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1 대한치과이식 ( 임프란트 ) 학회지 2011;30(1): 완전무치악환자에서골유도재생술을통한치조골재건및다수의임프란트식립 : 증례보고 원광대학교산본치과병원구강악안면외과학교실온병훈, 박슬지, 지영덕 Ⅰ. 서론 Ⅱ. 증례보고 완전무치악환자에서임프란트식립을통한보철수복은수직적-수평적으로위축된치조제와구강점막의탄력저하로인해매우어렵다. 심하게위축된치조골에서다수의임프란트식립이계획된경우광범위한치조골의결손부를재건하기위해 onlay block bone graft 를시행후지연식립이추천된다. 이러한 block bone graft는견고성이있어외형을유지하거나재건부위의안정성이높다는장점을지닌반면, 감소된골생성능력, 느린재혈관화, 공여부위의합병증발생가능성등의단점을지닌다. Particulate bone을사용한골유도재생술은모든임프란트식립수술에있어서골이식이필요할때가장많이사용하는술식으로임프란트식립시약간의 dehiscence 혹은 fenestration wound가있을경우 1차적으로고려하는골이식방법이다. 이는술자의편의성, 환자의높은만족도등의장점을지니지만광범위한수평, 수직적치조골결손부의수복시에치료의예지성이낮아사용이의문시되어왔다. 심한치조골흡수를보이는전악무치악환자에서비흡습성막을사용하거나 onlay block bone graft를시행하는대신보다비침습적인흡습성막을사용한골유도재생술을통하여다수의임프란트식립에필요한충분한양의치조골재건이가능하였기에이를보고하고자한다. Corresponding author: Young-Deok Chee Dept. of OMFS, Wonkwang university, Sanbon Dental Hospital 1142 Sanbondong Gunposi Gyeonggi-do Tel: omschee@wonkwang.ac.kr Received Apr15,2011 Revised May20,2011 Accepted Jun10, 년부터 2010년까지원광대학교산본치과병원구강악안면외과에내원하여임프란트식립후고정성보철치료로수복한최소편악무치악환자 8명을대상으로하였다. 상악편악무치악환자 4명에서 48개의임프란트가식립되었고, 하악편악무치악환자 4명에서는총 36 개의임프란트가식립되었다 (table 1). 편악당최소 8개에서최대 12개의임프란트가식립되었으며환자의연령분포는 42세에서 67세로평균 55.2세였다. 모든시술은 Dormicum (Roche Pharma Ltd., Reinach, Switzerland) 정맥투여통한의식하진정상태에서국소마취하시행되었으며모든환자는시술과정에잘적응하였다. 경과관찰기간은임프란트식립일을기준으로최소 8개월, 최장 72 개월로평균 42±22.36개월이었다. 모든환자에서수술전인상채득을통한진단모형을제작하여악간관계분석및외과용스텐트를제작하였다. 모든임프란트는동일한술자에의해식립되었으며 4명의환자에는 GS II (Osstem Implant Co., Pusan, Korea) 식립하였고, 3명은 Implantium (Dentium Co., Suwon, Korea), 1명은 Camlog (CAMLOG Biotechnologies AG., Basel, Switzerland) 으로식립하였다. 치조제증대술및상악동골이식시사용한다양한골이식재로 Puros (Zimmer Dental., Carlsbad, CA, USA), OraGraft (LifeNet Health Inc., Virginia Beach, VA,USA), Bio-Oss (Geistlich- Pharma.,Wolhusen, Switzerland), Osteon (Genoss., Suwon, Korea), 콜라겐성분의흡수성차폐막으로는 Lyoplant (B.BraunAesculap., Tuttlingen, Germany) 가

fixture 10 10 8 10 12 8 8 8 1st surgery GBR GBR, GBR GBR GBR GBR GBR GBR Sinus (Sinus graft, graft 6M ago) 2nd surgery - - - - - FGG FGG - Final setting 13M 11M 10M 10M 9M 14M 12M 8M Latest visit 36M

5명의환자에서골이식재의더나은조작을얻기위해부가적인조직접합제로 Tisseel (Baxter Biosciences., Vienna, Austria) 을사용하였다. 상악에서는총 48 개의임프란트가환자 1인당최소 8개에서최대 10개, 평균 9.5개식립되었다. 4명의환자중환자 1, 3은식립과동시에골유도재생술을시행하였으며 (Fig.

최종보철물시적이후를기준으로평균 12개월동안경과관찰시행하였고가장최근방문까지모든임프란트는생존하였다. 하악에서는총 36 개의임프란트가환자 1인당최소 8개에서최대 12개, 평균 9개식립되었다. 모든증례에서임프란트식립과동시에골유도재생술통해치조제증대술시행하였으며 2차수술은평균 4.8개월이후에시행하였다.

2 80 온병훈, 박슬지, 지영덕 Table 1. Distribution of Patient Case Arch Maxilla Mandible Sex M M F F M F M F Age Fixture GS II GS II Implantium Implantium GS II GS II Camlog Implantium Number of fixture st surgery GBR GBR, GBR GBR GBR GBR GBR GBR Sinus (Sinus graft, graft 6M ago) 2nd surgery FGG FGG - Final setting 13M 11M 10M 10M 9M 14M 12M 8M Latest visit 36M 45M 56M 10M 68M 40M 72M 8M Table 2. Survival Rate of implants according placement arch Placement arch Survival Rate(%) Maxilla 100% Mandible 97.22% 사용되었다. 5명의환자에서골이식재의더나은조작을얻기위해부가적인조직접합제로 Tisseel (Baxter Biosciences., Vienna, Austria) 을사용하였다. 상악에서는총 48 개의임프란트가환자 1인당최소 8개에서최대 10개, 평균 9.5개식립되었다. 4명의환자중환자 1, 3은식립과동시에골유도재생술을시행하였으며 (Fig. 1,3) 환자 2는식립과함께양측상악동거상술및골이식, 골유도재생술을시행하였다 (Fig. 2). 환자 4는임프란트식립 6개월전양측상악동거상술및골이식, 골유도재생술을시행하였다 (Fig. 4). 각환자에서모든임프란트는당일에식립되었다. 2차수술은식립후평균 6.7개월후시행되었다. 2차수술시추가적인뼈이식, 연조직수술은시행하지않았다. 최종보철물시적이후를기준으로평균 12개월동안경과관찰시행하였고가장최근방문까지모든임프란트는생존하였다. 하악에서는총 36 개의임프란트가환자 1인당최소 8개에서최대 12개, 평균 9개식립되었다. 모든증례에서임프란트식립과동시에골유도재생술통해치조제증대술시행하였으며 2차수술은평균 4.8개월이후에시행하였다. 환자 6, 7에서는 2차수술시부가적으로유리치은이식술을시행하였다 (Fig. 6,7). 36개임프란트중 1개는실 패하였다 (Table 2). 환자 6의하악우측제1소구치임프란트식립부위에서임시치아시적후기능시 fixture mobility 관찰되어해당임프란트를제거하였고, 2개월후같은직경과길이의임프란트를같은부위에재식립하였다. 재식립부위를포함한모든임프란트는경과관찰기간내모두생존하였다. Ⅲ. 고찰완전무치악을치료하는방법에는임프란트고정성보철, 총의치, 임프란트지지형고정성보철등이있다. 완전무치악에서임프란트식립후고정성보철치료시행시수직적-수평적으로위축된치조제와구강점막의탄력저하로인해어려운치료가될수있다. 이러한골결손부위에서의임프란트식립을위한치조골증강을위해다양한술식이사용되어왔는데자가골을블록형태로이식하는방법, 골이식재를사용한골유도및골전도, 성장인자를이용한골형성, 인위적인골절골에의한골신장술, 차폐막을이용한골유도재생술등이있다 1). 특히수직적치조골결손부위를재건하기위해최우선적으로자가골이식을고려할수있으나이식후예기치못한심한골흡수발생가능성및골채취과정으로인해발생가능한신경손상등합병증이따르게되어자가골이외의다양한골이식재의사용이활발하게이뤄지고있으며이를통해자가골채취에따른위험이감소하였다 2). 자가골채취시하악정중부에서얻어지는 noncompressed

3 완전무치악환자에서골유도재생술을통한치조골재건및다수의임프란트식립 : 증례보고 81 Fig 1. Case 1. A~H: Surgical procedures of implant fixture installation. I: panoramic view of 36 months after surgery. Fig 2. Case 2. G: After the 2nd surgery. I: panoramic view of 10 months after surgery. Fig 3. Case 3. A~E: Surgical procedures of implant fixture installation. F: 7 months after 1st surgery.g: 12 months after 1st surgery. I: panoramic view of 56 months after surgery. Fig 4. Case 4. G: 9 months after 1st surgery. I: panoramic view of 10 months after surgery.

I: panoramic view of 68 months after surgery. Fig 6.

G: After 2nd surgery I: panoramic view of 40 months after

A~D: Surgical procedures of implant fixture installation.

4 82 온병훈, 박슬지, 지영덕 Fig 5. Case 5. G: 7 months after 1st surgery. I: panoramic view of 68 months after surgery. Fig 6. Case 6. G: After 2nd surgery I: panoramic view of 40 months after surgery. Fig 7. Case 7. A~D: Surgical procedures of implant fixture installation. E, F: 2nd surgeryg: Overdenture of maxilla H: After prosthesis delivery I: panoramic view of 72 months after surgery Fig 8. Case 8. G: After 2nd surgery. I: panoramic view of 8 months after surgery.

5 완전무치악환자에서골유도재생술을통한치조골재건및다수의임프란트식립 : 증례보고 83 corticocancellous bone의평균적부피는 4.71mL 3), 하악상행지에서는평균 2.36mL 4) 로더많은양의골이식필요시에는 ilium, tibia 등의부위에서자가골채취가가능하다. 그러나드물게 ilium, tibia에서골채취후해당부위의골절및감염등의합병증이발생하기도하므로주의를요한다 5,6). 이러한다양한술식에의해성공적으로재건된치조골에식립한임프란트는일반자연골에식립된임프란트와비슷한성공률을보여왔다 7). 수직적인치조골결손의회복과관련하여골이식후연조직의 collapse 발생시충분한수직적골신장이어려울수있으므로 8) 비흡습성막의사용을고려하기도한다. Artzi 등은티타늄메쉬와이종입자골이식재를사용하여예지성있게치조골높이를증가시킬수있다고하였으나 9) 이는반드시재수술이요구되며연조직치유전티타늄막의노출되는합병증이발생할가능성이있는술식으로평가된다. 티타늄메쉬가노출될확률이높아질수록수술부위의감염발생확률도높아진다 10). 수직골증대술이수평적골결손부위의회복보다더어려운이유는연조직을 envelop형태로형성후골이식시부피증가에따른장력에의한이식재의노출확률이보다높기때문으로적절한골이식재의적용과 soft tissue engineering은골이식성공을위한핵심이다 11). 본증례에서는심한수직적-수평적골소실을보이는무치악결손부에서기존의블록형자가골이식나티타늄메쉬사용을동반한입자골이식을시행하는대신이식재와조직접착제, 흡습성차폐막의사용으로다수의임프란트식립에적합한결손부위의재건을시행하였으며술후지속적인예후평가에서도이상적인결과를나타냈다. 특히조직접착제의부가적인사용으로입자골의조작성향상을도모하였고식재의움직임을예방할수있었으며또한부가적인공여부를형성하지않아환자들의술후불편감을감소시킬수있었다. Ⅳ. 결론과거에는전악무치악환자의임프란트는전신마취하식립하기도하였으나본증례에서는국소마취상태에서 도적절한임프란트식립이가능하였으며최장 6년간의 follow up기간동안 98% 의생존율을나타냈다. REFERENCES 1. Roden RD Jr. Principles of Bone Grafting. Oral and Maxillofacial Surgery Clinics of NA ; 22(3): Chiapasco M, Abati S, Romeo E, Vogel G. Clinical outcome of autogenous bone blocks or guided bone regeneration with e-ptfe membranes for the reconstruction of narrow edentulous ridges. Clin Oral Implants Res. 1999;10(4): Montazem A, Valauri DV, St-Hilaire H, Buchbinder D. The mandibular symphysis as a donor site in maxillofacial bone grafting: a quantitative anatomic study. J. Oral Maxillofac. Surg. 2000;58(12) : Gungormus M, Yilmaz AB, Ertas U, Akgul HM, Yavuz MS, Harorli A. Evaluation of the mandible as an alternative autogenous bone source for oral and maxillofacial reconstruction. J. Int. Med. Res ;30(3): Thor A, Farzad P, Larsson S. Fracture of the tibia: complication of bone grafting to the anterior maxilla. Br J Oral Maxillofac Surg. 2006;44(1): Covani U, Ricci M, Mangano F, Santini S, Barone A. Fracture of anterior iliac crest following bone graft harvest in an anorexic patient: case report and review of literature. J Oral Implantol ; 7. Hammerle CHF, Jung RE, Feloutzis A. A systematic review of the survival of implants in bone sites augmented with barrier membranes (guided bone regeneration) in partially edentulous patients. J. Clin. Periodontol. 2002;29 Suppl 3: Pikos MA. Atrophic posterior maxilla and mandible: alveolar ridge reconstruction with mandibular block autografts. Alpha Omegan ;98(3): Artzi Z, Dayan D, Alpern Y, Nemcovsky CE. Vertical ridge augmentation using xenogenic material supported by a configured titanium mesh: clinicohistopathologic and histochemical study. Int J Oral Maxillofac Implants. 2003;18(3): Louis PJ, Gutta R, Said-Al-Naief N, Bartolucci AA. Reconstruction of the maxilla and mandible with particulate bone graft and titanium mesh for implant placement. J. Oral Maxillofac. Surg ;66(2): Louis PJ. Bone Grafting the Mandible.Oral and Maxillo-facial Surgery Clinics of NA ;23(2):

6 84 온병훈, 박슬지, 지영덕 Alveolar bone reconstruction and multiple dental implantations with Guided bone generation in the complete edentulous patients: Case Report Byung-Hun Ohn, Seul-Ji Park, Young-Deok Chee Dept. of Oral & Maxillofacial Surgery, Sanbon Dental Hospital, Wonkwang University The treatment of completely edentulous patients by implant restoration is difficult that most edentulous patients have vertical and/or horizontal bone resorption of residual ridge and lack of resistance of the oral mucosa. When multiple implantations are planned for the severely atrophied alveolar ridge, usually delayed implant placement is recommended after the procedure of onlay block bone graft. Block bone graft has the advantage of maintaining the contour of bone and stabilizing the reconstructed site. It however, shows the reduced capability of osteogenesis and has slower revasculization tendency and more possibility of complication in the recipient site. Guided bone generation(gbr) using particulate bone is the most popular procedure, when bone graft is needed like the cases of dehiscence or fenestration wound with implant installations. Even though this method provides convenience for operator and satisfaction for patients, it is not usually indicated for reconstruction of severely atrophied alveolar bone because of its poor prognosis. These are the cases we performed minimal invasive approach with GBR procedure for the case of complete edentulous arch with large bone defects using the absorbable membrane rather than using non-absorbable membrane or onlay block bone graft to make sufficient bone reconstruction for multiple implant placement. [THE JOURNAL OF THE KOREAN ACADEMY OF IMPLANT DENTISTRY 2011;30(1):77-82] Key words: Complete edentulism, Implant, GBR

ISSN Implantology 2013; 17(1): 12~22 심한치조골흡수에서티타늄메쉬를이용한치조골재건에대한증례 이규안, 김민수, 이중석, 정의원, 김창성, 조규성, 채중규, 최성호 연세대학교치과대학치주과학교실, 치주조직재생연구소 Ridge Au

ISSN Implantology 2013; 17(1): 12~22 심한치조골흡수에서티타늄메쉬를이용한치조골재건에대한증례 이규안, 김민수, 이중석, 정의원, 김창성, 조규성, 채중규, 최성호 연세대학교치과대학치주과학교실, 치주조직재생연구소 Ridge Au ISSN 1229-5418 Implantology 2013; 17(1): 12~22 심한치조골흡수에서티타늄메쉬를이용한치조골재건에대한증례 이규안, 김민수, 이중석, 정의원, 김창성, 조규성, 채중규, 최성호 연세대학교치과대학치주과학교실, 치주조직재생연구소 Ridge Augmentation Using Titanium Mesh in Severe Alveolar Bone