많은시료들을이용하여실활치들과진행성치주질환에이환된치아들로제조한자가치아골이식재의유기성분분석을다시시행할필요가있다고사료된다. REFERENCES 1. Kim YK, Yeo HH, Ryu CH, Lee HB, Byun UR, Cho JE. An experimental study on the tissue reaction of toothash implanted in mandible body of the mature dog. J Korean Assoc Maxillofac Plast Reconstr Surg 1993;15: Kim YK, Yeo HH, Yang IS, Seo JH, Cho JO. Implantation of toothash combined with plaster of paris: Experimental study. J Korean Assoc Maxillofac Plast Reconstr Surg 1994;16: Kim YK, Yeo HH. Implantatin of toothash combined with plaster of paris: clinical applications. J Korean Assoc Maxillofac Plast Reconstr Surg 1994;16: Kim YK, Yeo HH, Cho JO. The experimental study of implantation combined with toothash and plaster of paris in the rats: comparison according to the mixing ratio. J Korean Assoc Maxillofac Plast Reconstr Surg 1996;18: Journal of Dental Implant Research 2015, 34(1) 7-11

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18 Vol. 34 No. 1, June 2015 Journal of Dental Implant Research 2015, 34(1) 인접자연치를침범한임플란트와침범받은자연치의임상적예후 구정귀 1, 윤필영 1, 최용훈 2, 이양진 3,4, 안교진 1, 이희진 1, 김영균 1,4 분당서울대학교병원치과구강악안면외과 1, 분당서울대학교병원치과보존과 2, 분당서울대학교병원치과보철과 3, 서울대학교치의학대학원, 치학연구소 4 The clinical prognosis of implants invading the adjacent natural tooth and invaded teeth Jeong-Kui Ku 1, Pil-Young Yun 1, Yong-Hoon Choi 2, Yang-Jin Yi 3,4, Kyo-Jin Ahn 1, Heejin Lee 1, Young-Kyun Kim 1,4 1 Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, 2 Department of Conservative Dentistry, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, 3 Department of Prosthetic Dentistry, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, 4 Department of Dentistry, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea Purpose: There is always a risk of invasion of the implant into adjacent tooth. The purpose of this study is to evaluate the clinical outcome of the implant and the invaded adjacent natural tooth when the implant directly invades the adjacent tooth or comes close to it. Materials and Methods: The present study was conducted on patients of Seoul National University Bundang Hospital who had received implant placements that implant directly invaded an adjacent tooth or came close to the root of the adjacent tooth ( 1 mm). Among a total of 35 patients (19 males, 16 females, mean age 61.2±11.1), 39 implants were investigated. The implants which invaded natural teeth were classified into three types (direct invasion, contact with the root of the tooth, and being close to the root of the tooth with less than or equal to 1 mm distance) using a periapical radiograph. The survival rate of the implants and clinical prognosis of the invaded teeth were investigated. Results: The most invaded natural teeth were canine and premolars. Among the invaded teeth, 39 teeth that had a proper medical record were investigated. Direct invasion had occurred in 12 cases, contact with the root of the tooth in 13 cases, and being close to the root of the tooth ( 1 mm distance) in 14 cases. A total of two implants failed and removed, and the average survival rate was 94.9%. As for the state of invaded natural teeth, 27 teeth (69.2%) functioned in a sound and vital state. Three invaded teeth (7.7%) were extracted and nine teeth (23.1%) functioned without problems after receiving root canal treatment. Conclusions: Within the limitation of and short-term evaluation, invasion of implant to adjacent tooth would have a minor influence on the prognosis of a tooth and outcomes of an implant when an appropriate root canal treatment was performed in cases of pulp necrosis through regular checkups. (JOURNAL OF DENTAL IMPLANT RESEARCH 2015;34(1):12-21) Key Words: Dental implant, Injury, Damage, Invasion, Tooth, Periodontal ligament 서론 임플란트는치조골, 인접치및대합치의상태에따라식립위치가결정된다. 치조골의상태에따라식립각도에제한이있는경우가있 으며, 주변인접치의해부학적배열상태에따라임플란트식립위치및각도를고려해야한다 1). 그러나전치나소구치부위같이상실부위의폭이좁거나주위치아의치근에비정상적인 curvature가있는경우에임플란트를식 Received March 11, 2015, Revised March 30, 2015, Accepted April 21, 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, , 경기도성남시분당구구미동 300, 분당서울대학교병원치과구강악안면외과 Correspondence to: Young-Kyun Kim, Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, 300, Gumi-dong, Bundang-gu, Seongnam , Korea. Tel: , Fax: , kyk0505@snubh.org JOURNAL OF DENTAL IMPLANT RESEARCH

19 Ku JK, et al: The clinical prognosis of implants invading the adjacent natural tooth and invaded teeth 13 립하면서주변치아들을침범할위험이항상존재한다. 또한임플란트식립시주변인접치를침범하는것은주로부적절한식립각도, 인접치와거리계측오차, 잔존치조골의폭과높이부족으로넓은직경의임플란트를식립하는경우에발생할수있다. 2013년 Yoon 등은임플란트 fixture에의해치아손상이발생한 3명의환자를대상으로한증례를보고하였다. CBCT를촬영하여임플란트와인접자연치의위치관계를확인한결과자연치와근접했지만인접치의 periodontal ligament은손상되지않은임플란트 1개와인접치치근과닿은임플란트 2개중임플란트와손상받은치아모두 1년이상방사선학적임상적으로부정적인증상이없었다는것을발표한바있다 2). 그러나그들의연구는적은환자수와짧은경과관찰기간으로그예후판단에한계가있다. 임플란트식립시인접치손상과관련한연구들은대부분 orthodontic mini-implant와관련된논문들이고 dental endosseous implant와관련된논문은매우드물었다. 따라서본연구의목적은임플란트가인접한자연치를직접침범하거나근접했을때다수의임플란트및침범받은자연치들의장기적인임상적인예후를평가하는것이다. 대상및방법 본연구는분당서울대학교병원치과에서 2004년 1월부터 2010 년 12월까지임플란트를식립한환자들중임플란트가인접한자연치를직접침범하거나치근에 1 mm 이하의거리로근접한환자들을대상으로하였다. 총 35명의환자 ( 남자 19, 여자 16, 평균나이 61.2세 ) 에서 39개의식립부위가연구대상에해당되었으며수술이후평균 64.3±36.28개월 ( 최소 8.5개월, 최대 127.3개월 ) 경과를관찰하였다. 본연구는분당서울대학교병원 Institutional Review Board의승인 (IRB No. B ) 하에시행되었다. 침범받은자연치의치근부위를치근단방사선사진을통해침범유형을다음과같이분류하였다 : 직접침범 (Group I),(Fig. 1) 치근과접촉 (Group II),(Fig. 2) 치근과 1 mm 이하로근접 (Group III) (Fig. 3) 방사선사진및임상검사를통하여침범받은자연치의술전임상적상태를건전, 근관치료가시행된상태, 기타 ( 우식증, 파절, 치주염또는치근단병소 ) 로구분하였다. 경과관찰기간도중침범받은자연치의임상적인예후와시행된치료의종류를조사하였다. Osstell Mentor (Osstell R, Gothenburg, Sweden) 로측정되었던임플란트초기및이차안정도 (primary and secondary stability) 를조사하였고, 술후합병증을조사하였다. Implant stability quotient (ISQ) 변화는 paired-t test, 각그룹별 ISQ 차이는 one-way ANOVA, 임플란트의생존율에관하여 One-Sample t-test, 그리고상악과하악의임플란트생존율차이에대하여 Independentsample t-test를시행하였다 (SPSS Inc., Chicago, IL, USA). Fig. 1. Implant invaded the adjacent tooth directly (Group I). Fig. 2. Implant was contacted with root surface (Group II). Fig. 3. Implant approached to the root of the tooth with less than or equal to 1 mm distance (Group III). Journal of Dental Implant Research 2015, 34(1) 12-21

20 14 구정귀등 : 인접자연치를침범한임플란트와침범받은자연치의임상적예후 결과 총 39개임플란트가인접치를침범하였다. 임플란트의식립부위는중절치 1개, 견치 1개, 제 1소구치 15개, 제 2소구치 7개, 제 1대구치 12개, 제 2대구치 3개로대부분소구치부위의식립시인접치를침범하는양상을보였다. 침범받은자연치는측절치 2개, 견치 13개, 제 1소구치 7개, 제 2소구치 14개, 제 1대구치 3개로대부분견치및소구치부위의치아들이침범을받았다. 침범받을당시자연치의상태는 28개는생활력이있는건전한상태였고, 7개는근관치료후정상적으로기능하고있는상태였으며, 나머지 4개는치관파절, 치근단병소, 심한치주염상태에있는치아들이었다. 침범유형에따라분류를해보면직접침범 12개, 치근과접촉 13개, 치근과 1 mm 이하로근접 14개로조사되었다 (Table 1). 39개의임플란트중총 2개의임플란트가실패하여제거되었으며평균생존율은 94.87±0.22% 였다. 상악에식립된 19개임플란트의평균생존율은 94.74±0.22%, 하악의 20개임플란트는 95.00± 0.22% 로상악과하악에따른통계학적차이는보이지않았다 (Table 2). Osstell을이용하여측정한 primary stability는 65.92±12.02 ISQ였고, secondary stability는 72.82±7.50 ISQ 로통계적으로유의하게증가한것이관찰되었다 (P<0.05) (Table 3). 각그룹별 stability는통계적으로유의한차이를보이지않았다 (P>0.05) (Table 4). 침범받은자연치들중생활력이있던 30개의치아들중 20개는특별한부작용을보이지않았고 5개의치아는 pulp necrosis로 root canal treatment 후별다른문제없이기능중이며, 심한치근만곡이있던 1개의치아는발치되었다.(Fig. 4) 근관치료가된치아중근단에병소가있던 1개의치아와심한치주염상태에있던치아도임플란트식립이후발치하게되었다.(Fig. 5, 6) 한편근단에병소가있던치아 1개와치아파절이심한치아 1개는근관치료를시행한후문제없이기능하였다. 총침범받은자연치 39개중 3개 (7.7%) 가발치되었고 9개 (23.1%) 가근관치료후특별한문제없이기능중이며, 27개 (69.2%) 가별다른처치없이정상기능을하였다 (Table 5). Table 1. Location and state of invaded natural teeth and invading implants Location State Installation of implant Central incisor 1 Direct invasion 12 Canine 1 1 st premolar 15 Contact with the root of the tooth 13 2 nd premolar 7 1 st molar 12 Close to the root of the tooth 1 mm distance 14 2 nd molar 3 The invaded adjacent tooth Sound 28 Lateral incisor 2 Prior RCT 7 Canine 13 Etc (Crown fracture, Periapical lesion, 4 1 st premolar 7 severe periodontitis) 2 nd premolar 14 1 st molar 3 RCT: root canal treatment. Table 2. Independent samples t-test for detect differences of survival rate between mandible and maxilla Mandible Maxilla Levene's Test for Equality of Variances T-test for Equality of Means N Mean SD N Mean SD F Sig T Df Sig. (2-tailed) Survival rate Table 3. Paired samples test for detect differences between initial and second stability by using osstell mentor Initial stability Second stability Paired differences between initial and second stability Mean SD Mean SD Mean Std. Deviation T Df Sig. (2-tailed) Stability measurement used by osstell mentor Group I Group II Group III Journal of Dental Implant Research 2015, 34(1) 12-21

21 Ku JK, et al: The clinical prognosis of implants invading the adjacent natural tooth and invaded teeth 15 Table 4. One-way ANOVA for detect differences among the groups of invasive type in initial and second stability Sum of Squares Df Mean Square F Sig. Initial stability Between Groups Within Groups Total Second stability Between Groups Within Groups Total Fig. 4. Implant was contacted with the severely curved root. Finally the invaded tooth was extracted. Fig. 5. (A, B) Re-root canal treatment was performed before implant placement. (C) Periapical view 3 months after implant placement. Root of adjacent tooth was invaded by implant. (D) Periapical radiograph 5 months after implant placement. (E) Periapical radiograph 18 months after implant placement. Periapical radiolucency was increased. (F) Periapical radiograph 42 months after implant placement. Invaded tooth was decided to be ectracted. (G) Periapical radiograph 9 months after extraction of invaded tooth. Journal of Dental Implant Research 2015, 34(1) 12-21

22 16 구정귀등 : 인접자연치를침범한임플란트와침범받은자연치의임상적예후 Fig. 6. (A) Initial panoramic radiograph. Alveolar bone was resorbed more than 1/3 of #33 root. (B) Postoperative periapical view. Root of #33 was contacted with implant. (C) Periapical radiograph 4 months after implant placement. (D) Panoramic radiograph 10 months after implant placement. (E) The invaded tooth was extracted and implant was placed immediately after 11 months. (F) Periapical radiograph 30 months after implant placement. 1. 각 group별임플란트와침범된자연치의임상적예후 1) Group I: 자연치치근을직접손상시킨임플란트와침범받은자연치총 12개증례로평균 69.81±47.07개월동안경과관찰이이루어졌다. 1개의임플란트는지속적인임플란트주위염에의한골소실로식립 8.5개월후제거하였고, 1개의임플란트는 1차와 2차 osstel 측정시각각 75와 69가기록되었지만, 골유착실패로식립 11.6개월후제거하였다. 결국총 2개의임플란트가실패하여생존율은 83.33±38.92% 였다.(Fig. 7, 8) 12개임플란트의 1차와 2차안정성은각각 72.17±11.34와 71.16±7.81로이차안정성이약간감소한양상을보였으나통계적으로유의성있는차이는없었다. 1개의건전하던치아 (#23) 는임플란트식립후 maxillary sinusitis과함께치수의괴사되는것이관찰되어임플란트식립 4.1개월후근관치료를시행하였고 (Fig. 9) 다른 1개의치아는자연치에대한특별한기록없이 6개월간격의경과관찰기간동안타병원에서 RCT를받았다. 그외건전했던나머지치아들은특이증상은없었다. 기존에 periapical radiolucent lesion이있던치아 (Fig. 5) 는임플란트식립 44.4개월후발치되었고, caries가심했던치아 (Fig. 10) 1개는임플란트식립 4.7개월후근관치료가시행되었다 (Table 6). Table 5. Clinical prognosis of invaded natural teeth Number (39) No change % RCT after implantation % Extraction after implantation % 2) Group II: 자연치치근과접촉된임플란트와자연치총 13개증례는평균 62.70±25.47개월동안경과관찰이이루어졌다. 경과관찰기간도중모든임플란트는특이증상없이기능했다. 13개임플란트의 1차와 2차안정성은각각 64.44±13.37와 76.06± 7.93으로통계적으로유의하게증가되었다 (P<0.05). 침범된인접치들중한개의치아는임플란트식립 5.9개월후신경괴사로근관치료가시행되었고, 다른 1개의치아는자연치에대한특별한기록없이 1년간격의경과관찰기간동안타병원에서 RCT를받았다. 기존에치근단병소가있던 1개의치아 (Fig. 11) 는임플란트식립 1 개월후근관치료를하였으며나머지인접자연치들은특이증상은없었다 (Table 7). Journal of Dental Implant Research 2015, 34(1) 12-21

23 Ku JK, et al: The clinical prognosis of implants invading the adjacent natural tooth and invaded teeth 17 Fig. 7. (A) Periapical radiograph after implant placement. Nonvital root of adjacent 2nd molar was invaded by implant. (B) Periapical radiograph 2 weeks after implant placement. (C) Periapical radiograph 4 months after implant placement. Marginal bone was lost around the implant. (D) Implant was mobile and removed 6 months after implant placement. (E) Ultrawide implant was re-installed with bone graft. (F) Periapical radiograph 12 months after re-implant. Crestal bone level is stable. Fig. 8. (A) Periapical radiograph after implant placement. Root surface was invaded directly by implant. (B) Periapical radiograph 4 months after implant placement. (C) Periapical radiograph 12 months after implant placement. Peri-implant bone loss and mobility were developed. (D) The mobile implant was removed and replaced immediately after 13 months. (E) Periapical radiograph 3 months after re-implanation. (F) Periapical radiograph 12 months after re-implantation. Marginal bone level was stable around the implant. The invaded root surface was repaired. 3) Group III: 자연치치근과 1 mm 이내로근접한임플란트와 자연치 총 14 개증례로서평균 16.74±31.92 개월경과관찰이이루어졌 다. 경과관찰기간도중모든임플란트는특이증상없이기능했다. 14 개임플란트의 1 차와 2 차안정성은각각 61.14±13.21 와 74.00± 8.70 으로 2 차안정성이더증가한것으로보이나, 통계적으로유의 Journal of Dental Implant Research 2015, 34(1) 12-21

24 18 구정귀등 : 인접자연치를침범한임플란트와침범받은자연치의임상적예후 하지는않았다. 건전했던치아들중 1개는임플란트식립 8.4개월후근관치료가시행되었고, 치관파절이있던치아 1개와치근단병소가있던치아 1개는각각임플란트식립 10.3개월, 61.1개월후근관치료가시행되었다.(Fig. 12) 심한치주염에이환된치아 1개는임플 란트식립 10.4개월후그리고우식증이진행되었으나만곡된치근으로근관치료가어려웠던 1개의치아는임플란트식립 65.0개월후발치되었다 (Table 8).(Fig. 13) 고찰 여러문헌들에서 root의 cementum과그주변의치주조직은손상받은후회복이될수있다고알려져있다 3-6). 교정용미니스크류 Fig. 9. Root canal treatment was performed in the invaded natural tooth. Fig. 10. The curved root apex of the 2 nd premolar was contacted with the implant. Distal decay is observed. Table 6. Clinical prognosis of the natural teeth and implants which implants invaded the adjacent tooth directly (Group I) Implant Number (12) Nature tooth Number (12) Survival % No change % Failure % RCT after implantation % Extraction after implantation % Fig. 11. (A) Preoperative panoramic radiograph. Periapical radiolucency is shown at right 1 st implant placement. The implant was contacted with adjacent tooth root. premolar. (B) Periapical radiograph after Journal of Dental Implant Research 2015, 34(1) 12-21

25 Ku JK, et al: The clinical prognosis of implants invading the adjacent natural tooth and invaded teeth 19 Table 7. Clinical prognosis of the natural teeth and implants which implant was contacted with root surface (Group II) Implant Number (13) Nature tooth Number (13) Survival % No change % Failure % RCT after implantation % Extraction after implantation % Fig. 12. (A) Periapical radiograph after implant placement. Implant approached to the root of the adjacent tooth with less than or equal to 1 mm distance. (B) Periapical radiograph 34 months after implant placement. (C) Periapical radiograph 59 months after implant placement. Radiolucency was increased. (D) Intentiona replantation of invaded premolar was performed 60 months after implant placement. (E) Periapical radiograph 67 months after implant placement. Periapical radiolucent lesion was disappeared. Fig. 13. (A) Periapical radiograph after implant placement. Implant was contacted with curved root apex. (B) Periapical radiograph 12 months after implant placement. (C) Periapical radiograph 41 months after implant placement. (D) Periapical radiograph 64 months after implant placement. Advanced caries was observed in mesial side of 2nd premolar. This tooth was extracted. (E) Periapical radiograph 115 months after implant placement. 3-unit bridge was mounted. Table 8. Clinical prognosis of the natural teeth and implants which implant approached to the root of the tooth with less than or equal to 1 mm distance (Group III) Implant Number Nature tooth Number Survival % No change % Failure 0 RCT after implantation % Extraction after implantation % 연구에서치아의치근들이근접하거나해부학적변이또는미니스크루임플란트의식립방향이잘못설정되어미니스크류가치주인대나치근을침범할때에도탈락가능성이높다고한다 7). 강등의동물실험에서미니스크류가치근에접촉되게식립한경우탈락율은 79.22% 으로치조골에식립된경우의 8.3% 에비해유 의하게낮은결과를보고하였다. 또한침범된치근의손상이적은대부분의경우접촉되었던미니스크류제거후골또는백악질과유사한조직으로치유되며임플란트제거시정상적인 PDL과치근의원래형태를회복하였으나, 일부에서골유착을보이거나치근의원래형태를회복하지못했다. 미니스크류를제거하지않은표본에 Journal of Dental Implant Research 2015, 34(1) 12-21

26 20 구정귀등 : 인접자연치를침범한임플란트와침범받은자연치의임상적예후 서미니스크류의동요도없이 dense bone surrounding the mini-srcrew되어있는소견이관찰되기도하였고, 치근에서는손상부가상아질이나백악질이아닌다른광화물로일부치유된것이관찰되었다 8). 또한 Asscherickx (2005) 의동물실험에서는임플란트에손상받은치아는대부분정상치주조직 (cementum, periodontal ligament, bone) 으로재생된다고보고한바있다. 그러나 Jagangiri (2005) 은 6마리개를대상으로한실험에서치아와임플란트가 contact 되었을때모든임플란트는 osseointegration이된것이관찰되었으나, 4마리개에서만 periodontal ligament like formation이관찰된다고보고한바있다. 따라서가능한 CT 등의방사선학적사진을이용하여치아및인접해부학적구조물에손상이가해지지않도록주의하는것은필요하다 9-11). 그러나교정치료시사용하는고정스크류가자연치의치근과접촉된대부분치아들을경과관찰해보면비정상적인동요도를보이지않으며생활력이유지된다는것을알수있다 12-14). Hembree 등의연구에따르면미니스크류임플란트식립후치아, 치주조직의명확한손상을가할수있으며, 대부분의치아는그들의부착상태의재생이되었지만, 일부또는재생되지않는경우도상당수있다고하였다 15). 그러나치주인대강을침범함으로서혈행공급을방해하여치수의생활력을잃어치근단병소를야기할가능성이있다 16). 치근흡수가호발하는환경은혈행이잘되는결체조직이없거나광화된조직으로덮혀있지못할때, 그리고외상이나세균에의해염증성자극을받을때이다 17). 따라서치주조직이회복을할때만성적인자극을받으면, 치근이흡수되고유착이되는위험이증가한다 18). 이번연구의결과에서우식이나치주염과같은인접임플란트외적인요인에의해추가적인치료가필요한경우는있었으나, 기존에건전했던치아들중에서는각그룹당 1개치아만신경이괴사되는소견으로근관치료를시행하였다. 따라서임플란트가인접자연치에손상을준정도와자연치의임상적예후에악영향을끼치는정도는상관관계가뚜렷하지않은것으로보인다. 또한인접자연치와근접하게식립된전체임플란트의평균생존율은 94.74% 로일반적인임플란트생존율과크게다르지않는다 1). 그러나실패한임플란트는모두치근을직접손상시킨그룹중에서발생하였고, 통계적으로유의성은없었지만 ISQ가감소하는양상을보여치근을직접손상시킨경우 (Group I) 가다른경우에비해임플란트예후에좋지않은것으로생각된다. 침범받은자연치의경우기존치근단방사성투과상병소, 우식, 치주염, 치관파절등외적인요인으로인한추가적치료가필요한치아가있었다. 2개의자연치에서각각 6개월, 12개월의경과관찰기간동안해당치아에대한기록없이외부병원에서근관치료를받은것을제외하고, 외부요소와관계없이직접인접치를침범, 접촉, 1 mm 이내로근접한각그룹모두각각 1개치아는뚜렷한이유없이치수가괴사되어임플란트식립 4.1, 5.9, 8.4개월후근관치료를시행하였다. 그러나발치를해야할정도로증상이악화된 경우는없었다. 따라서본연구결과에따르면임플란트가따라서임플란트식립시인접자연치와근접한경우정기적추적관찰을통한조기치료를통해증상이악화되어심각한합병증이발생하지않도록해야할것으로생각된다. 이번연구는인접한자연치와임플란트와의위치관계를 2차원적인치근단방사선사진만으로판단하였기에그한계가있고, 임플란트와인접한자연치와의해부학적위치관계를정확하게알기위하여 3차원적방사선사진과더많은수의임플란트와침범받은자연치에관한장기적인연구가필요할것으로사료된다. 결 론 임플란트가인접자연치를침범했을때전체임플란트생존율은통상의경우와크게다르지않았다. 임플란트식립시인접자연치를침범하였을때자연치에심각한부작용이나타나는경우는드물었다. 치수괴사로근관치료가필요한경우는있었지만, 건전한치아가발치까지이어지는경우는없었다. 따라서정기적인관찰을통해적절한치료가이루어진다면치아나임플란트의예후에심각한악영향은미치지않는것으로판단된다. REFERENCES 1. Chee W, Jivraj S. Failures in implant dentistry. Br Dent J 2007; 202: Yoon WJ, Kim SG, Jeong MA, Oh JS, You JS. Prognosis and evaluation of tooth damage caused by implant fixtures. J Korean Assoc Oral Maxillofac Surg 2013;39(3): W.J. Grzesik, A.S. Narayanan. Cementum and periodontal wound healing and regeneration. Crit Rev Oral Biol Med 2009;13: Schupbach, T. Gaberthuel, F. Lutz, B. Guggenheim. Periodontal repair or regeneration: structures of different types of new attachment. J Periodontal Res 1993;28: L. Hellden. Periodontal healing following experimental injury to root surfaces of human teeth. Scand J Dent Res 1972;80: Garrett, G. Bogle, D. Adams, J. Egelberg. The effect of notching into dentin on new cementum formation during periodontal wound healing. J Periodontal Res 1981;16: K. Asscherickx, B.V. Vannet, Wehrbein, M.M. Sabzevar. Success rate of miniscrews relative to their position to adjacent roots. Eur J orthod 2008;30(4): Kang YG, Kim JY, Lee YJ, Chung KR, Park YG. The stability of miniscrews invading the dental roots and the effect on the periodontal tissues in beagle dogs. Angle Orthod 2009;79(2): K. Asscherickx, B.V. Vannet, H. Wehrbein, M.M. Sabzevar. Root repair after injury from mini-screw. Clin Oral Implants Res 2005;16: L. Jahangiri, R. Hessamfar, J.L. Ricci. Partial generation of pe- Journal of Dental Implant Research 2015, 34(1) 12-21

27 Ku JK, et al: The clinical prognosis of implants invading the adjacent natural tooth and invaded teeth 21 riodontal ligament on endosseous dental implants in dogs. Clin Oral Implants Res 2005;16: T. Ishii, K. Nojima, Y. Nishii, T. Takaki, H. Yamaguchi. Evaluation of the implantation position of mini-screws for orthodontic treatment in the maxillary molar area by a micro CT. Bull Tokyo Dent Coll 2004;45: F. Roccia, A. Tavolaccini, A. Dell'Acqua, M. Fasolis. An audit of mandibular fractures treated by intermaxillary fixation using intraoral cortical bone screws. J Craniomaxillofac Surg 2005; 33: G.L. Borah, D. Ashmead. The fate of teeth transfixed by osteosynthesis screws. Plast Reconstr Surg 1996;97: G. Fabbroni, S. Aabed, K. Mizen, D.G. Starr. Transalveolar screws and the incidence of dental damage: a prospective study. Int J Oral Maxillofac Surg 2004;33: M. Hembree, P.H. Buschang, R. Carrillo, R. Spears, P.E. Rossouw. Effects of intentional damage to the roots and surrounding structures with miniscrew implants. Am J Orthod Dentofacial Orthop 2009;135:280.e Sussman HI. Periapical implant pathology. J Oral Implantol 1998;24: Gold SI, Hasselgren G. Peripheral inflammatory root resorption. A review of the literature with case reports. J Clin Periodontol 1992;19: Wikesjo UM, Nilveus R. Periodontal repair in dogs. Healing patterns in large circumferential periodontal defects. J Clin Periodontol 1991;18: Journal of Dental Implant Research 2015, 34(1) 12-21

28 Vol. 34 No. 1, June 2015 Journal of Dental Implant Research 2015, 34(1) A retrospective study of Snucone implants: Clinical and radiographic results Sunam Yang, Hyunsu Lee, Hyeongi Yi, Dongwoo Lee, Heesang Lee, Hongjae Kwak, Panjun Kim, Kiwook Song, Woonheuk Jung Department of Oral and Maxillofacial Surgery, Hankook Hospital, Cheongju, Korea As osseointegration implant has become one of the important treatment methods to treat partially and fully edentulous patients, various implant systems have been developed by several manufacturers. However, there is few studies on Korean implant when compared to foreign implant. And it is true that people vaguely disbelieve Korean implant relatively. Therefore, these authors have analyzed clinical results of 5 years about 41 implants targeting the total 23 patients who had AF fixtures (Snucone, Korea) implanted in this clinic. The analytical results have found that the survival rate is 100% and the average marginal bone loss is measured 0.62±0.69 mm. And the diameter and length which were most used are 4.3 mm (61%) and 8.0 mm (46.4%) respectively. It is thought that this study needs to continue to be studied for a long time to come as the one which analyzed the clinical results gotten by monitoring the condition for 5 years after implant placement. (JOURNAL OF DENTAL IMPLANT RESEARCH 2015;34(1):22-26) Key Words: Snucone imlant, Survival rate, Retrospective studies, Dental implant INTRODUCTION Since implants were designed by Brånemark, forms and surface treatment of dental implants have continued to develop variously 1). Since implants were first applied to fully edentulous patients, they are now applied to partially edentulous patients and treatment of single-tooth loss as the range increased. As a result, dental implant has become one of important options in restoration of tooth loss and has made a great contribution to development of dental sciences. Dental implants include the advantages that restoration of defects is possible without the teeth preparation around tooth defects, they can endure higher occlusal loading than removable dentures, and masticatory efficiency is high. However, dental implants include the disadvantages that implant placement procedures are required, the placement can fail if bone density or bone volume is improper, and it should take so long from implant to prosthetic rehabilitation. It is true that implants are now forming an ever-greater part of the dental and clinical areas because of their own advantages mentioned before despite these disadvantages. Unlike the past situations that we could not help depending on foreign implants for a long time, various Korean implants of good quality have shown the clinical results which are not behind foreign implants as they have been developed in Korea. However, there are few reports about the clinical results and safety of Korean implants as the studies are more insufficient than foreign implants. Eventually, evaluation of Korean implants was not done and people got to disbelieve them vaguely. Accordingly, the author reports the clinical results gotten by monitoring the condition over time for about 5 years targeting patients who had AF fixtures (Snucone, Korea) implanted in this clinic. Received May 18, 2015, Revised June 1, 2015, Accepted June 15, 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. Correspondence to: Sunam Yang, Department of Oral and Maxillofacial Surgery, Hankook Hospital, 106, Danjae-ro, Sangdang-gu, Cheongju , Korea. Tel: , Fax: , sny1110@nate.com JOURNAL OF DENTAL IMPLANT RESEARCH

29 Yang SN, et al: A retrospective study of Snucone implants: Clinical and radiographic results 23 MATERIALS AND METHODS 1. Research subjects It was intended for 23 patients who have implants placed in this clinic from Jun to Dec The number of placed implants was 41. AF fixtures (Snucone, Korea) were used in all the implant procedures.(fig. 1) Snucone s products were all used for abutment used in oral rehabilitation. 2. Research methods Patients gender, age, implant placement position, implant diameters and length, bone graft, periods from implant to secondary surgery, change of marginal bone around implants between the time that implants are placed and the time after 5 years, and the survival rate of implants were analyzed. The height of marginal bone around implants were measured in the panorama pictures (Vatech, Korea) taken in the days that implants were placed and 5 years after implant placement. For change of the marginal bone height around implants, each change of mesial sides and distal side was measured and the average was calculated. persons who are in 50s were 7 (30.4%), the persons who are in 60s were 9 (39.1%).(Fig. 3) 3. Implant placement position Among the total 41 implants, 18 implants (43.9%) and 23 implants (56.1%) were placed in the upper and lower jaws respectively. 3 (7.3%) were implanted in the anterior teeth of the upper jaws, 3 (7.3%) in the premolar teeth of the upper jaws, 12 (29.3%) in the molar teeth of the upper jaws, 2 (4.9%) in the anterior teeth of the lower jaws, 6 (14.6%) in premolar teeth of the lower jaws, and 15 (36.6%) in molar teeth of the lower jaws(table 1).(Fig. 4) 4. Diameter and length For placed implants diameter, 9 (22.0%) of 3.8 mm, 25 (61.0%) of 4.3 mm, and 7 (17.0%) of 4.8 mm were used. RESULTS 1. Patients gender Among the total 23 patients, men were 13 persons (56.5%) and women were 10 persons (43.5%).(Fig. 2) 2. Patients age Among the total 23 patients, the person who is in 20s was one (4.3%), the persons who are in 30s were 3 (13.1%), the persons who are in 40s were 3 (13.1%), the Fig. 2. Gender distribution. Fig. 1. AF fixture (Snucone, Korea). Fig. 3. Age distribution. Journal of Dental Implant Research 2015, 34(1) 22-26

30 24 Yang SN, et al: A retrospective study of Snucone implants: Clinical and radiographic results Table 1. Implant placement position Position Fixtures Position Fixtures Table 2. Diameter and length Diameter (mm) Length (mm) Fixtures Total 18 Total Total 41 Fig. 5. Diameter. Fig. 4. Implant placement position (A: anterior, PM: premolar, M: molar, Mx: maxilla, Mn: mandible). And for their length, 9 (46.4%) of 3.8 mm, 16 (39.0%) of 10.0 mm, and 6 (14.6%) of 12.0 mm were used (Table 2). (Fig. 5, 6) 5. Bone graft Among the total 41 implants, the cases that bone graft is done are 13 (31.7%), the cases that maxillary sinus floor elevation is done are 4 (9.75%), and the cases that alveolar bone graft is done are 9 (21.95%).(Fig. 7) 6. Periods from implant placement to secondary surgery For the periods from implant placement to secondary surgery, the average period is 4.8 months and the shortest period is 3 months, and the longest period is 8.5 months. 7. Change of marginal bone around implants Change of marginal bone in panorama pictures of the Fig. 6. Length. implant date and panorama pictures when patients visited the clinic was analyzed to monitor the condition over time. For the period to monitor the condition over time, the shortest period is 4 years and 9 months and the longest period is 5 years and 11 months. For the height of marginal bone, the length from the fixture platforms to alveolar Journal of Dental Implant Research 2015, 34(1) 22-26

31 Yang SN, et al: A retrospective study of Snucone implants: Clinical and radiographic results 25 Fig. 7. Bone graft. crest was measured in each mesial side and distal side. Change of marginal bone in mesial and distal sides was calculated based on the measurement values. The average loss of marginal bone around implants during the period to monitor the condtion over time was 0.62±0.69 mm. 8. The survival rate of implants The total 41 implants were placed and there were no any cases that implants were removed due to occurrence of mobility, loss, or fracture. DISCUSSION Since implants were introduced to dental science, they became one of the important treatment methods which restore teeth loss as the results of the long-term studies and successful clinical application. Several research results have found that implants differences in surface treatment and design have an effect on the clinical results and various manufacturers implant systems have now been used. For AF fixtures (Snucone, Korea), design of tooth root forms and internal connection methods are applied as the product that surface treatment is done by the SLA method. SLA surface treatment is one of the most widely used implant treatment methods and is known to is favorable for improvement of implant biocompatibility and formation of bone around implants 2). As there was no any implants which failed in the total 41 implants analyzed in this study, the 100% success rate was shown. R. Lazzara et al. reported that the success rate of 93.8% in the upper jaws and 97.0% in the lower jaws in the study of 1,969 3I implants for the last 5 years 3). Jan L. Wennstrom et al. reported that the success rate of 97.7% in the study of 45 Astra implants (Astra tech, Sweden) for 5 years 4). Bilge GokcenRohlig et al. reported that the success rate of 91.0% in the upper jaws and 97.8% in the lower jaws in the study of 146 ITI implants for 5 years 5). The average loss of marginal bone analyzed through the radiographic examination in this study was 0.62± 0.69 mm for 5 years. Per Astrand et al. conducted the comparative study on marginal bone loss of Astra (Astra Tech, Sweden) and Brånemark implants (Nobel Biocare, Sweden) for 5 years 6). For the marginal bone loss, Astra implants showed 1.74±0.45 mm and 1.06± 0.19 mm in the upper and lower jaws and Brånemark implants (Nobel Biocare, Sweden) did 1.98±0.21 mm and 1.38± 0.17 mm in them. The fixture diameter and length which are most used in implant are 4.3 mm (61%) and 8.0 mm (46.4%) respectively. For th most implanted parts, the molar teeth in the upper jaws are 12 (29.3%) and the molar teeth in the lower jaws are 15 (36.6%). It is thought that this study needs to continue to be studied for a long time to come as the one which analyzed the clinical results gotten by monitoring the condition for 5 years after implant placement. CONCLUSION The author draws the following conclusion by analyzing the clinical results of about 5 years about 41 implants targeting the total 23 patients who have AF fixtures (Snucone, Korea) in this clinic. 1. Implant s survival rate was 100%. 2. The average marginal bone loss was not higher than that of other reports as it is 0.62±0.69 mm. 3. The diameter and length most used in implants were 4.3 mm (61%) and 8.0 mm (46.4%) respectively. REFERENCES 1. Gaviria L, Salcido JP, Guda T, Ong JL. Current trends in dental implants. J Korean Assoc Oral Maxillofac Surg 2014;40: Kim HI, Choi SH, Ryu JJ, Koh SY, Park JH, Lee IS. The biocompatibility of SLA-treated titanium implants, Biomed Mater Journal of Dental Implant Research 2015, 34(1) 22-26

32 26 Yang SN, et al: A retrospective study of Snucone implants: Clinical and radiographic results 2008;3: Lazzara R, Siddiqui AA, Binon P, Feldman S, Weiner R, Phillips RM, et al. Retrospective multicenter analysis of 3i endosseous dental implants placed over a five-year period. Clinical Oral Implants Research 1996;7: Wennström JL, Ekestubbe A, Gröndahl K, Karlsson S, Lindhe J. Implant-supported single-tooth restorations: A 5-year prospective study. Journal of Clinical Periodontology 2005;32: Gokcen-Rohlig B, Yaltirik M, Ozer S, Tuncer ED, Evlioglu G. Survival and Success of ITI Implants and Prostheses: Retrospective Study of Cases with 5-Year Follow-Up. European Journal of Dentistry 2009;3: Åstrand P, Engquist B, Dahlgren S, Gröndahl K, Engquist E, Feldmann H. Astra Tech and Brånemark system implants: A 5-year prospective study of marginal bone reactions. Clinical Oral Implants Research 2004;15: Journal of Dental Implant Research 2015, 34(1) 22-26

33 Vol. 34 No. 1, June 2015 Journal of Dental Implant Research 2015, 34(1) 자가치아블록을이용한골이식술 : 후향적증례관찰연구 구정귀, 김영균, 엄인웅 1 분당서울대학교병원치과구강악안면외과, 한국치아은행연구소 1 The retrospective clinical study of the autogenous tooth block bone graft Jeong Kui Ku, Young-Kyun Kim, In-Woong Um 1 Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, 1 R&D Institute, Korea Tooth Bank. Seoul, Korea Purpose: A method using autogenous tooth bone graft material that was made by his extracted tooth with appropriated process was developed and has been applied to the clinical cases. Also the tooth bone graft was reported excellent clinical effects and results. The aim of this study is to analyze the clinical application cases of Autogenous tooth block bone grafting material and to approve of effectiveness of its clinical outcomes. Materials and Methods: 34 patients (24 males, 10 females) who visited Seoul National University Bundang Hospital had made Autogenous tooth block bone for graft procedure due to the insufficient residual bone volume and height for an implantation. The stability of an implant was measured by ISQ (Implant Stability Quotient) with an Osstell Mentor. The postoperative complications were analyzed during healing period. The significance of ISQ changes was statistically evaluated by a paired-t test. Results: Twenty four patients had been grafted with autogenous tooth block bone and had installed 49 dental implants in Seoul National University Bundang Hospital. The mean follow up period was 30.82±14.17 months. The mean initial stability of overall implants was measured as 60.86±13.81 ISQ and second stability 75.02±9.44 ISQ. It showed statistically significant difference (P<0.001). There were no remarkable complications or side effects during the all procedures. Conclusions: Within the limitation of our study, it is suggested that the clinical outcomes of autogenous tooth block bone is outstanding with the stability of the implant in the grafted sites. (JOURNAL OF DENTAL IMPLANT RESEARCH 2015;34(1):27-34) Key Words: Implant, Bone graft, Graft material, Implant stability 서론 임플란트수복이보편화된치료술식으로자리잡으면서주변경조직결손부의수복을위한골이식재료에대한관심이더욱높아지고있다. 현재환자로부터채취한자가골이골형성능이우수하고생체친화적이어서가장우수한재료로알려져있으나채취량에한계가있고공여부에 2차적으로수술이필요하다는단점이있다. 또한동 종골, 이종골은비싼가격및감염전파에대한불안감이있으며합성골은골형성, 골유도능력이전혀없다는단점이있다. 이런단점등을해결하기위해, 발치된자가치아를이용한골이식재의개발이이루어졌으며임상에적용할수있는근거가확보되었다 1-6). 임상에서골이식재형태는블록골혹은입자형이주로사용되고있다. 블록골은치조능수직및수평증대술, 상악동점막거대천공부위재건, 임플란트식립시초기고정증대등의목적으로사용되며 Received April 23, 2014, Revised May 20, 2014, Accepted May 30, 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, , 경기도성남시분당구구미로 82, 173번길, 분당서울대학교병원치과구강악안면외과 Correspondence to: Young-Kyun Kim Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, 300, Gumi-dong, Bundang-gu, Seongnam , Korea. Tel: , Fax: , kyk0505@snubh.org This study was supported by graft no from Korea Tooth Bank Research Fund. JOURNAL OF DENTAL IMPLANT RESEARCH

34 28 구정귀등 : 자가치아블록을이용한골이식술 : 후향적증례관찰연구 우수한강도와형태유지효과로인해국소적인골결손부외형수복에좋은효과를보인다. 그러나이식후고정이필요하며술식이복잡하고재혈관화가늦기때문에치유기간이오래걸리는단점이있다. 입자형골이식재는다루기쉽고재혈관화가빠른장점이있지만형태유지가잘안되고골개조후상당량의골이식재가소실되는단점이있다 7-9). 본연구의목적은발치된자기치아들을탈회냉동건조블록으로처리한후다양한골이식술에적용한증례들을후향적으로분석하여골이식술과식립된임플란트의경과를평가함으로써블록형치아골이식재의임상적유효성을밝히기위함이다. Table 1. Types of bone grafts procedure Types 재료및방법 본연구는 2008년 1월부터 2014년 12월까지분당서울대학교병원치과에내원한환자들중블록으로처리한자가치아골이식재가있는 34명의환자 ( 남 24명, 여 10명 ) 들을대상으로하였으며분당서울대학교병원생명윤리심의위원회의승인 (IRB No: B ) 을득한후시행되었다. 연구대상환자들의나이는최소 25세, 최대 66세로평균 44.06±11.0세였다. 1. 자가치아골이식재블록처리방법 1) 치근블록처리 AutoBT R block, which was treated with a demineralized dentin matrix, was cut to an appropriate size and shape, and it was then transplanted for the restoration of adjacent defect areas. 발치된치아를 70% 에틸알콜에보관한상태로특수처리를위해한국치아은행 (Korea Tooth Bank Co., Seoul, Korea) 으로보낸다. 치관과치근을분리한후연조직, 치석과같은이물질을제거하고, 증류수와과산화수소용액에넣고, 초음파세척기로잔존이물질들을제거한다. 깨끗해진치근조각은 Ethyl alcohol로탈수시킨후 Ethyl ether solution으로지방질을제거한다. 만들어진자가치아뼈이식재는 Ethylene oxide gas로멸균하고, 냉동건조과정을진행하여밀봉시킨다. 2) 치관부처리분리된치관부는치근부와거의유사한과정을거치지만, 증류수 Number of implants Ridge augmentation 23 Sinus bone graft 10 GBR 8 Sinus bone graft+ridge augmentation 7 Extraction socket graft 1 Total 49 및과산화수소용액에넣기전에 0.5 mm 1.0 mm입자가될때까지분쇄하여분말형태로제조한다. 2. 경과관찰 의무기록지를검토하여골이식술의종류, 추가골이식재사용유무, 임플란트식립방법, 식립된임플란트의위치, 이식후술후합병증등을조사하였다. 식립된임플란트의안정도 (stability) 는 Osstell Mentor (OsstellR, Gothenburg, Sweden) 를이용하여 ISQ (Initial Stability Quotient) 값으로측정되었다. 임플란트식립직후측정된초기안정도 (initial stability) 를조사하였고이차수술혹은첫인상채득시측정된이차안정도 (secondy stability) 를조사하였다. 2단계수술과정을거칠때 ISQ 수치변화는 SPSS version 17.0 (SPSS Inc., Chicago, IL, USA) 프로그램을이용하여 paired t-test로검정하였고, 상악과하악에서의 ISQ 차이는독립 t-test로검정하였다. 결 블록으로처리한자가치아골이식재가있는 34명의환자들중골이식만본원에서받은환자는 10명이었고, 임플란트식립까지진행한환자는 24명 ( 남자 18, 여자 6) 이었다. 골이식술은수평혹은수직치조능증대술이 23개로가장많았고상악동골이식술 10개, 골유도재생술 8개, 상악동골이식과치조능증대술에함께이용된경우가 7 개, 발치창골이식술 1개였다. 2가지이상의골이식술이함께사용된경우엔시행된각각의행위를별도로정리하였다 (Table 1). 블록이단독으로사용된경우는 2개였으며대부분입자형골이식재들이함께사용되었다. 입자형골이식재는동종골 3개, 이종골 3개, 합성골 2개가사용되었고, 나머지 39개부위에서는모두자가치아골이식재분말들이사용되었다. 차폐막은 4개임플란트에서는사용되지않았고, 3개의임플란트에서비흡수성차폐막이사용되었다. 나머지 42 개임플란트에서모두흡수성콜라겐막이사용되었다. 1개의임플란트에서는골이식과차폐막을모두쓰지않았고, 골이식만한임플란트가 1개, 추가적인골이식없이차폐막만덮은임플란트가 1개있었다 (Table 2).(Fig. 1-14) 블록형자가치아골이식재로골이식한부위에식립된임플란트는 49개였다. 임플란트보철기능후추적기간은 10개월에서 72개월로평균 30.82±14.17개월이었다. 1차수술후초기안정도는평균 Table 2. Summary of additional graft material and membrane Types of additional graft material 과 Types of membrane None 2 None 4 Allograft 3 Resorbable 42 Xenograft 3 Non-resorbable 3 Alloplast 2 AutoBT powder 39 Journal of Dental Implant Research 2015, 34(1) 27-34

35 Ku JK, et al: The retrospective clinical study of the autogenous tooth block bone graft 29 Fig. 1. Initial periapical view. Fig. 4. AutoBT block bone graft. Fig. 2. Initial intraoral photograph. Fig. 5. Periapical view after bone graft. Fig. 3. Severe alveolar bone atrophy was observed. Fig. 6. Intraoral photograph 6 month after bone graft ±13.81이였으며, 2차수술시측정한이차안정도는 75.02± 9.44였다. 2차수술시평균 ISQ의증가는통계적으로유의미한것으로나타났다 (P<0.001, Table 3). 전과정에서특이할만한합병증이나부작용은보고되지않았다. 1회법수술과정으로 4명의환자들에서 7개의임플란트가식립되었다. 이들의초기안정도는평균 62.63±12.96 ISQ였고, 평균 2.86±1.59개월후보철인상을채득할때측정한이차안정도는 78.50±8.69 ISQ로증가하였으나통계적으로유의미하지는않았다 (P=0.053). 2회법수술과정으로 20명의환자들에서 42개의임플란트가식립되어초기안정도는 59.46±14.11 ISQ였고, 평균 4.54±1.86개월후측정한이차안정도는 74.46±9.54 Journal of Dental Implant Research 2015, 34(1) 27-34

36 30 구정귀등 : 자가치아블록을이용한골이식술 : 후향적증례관찰연구 Fig. 7. Implant was placed 6 month after bone graft. Well maintained block bone graft material was observed on buccal side. Initial stability was measured as 75 ISQ. Fig. 10. Periapical radiograph after second surgery. Increasing peri-implant bone density was observed. Fig. 8. Periapical view after implant placement. Fig. 11. Periapical radiograph immediately after prosthetic loading. Fig. 9. Implant was exposed 3 month after 1 st Second stability was measured as 85 ISQ. implant surgery. ISQ로통계적으로유의미하게증가했다 (P<0.001). 골이식과임플란트식립시기에따라, 13개임플란트가골이식과동시에 2-stage (submerged type) 로식립된뒤평균 5.86±2.10 개월을기다린후에보철치료가시행되었다. 나머지 36개임플란트는골이식후평균 5.23±1.91개월의치유기간을부여한후이차적으로식립되었다 (Table 4). 골이식과동시에 2-stage로식립한임플란트의초기안정도는 55.92±14.85 ISQ, 이차안정도는 74.92±4.93 ISQ로통계적으로유의미하게증가하였다 (P<0.01). 지연식립을시행한임플란트중 1-stage로식립된 7개의임플란트에서초기안정도는 62.63±12.96 ISQ였고, 평균 2.86±1.59개월후보철적인상 Journal of Dental Implant Research 2015, 34(1) 27-34

37 Ku JK, et al: The retrospective clinical study of the autogenous tooth block bone graft 31 Fig. 12. Periapical radiograph 12 months after prosthetic loading. Fig. 14. Periapical radiograph 35 months after prosthetic loading. 차이를보이지않았다 (Table 7). 전체환자들의골이식후관찰기 간중특이합병증이나부작용은없었고, 임플란트의골유착이파괴 되거나현저한치조정골흡수를보인증례들은전혀없었다 고 찰 Fig. 13. Periapical radiograph 27 months after prosthetic loading. 을채득할때측정한이차안정도는 78.50±8.69 ISQ로증가하였으나통계적으로유의미하지는않았다 (P=0.053). 또한지연식립한 29 개임플란트는 2-stage로식립되어초기안정도는 61.16±13.72 ISQ 로측정되었고, 평균 3.96±1.86개월의회복기간을둔후이차안정도는 74.24±11.19 ISQ로측정되어통계적으로유의미하게증가하였다 (P<0.001, Table 5). 식립된 49개의임플란트중상악에는 27개, 하악에 22개가식립되었다. 상하악간초기안정도와이차안정도는통계적으로유의미한차이를보이지않았고 (Table 6), 골이식술및골이식재, 차폐막의종류에따른초기안정도와이차안정도역시통계적으로유의미한 Kim 등은 1993년이래발치된사람의치아들을이용하여골이식재를개발하려는다양한연구가시행되어왔다. 그러나이연구들은면역거부반응을억제하기위해고온에서치아들을태워분말과블록형의합성골이식재를제조하였다 10-15). 기존연구들을기반으로 2008년발치된환자들의치아들을특수처리하여입자형골이식재를제조한후환자자신에게다시이식하는자가치아골이식재가개발되었다. 이후자가치아골이식재의무기물분석, 주사전자현미경적분석및조직형태계측학적연구를통해골유도및골전도에의한우수한골치유를보이는것을입증하였다. 또한골유도재생술에자가치아골이식재를이용한임상논문에서차단막을사용하지않았음에도불구하고 3 6개월후조직시편에서모두양호한골치유가이루어지는것이확인되었다. 자가치아골이시개이식부위의조직학적치유과정을살펴볼때이식재가흡수되면서신생골로대체되고신생골은잔존이식재와직접적인유합을이루고있었다. 매우우수한골유도및골전도에의한치유과정이전시편들에서관찰되었고층판골이풍부하게관찰됨으로써골개조가신속히이루어지는것을확인할수있었다. 따라서자가치아골이식재는조기에흡수되지않고차단막으로서의역할을적절히수행하면서골유도및골전도에의한골치유가이루어지는생체적합성이있는재료라고언급되었다 16-18). 골결손량이큰부위의재건이나치조능증대술과같이많은양의골증대량이필요한경우엔자가골이식이가장좋은결과를보인다. Journal of Dental Implant Research 2015, 34(1) 27-34