대한소아치과학회지 39(2) 2012 Type III 치내치를동반한상악측절치에이환된치근단병소의근관치료 김기림 이제호 김성오 송제선 최병재 김승혜 최형준 연세대학교치과대학소아치과학교실 국문

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1 Type III 치내치를동반한상악측절치에이환된치근단병소의근관치료 김기림 이제호 김성오 송제선 최병재 김승혜 최형준 연세대학교치과대학소아치과학교실 국문초록치내치는치아조직이석회화되기전에법랑기가치유두내로함입되어형성된발육성기형이다. 가장널리통용되는치내치의분류법은방사선사진상에서함입 (invagination) 이얼마나치관에서치근쪽으로연장되어있는지에따라분류하는 Oehler s classification system이다. 그중 Oehler s classification type III는함입이치근까지연장되어치주인대와직접적으로 pseudo foramen 을통해교통하는경우를말하며대체로치수와는독립적으로존재한다. Type III 함입을통한감염은언제나치주조직의염증성반응을야기할가능성이있으며, 이처럼 pseudo foramen 주위로염증성병변이발생한경우이를 peri-invagination periodontitis 라한다. 본증례는 Oehler s type III 치내치를갖는상악측절치의 peri-invagination periodontitis 을주소로내원한두환자에게각각다른치료적접근을통하여양호한결과를얻었다. 치내치에대한처치시조기진단과예방적치료를통한치수의건강유지가매우중요하나, 이미치수까지질환에이환되었을경우환아의나이, 치근성숙도, 함입의종류, 염증의치수이환여부등을고려하여치료계획을수립해야한다. 주요어 : 상악측절치, 치내치, 근관치료, Oehler s classification Ⅰ. 서론치내치는상아질조직이석회화되기전에치아기 (enamel organ) 가치유두 (dental papilla) 로함입되거나깊어져나타나는발육성기형이다 1,2). 그러나치내치형성의근본적원인은아직도명백히밝혀지지않아논란의여지가많으며, 치열궁의성장압력으로인한치아기 (enamel organ) 의만곡과내측법랑상피의중심성장의실패및편향된성장으로인한치유두 (dental papilla) 의침범, 발육기간동안치아기의변형과돌출, 감염, 외상, 유전적소인등의다양한가설들이거론되고있다 2,3). 현재일반적으로통용되는 dens invaginatus 란용어는 Hallet이처음으로제안하였다 4). 치내치는영구치에서드물지않으며여러연구에따르면유병율은 % 정도로다양하였으며 5-10), 임상적으로발견하기어려우므로특별한임상적증상이나타나기전까지는간과되기쉽다. 또한치내치는우식, 치수및치주질환등의원인이될가능성이높기때문에조기 진단에따른적절한치료가필요하다. 발생부위는상악측절치에서호발하며중절치, 소구치, 견치, 대구치순으로그빈도가감소하는것으로알려져있다. 치내치중약 90% 가측절치였으며하악영구치아및유치열에발생한경우는매우드물게보고되고있다 4,8,11,12). 3,020명의치내치환자를대상으로한연구에서약 43% 가양측모두에서존재하였음이보고되었다 13). 치내치가존재할경우치관의형태변화는순설또는근원심길이의증가, 절단절흔및순측구의형성, 쇄기또는원뿔형태, 과도한설면결절또는 talon cusp 등이있을수있다 2,4,7,11,14,15). 또한다른치아이상과동반될수있으며기형이나증후군과연관이있을가능성도고려해보아야한다. 치내치의분류는 Oehler에의한것이단순하고적용하기쉬워가장일반적으로받아들여지고있다. 이방식은함입 (invagination) 이방사선사진상에서얼마나치관에서치근방향으로함입되어있는지에따라 3가지유형으로분류되며다음과 교신저자 : 최형준서울특별시서대문구연세로 50 / 연세대학교치과대학소아치과학교실 / / choihj88@yuhs.ac 원고접수일 : 2012 년 02 월 05 일 / 원고최종수정일 : 2012 년 04 월 17 일 / 원고채택일 : 2012 년 05 월 04 일 181

J Korean Acad Pediatr Dent 39(2) 2012 같다 16) (Fig. 1). Type I은함입이법랑-백악경계상방으로최소함입되어있으며법랑질로이장되어있다.

Type IIIB는함입이치근단공에서치주인대와교통하며대체로치수와는교통하지않는다. Type I이가장흔하며 (79%) Type II(15%), Type III(5%) 순으로관찰된다 17).

본증례들은상악측절치에발생한치내치를가진두환아가유사한증상을주소로내원하였으나각각다른치료계획을적용하여양호한결과를얻었기에보고하는바이다. Ⅱ. 증례보고 1.

방사선사진검사상측절치에 Oehler s classification type III로판단되는치내치및치근단병소가관찰되었으며미성숙치근으로치근단은열려있었다 (Fig. 2).

15개월간의정기적인검진결과임상증상및방사선사진상의병소는사라졌으나완전한회복은보다장기간의경과관찰이필요하다 (Fig. 3). 2.

임상구강검사및방사선사진검사결과해당치아에 Oehler s classification type III 치내치및치근단병소가관찰되었으며치근의병적흡수가진행중이었다 (Fig. 4).

Classification of invaginated teeth by Oehlers (1957). Fig. 3. Periapical view.

restored with glass ionomer cement, (B) after 6 months, (C) after 15 months, radiopacity of periapical area of

2 J Korean Acad Pediatr Dent 39(2) 2012 같다 16) (Fig. 1). Type I은함입이법랑-백악경계상방으로최소함입되어있으며법랑질로이장되어있다. Type II는함입이치수강내로함입되어있으나치주인대와교통하지않으며법랑질로이장되어있다. Type IIIA는함입이치근의측방으로연장되어 pseudo foramen 을통해치주인대와교통하며대체로치수와는교통하지않는다. Type IIIB는함입이치근단공에서치주인대와교통하며대체로치수와는교통하지않는다. Type I이가장흔하며 (79%) Type II(15%), Type III(5%) 순으로관찰된다 17). 또한 Type III의경우함입내의염증은치주인대의염증성반응을쉽게유발하며이를 peri-invagination periodontitis 라한다. 그러므로치내치에대한예방및치료계획시해당유형에대한고려가필요하다. 본증례들은상악측절치에발생한치내치를가진두환아가유사한증상을주소로내원하였으나각각다른치료계획을적용하여양호한결과를얻었기에보고하는바이다. Ⅱ. 증례보고 1. 증례 1 별다른의과적병력이없는 7세여아가상악좌측측절치의 발치를위해연세대학교치과대학병원소아치과에의뢰되었다. 임상구강검사상왼쪽볼부위에구내및구외종창이관찰되었으며해당부위촉진시통증및작열감과자발통을호소하였다. 방사선사진검사상측절치에 Oehler s classification type III로판단되는치내치및치근단병소가관찰되었으며미성숙치근으로치근단은열려있었다 (Fig. 2). 해당치아의발거대신 Vitapex 를이용하여함입부위에국한된근관치료를시행하였으며치수강및근관은제외하였다. Glass ionomer cement로수복후정기적인관찰을계획하였다. 15개월간의정기적인검진결과임상증상및방사선사진상의병소는사라졌으나완전한회복은보다장기간의경과관찰이필요하다 (Fig. 3). 2. 증례 2 별다른의과적병력이없는 14세남아가상악좌측측절치의발치를위해연세대학교치과대학병원소아치과에의뢰되었다. 임상구강검사및방사선사진검사결과해당치아에 Oehler s classification type III 치내치및치근단병소가관찰되었으며치근의병적흡수가진행중이었다 (Fig. 4). Vitapex 를이용하여함입부위와치수강및근관에대한근관치료를시행하였으며 2년간의정기적검진결과임상증상및방사선사진상의병소는사라졌으며추후정기적관찰및보철치료계획이필요하다 (Fig. 5). A B C Fig. 1. Classification of invaginated teeth by Oehlers (1957). Fig. 3. Periapical view. (A) post-operation, endodontic treatment with Vitapex was tried only for the invagination, not for the pulp and restored with glass ionomer cement, (B) after 6 months, (C) after 15 months, radiopacity of periapical area of upper left lateral incisor increased. Fig. 2. Panoramic view and periapical view. : Periapical lesion was observed on Mx.left lateral incisor with Oehler's classification type III dens invaginatus. Fig. 4. Panoramic view and periapical view. Periapical lesion and pathologic root resorption was observed on Mx.left lateral incisor with Oehler's classification type III dens invaginatus. 182

incisor increased. Ⅲ. 총괄및고찰 치내치의깊은함입은음식물의정체를야기하여이에따른우식및치수질환을유발할수있다. 함입의내부법랑질은저광화되어있거나때때로존재하지않아치수강으로의직접적인통로역할을하기에치수조직의자극원이쉽게침투할가능성이있다.

Oehler s type I 및 II의경우함입에우식이나치수질환의소견이관찰되지않을경우가능한조기에예방적치료를시행하는것이중요하다 19). 산부식을이용한열구전색제또는 flowable 복합레진이함입의입구를봉하기에적당하며예방치료후에도주기적인관찰이요구된다 17).

3 A B C Fig. 5. Periapical view. (A) post-operation, endodontic treatment with Vitapex was tried both for the invagination and the pulp, (B) after 9 months, (C) after 2 years, radiopacity of periapical area of upper left lateral incisor increased. Ⅲ. 총괄및고찰 치내치의깊은함입은음식물의정체를야기하여이에따른우식및치수질환을유발할수있다. 함입의내부법랑질은저광화되어있거나때때로존재하지않아치수강으로의직접적인통로역할을하기에치수조직의자극원이쉽게침투할가능성이있다. 단순한우식및치수질환외에도치근단농양, 치아변위, 낭종, 내흡수등의합병증이발생할수있기때문에이러한합병증을예방하기위해서치내치에대한조기진단및적절한처치가필요하다 1-4,7,18). 치내치의처치는함입의종류, 근관형태, 기능과심미성, 보철적수복, 시간요소, 경제적혹은정신적요소, 전신적의학적상태등이고려되어야한다 7). Oehler s type I 및 II의경우함입에우식이나치수질환의소견이관찰되지않을경우가능한조기에예방적치료를시행하는것이중요하다 19). 산부식을이용한열구전색제또는 flowable 복합레진이함입의입구를봉하기에적당하며예방치료후에도주기적인관찰이요구된다 17). 만약치수질환에이환되었을경우근관치료를시행하는데, 특히미성숙치아에서치수내염증이제한적인경우치근단유도술을고려할수있다 20,21). 염증이보다광범위하게이환된경우는전통적인근관치료를시행하며이때충분한괴사조직제거및세척을위해치수강및함입부위를포함한치수강개방을시행해야한다 5,22-24). Oehler s type III의경우예방적치료는 type I과별다른차이가없다. 그러나본증례와같이 peri-invagination periodontitis 가존재하여이에대한적절한치료가필요한경우함입뿐만아니라치수에대한치료도함께시행할지여부를결정하는것이중요하다. 최근의여러연구를통해함입에근접한치수에염증이이환되었다는명확한증거가있지않는한, 함입에국한된통상적인근관치료를시행하는최대한보존적인접근이추천되고있다 24-28). 특히 pseudo foramen 이치아의측방에존재하는 Type IIIA에서적절한선택이된다. 이러한보존적치료후에는반드시주기적인경과관찰이필수적이며치근단병소의치유양상이관찰되지않을경우치수를포함하는추가적인치료가필요하다. 치수와함입을함께치료하는경우, 각각을독립적으로치료하는것과두공간을합쳐서치료하는 것의장, 단점에는아직일치된의견이없으며지속적인연구가진행중이다 5,6,29-31). 비외과적인근관치료가불가능하거나실패한경우외과적근단수술이나의도적재식술을고려할수있다. 발치는최후의고려대상으로치내치가심미적, 기능적문제를야기하거나다른치료가불가능한경우, 또는제3대구치나과잉치에치내치가이환된경우등을생각할수있다 2,7,18). 첫번째증례의경우, 환자의나이를고려할때해당측절치가미성숙치아이며방사선사진상함입이치아의전체길이보다짧게연장되어측방으로 pseudo foramen 을형성한 Oehler s type IIIA로판단된다. 그러므로보다보존적인접근을위해함입에국한하여 Vitapex 를이용한근관치료를시행하였다. 술후 15개월정도주기적인 Vitapex 교체및경과관찰중이며, 임상증상의소실및방사선사진상의병소가감소되는등양호한회복양상을보이고있어추후함입에국한한 gutta-percha 충전을계획중이다. 반면두번째증례의경우, 환자의나이를고려할때해당측절치의치근이이미충분히성숙된상태이며, 방사선사진상함입과치수강의명확한구분이관찰되고연장된 pseudo foramen 이치근단쪽에위치하여치주인대와교통함을알수있다. 또한치근단의명확한방사선투과성병소가관찰되며이미치수까지이환되었을가능성이높다고판단되었기에함입과치수에대한근관치료를함께진행하였다. 함입과근관을각각 Vitapex 를이용하여근관치료하였으며현재 2년여간주기적인 Vitapex 교체및경과관찰중이다. 역시양호한회복양상을보이고있으며추후 gutta-percha 충전을계획중이다. Ⅳ. 요약 Oehler s type III 치내치를갖는상악측절치의 peri-invagination periodontitis 를주소로 7세여아와 14세남아가해당치아의발거를위해의뢰되었다. 저자는임상검사및방사선사진검사결과환아의나이, 치근성숙도, 함입의종류, 염증의치수이환여부등을고려하여각각다른치료적접근을하였으며모두양호한결과를보였기에다음과같은지견을얻었다. 1. 치내치는조기진단및예방적처치가중요하다. 2. 임상검사및방사선사진검사상치료가필요한경우치내치 Oehler s classification 유형에따른적절한치료계획수립이필요하다. 3. Oehler's type III 치내치의치료시치수에대한처치를치료계획에포함시킬지여부를신중히고려하는것이중요하다. 참고문헌 1. Olmez S, Uzamis M, Er N: Dens invaginatus of a mandibular central incisor: surgical endodontic treatment. J Clin Pediatr Dent, 20:53-56,

4 J Korean Acad Pediatr Dent 39(2) Hulsmann M: Dens invaginatus: aetiology, classification, prevalence, diagnosis, and treatment considerations. Int Endod J, 30:79-90, Wells DW, Meyer RD: Vital root canal treatment of a dens in dente. J Endod, 19: , Mupparapu M, Singer SR: A rare presentation of dens invaginatus in a mandibular lateral incisor occurring concurrently with bilateral maxillary dens invaginatus: case report and review of literature. Aust Dent J, 49:90-93, Khabbaz MG, Konstantaki MN, Sykaras SN: Dens invaginatus in a mandibular lateral incisor. Int Endod J, 28: , Hovland EJ, Block RM: Nonrecognition and subsequent endodontic treatment of dens invaginatus. J Endod, 3: , De Sousa SM, Bramante CM: Dens invaginatus: treatment choices. Endod Dent Traumatol, 14: , Brkic H, Filipovic-Zore I, Kokic N: The treatment options of dens invaginatus complications in children: report of 3 cases. J Dent Child (Chic), 70:77-81, Er K, Kustarci A, Ozan U, et al.: Nonsurgical endodontic treatment of dens invaginatus in a mandibular premolar with large periradicular lesion: a case report. J Endod, 33: , Tarjan I, Rozsa N: Endodontic treatment of immature tooth with dens invaginatus: a case report. Int J Paediatr Dent, 9:53-56, Mupparapu M, Singer SR, Pisano D: Diagnosis and clinical significance of dens invaginatus to practicing dentist. N Y State Dent J, 72:42-46, 이정진, 최병재, 이제호, et al.: 하악중절치에발생한치내치. 대한소아치과학회지, 35: , Grahnen H, Lindahl B, Omnell K: Dens invaginatus. I. A clinical, roentgenological and genetical study of permanent upper lateral incisors. Odontologisk Revy, 10: , Backman B, Wahlin YB: Variations in number and morphology of permanent teeth in 7-year-old Swedish children. Int J Paediatr Dent, 11:11-17, Casamassimo PS, Nowak AJ, Ettinger RL, et al.: An unusual triad: microdontia, taurodontia, and dens invaginatus. Oral Surg Oral Med Oral Pathol, 45: , Oehlers FA: Dens invaginatus (dilated composite odontome). I. Variations of the invagination process and associated anterior crown forms. Oral Surg Oral Med Oral Pathol, 10: , Ridell K, Mejare I, Matsson L: Dens invaginatus: a retrospective study of prophylactic invagination treatment. Int J Paediatr Dent, 11:92-97, 윤석희, 이재천, 김영재 : 상악측절치의치내치에대한증례보고. 대한소아치과학회지, 31: , Bishop K, Alani A: Dens invaginatus. Part 2: clinical, radiographic features and management options. Int Endod J, 41: , Morfis AS, Lentzari A: Dens invaginatus with an open apex: a case report. Int Endod J, 22: , Holtzman L, Lezion R: Endodontic treatment of maxillary canine with dens invaginatus and immature root. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 82: , Grossman LI: Endodontic case reports. Dent Clin North Am, 18: , Creaven J: Dens invaginatus-type malformation without pulpal involvement. J Endod, 1:79-80, Pitt Ford HE: Peri-radicular inflammation related to dens invaginatus treated without damaging the dental pulp: a case report. Int J Paediatr Dent, 8: , Szajkis S, Kaufman AY: Root invagination treatment: a conservative approach in endodontics. J Endod, 19: , Schwartz SA, Schindler WG: Management of a maxillary canine with dens invaginatus and a vital pulp. J Endod, 22: , Fristad I, Molven O: Root resorption and apical breakdown during orthodontic treatment of a maxillary lateral incisor with dens invaginatus. Endod Dent Traumatol, 14: , Gound TG, Maixner D: Nonsurgical management of a dilacerated maxillary lateral incisor with type III dens invaginatus: a case report. J Endod, 30: , Tsurumachi T, Hayashi M, Takeichi O: Non-surgical root canal treatment of dens invaginatus type 2 in a maxillary lateral incisor. Int Endod J, 35: , Girsch WJ, McClammy TV: Microscopic removal of dens invaginatus. J Endod, 28: , Silberman A, Cohenca N, Simon JH: Anatomical redesign for the treatment of dens invaginatus type III with open apexes: a literature review and case presentation. J Am Dent Assoc, 137: ,

5 Abstract ENDODONTIC TREATMENT OF A PERIRADICULAR LESION ON AN INVAGINATED TYPE III MAXILLARY LATERAL INCISOR Ki Rim Kim, Jae Ho Lee, Seong Oh Kim, Je Seon Song, Byung Jai Choi, Seung Hye Kim, Hyung Jun Choi Department of Pediatric Dentistry, College of Dentistry Yonsei University Dens invaginatus is a developmental anomaly resulting in a deepening or invagination of the enamel organ into the dental papilla prior to calcification of the dental tissues. The most widely used classification of dens invaginatus is the system described by Oehler categorizes invaginations into three classes as determined by how far they extend radiographically from the crown into the root. Oehler s classification type III is that the invagination extends through the root and communicates with the periodontal ligament. There is usually no communication with the pulp. In Type III lesions, any infection within the invagination can lead to an inflammatory response within the periodontal tissues giving rise to a peri-invagination periodontitis. In the cases presented here, we treated two patients who were refered for peri-invagination periodontitis on maxillary lateral incisor with Oehler s type III invagination by different approaches each, and they have shown satisfactory outcomes. Although there are several approaches to the management of dens invaginatus, the most important objective is to preserve the health of the pulp, which can be achieved by early diagnosis and the prophylactic treatment regardless of severity. When disease has developed, decision has to be made whether to treat the invagination and the pulp separately. Key words : Maxillary lateral incisor, Dens invaginatus, Endodontic treatment, Oehler s classification 185

상악측절치(dh)

상악측절치(dh) J Korean Academy of Advanced General Dentistry 2014;3:29-33 ABSTRACT Endodontic Treatment of 2 Maxillary Lateral Incisors with Dens Invaginatus; 2 Case Reports Jaemin Lee, Kee-Deog Kim, Bock-Young Jung,