대한소아치과학회지 35(2) 2008 치아석회화단계와골성숙도단계간의상관관계에대한연구 강동균 김태완 김영진 남순현 김현정 경북대학교치과대학소아치과학교실 국문초록 본연구는성장중인부정교합환자의진단이나치료계획의수립, 치료방법및시기, 예후등을결정하는데중요한판단지침이되는치아석회화

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1 대한소아치과학회지 35(2) 2008 치아석회화단계와골성숙도단계간의상관관계에대한연구 강동균 김태완 김영진 남순현 김현정 경북대학교치과대학소아치과학교실 국문초록 본연구는성장중인부정교합환자의진단이나치료계획의수립, 치료방법및시기, 예후등을결정하는데중요한판단지침이되는치아석회화단계와경추및수완부골성숙도간의연관성을규명하여개인의보다정확하고효율적인사춘기성장정도를평가하기위해시행하였다. 전신질환이없고교정치료경험이없는 7-16세의여아 154명, 남아 179 명, 총 333명의파노라마방사선사진, 측모두부규격방사선사진, 수완부방사선사진을분석하여평가하였다. 연구결과, 파노라마방사선사진의치아석회화단계를통하여사춘기성장정도를평가하는것은부정교합환자의진단및치료계획을수립하는데임상적으로유용한정보를제공할것으로판단되었다. 주요어 : 사춘기성장, 치아석회화단계, 수완부골성숙도, 경추골성숙도 Ⅰ. 서론 성장중인부정교합환자의치료에있어서개인의성장정도에대한정확한평가는적절한치료시기의선택및장기적인치료계획을수립하는데매우중요하다 1-4). 즉, 두개안면부의성장량을예측평가하는것은골격성부정교합과악안면부조화의치료시필수적이라할수있다. 그리고성장에대한고려는치료결과및치료예후의결정에도중요한의미를지니며악정형력의적용, 악기능교정장치의치료, 발치여부, 악교정수술등의임상적결정에기초가되어야한다 5-7). 또한, 부정교합환자중성장기어린이가차지하는높은비율을고려하면성장발육의평가와예측은더욱중요하다고할수있다. 이러한성장발육을평가하는방법으로는크게역연령과발육연령으로나눌수있다. 먼저, 역연령은생물학적나이를의미하는데동일한연령이라도개인에따라다양한신체성숙도 교신저자 : 김현정 대구광역시중구삼덕 2 가 50 번지경북대학교병원소아치과 Tel : jungkim@mail.knu.ac.kr 를나타내므로개인의성장발육평가지표로는부적당하다 2,6,8). 반면, 발육연령은개인의성숙도를평가하기위한생물학적지표로서성장의개체성, 변이성을반영할수있는평가방법이다. 신장이나체중을이용한신체성숙도평가. 치아의발육을평가하는치아성숙도평가, 수완부나경추골의성숙도를평가하는골성숙도평가, 이차성징의출현을고려하는성적성숙도평가등이해당된다 8-10). 신장과안면의최대성장기는오랫동안다수의문헌에서높은상관관계를가진다고보고되어왔다. Singh 11), Pike 12), Bergersen 13) 은신장과안면골격의최대성장기가일치한다고하였으며 Nanda 14), Bambha와 Natta 15), Fishman 6) 은안면의최대성장기가신장에비해 6 12개월늦게나타난다고보고하였다. 신장을이용한평가방법은가장정확하고변이성이적지만 13), 성장량의증가가너무작아성장기동안주기적인계측에의해서만확인이가능하고최대성장기가지난후에야파악이가능하다는한계가있다 16). 골성숙도평가방법은특정골의초기출현과그후에일어나는골석회화변화에있어골의형태와크기를관찰하는것으로다른평가방법에비하여성장과정의요소들과더욱밀접한관계를보여주기때문에성장기어린이의신체발달척도로가장많이이용된다 17). 또한, 이평가방법은성장에따른골석회 243

2 J Korean Acad Pediatr Dent 35(2) 2008 화정도의변화가모든사람에게서거의일정하며재현성이매우우수하다는장점이있다 18). 수완부는골성숙도평가에서가장많이이용되는부위인데수완부골에서는출생시부터성숙의종료시까지화골현상이계속진행되고수완부를구성하는각골은각기화골현상의개시기, 정도및양상이다르므로성숙도평가에유용하기때문이다 5,17,19,20). 또한, 판독이용이하고방사선사진촬영이간편하고재현성이매우우수하여골성숙도측정부위로널리사용되고있다 10,21,22). 이러한수완부골성숙단계에대해서여러문헌상에서많은지침들이기술되어왔다. 1937년 Todd 23) 는수완부방사선사진의임상적응용을제시하였으며, Greulich와 Pyle 18) 은수완부의표준골령을위한표준도해를작성하였다. 그후, Tanner 등 24) 은각각의골성숙도를점수화하여골성숙지수를산출하는 TW1 & TW2 방법을제시하였고, Grave과 Brown 22) 은수완부의아홉부위에서일어나는골화순서에따라 14단계로분류하였다. 1982년 Fishman 6) 은종적과횡적연구를통해 SMI(Skeletal maturity indicators) 방법을제시하였다. 경추골성숙도평가방법은측모두부규격방사선사진에서대부분제 2, 3, 4번경추의측면형태를관찰하는것으로수완부골성숙도와비교하여믿을만하고높은상관관계가있을뿐아니라추가적인방사선노출을피할수있는장점이있다. 1972년 Lamparski 25) 는수완부골과경추골의평가에차이점이없음을보고하였고, O Reilly와 Yaniello 26) 는2 6번경추의변화에따라 6단계의표준화된지표를제시하였다. Hassel과 Farman 20) 은수완부골과경추골성숙도의높은상관관계를보고하며골성숙단계를 6단계로분류하는 CVMI(cervical vertebrae maturation index) 를제시하였으며, 최근 Baccetti 등 27) 은 2, 3, 4번경추의성숙도에따라 5단계로나눈 CVMS (Cervical vertebral maturation stages) 를제시하였다. 치아의성숙도를평가하는방법은역연령과함께가장먼저이용된지표이지만치아의발육은개인적변이가큰특징이있다 9,28,29). 평가방법으로는치아맹출도에따른방법과치아석회화과정에따르는방법이있다. 이중치아의맹출도를이용하는것은치아맹출순서와시기가다양하며국소적인요소들의영향을많이받으므로정확한평가가어렵다고보고되어있다 8,30,31). 즉, 치아맹출도에따른평가방법은골격성장과의상관관계가비교적낮고변이를야기할수있는많은외인성요소로인해적합하지못한반면, 치아의석회화과정은주위환경에의한영향이적기때문에치아의성숙도를평가하는방법으로보다적합하다 32). 치아의석회화정도에따른표준화된방법은 Dermijian 등 33) 에의한방법과 Nolla 34) 에의한분류법이대표적이다. 치아석회화단계와골성숙도간의상관관계에대해서는상반되는여러보고가있었는데, Lauterstein 35), Sierra 36), Chertkow 37), Engströ m 등 38) 은높은상관관계를보고한반면 Acheson 39), Green 31), Dermijian 등 10) 은낮은상관관계를보고 하였다. 이는보다정확한개인의성장정도를예측하기위한치아성숙도와골성숙도의평가기준이논란의여지가있음을의미한다. 만약골성숙도를대신하여치아의석회화단계로써환자의성장을평가할수있다면부가적인방사선사진이필요없게되어환자에대한방사선노출을감소시킬수있고통상적인치료과정에서보다쉽게성장상태를평가할수있게된다. 골성숙도와치아석회화단계가높은상관관계를가진다면교정진단뿐아니라일상적치과치료시에도촬영하는파노라마방사선사진으로성장에대한유효한정보를얻을수있으리라기대하였다. 즉, 본연구의목적은골성숙도와의비교연구를통하여치아석회화단계를이용한성장평가방법이유효성을가지는가에대해알아보고자한다. Ⅱ. 연구대상및방법 1. 연구대상경북대학교치과진료처에 2004년 1월에서 2007년 2월사이에내원한성장기어린이로교정진단을위해동일한날짜에파노라마방사선사진, 측모두부규격방사선사진과수완부방사선사진을촬영한환아를연구대상으로하였다. - 성장발육에영향을미칠수있는선천적기형이없으며전신건강이양호한한국어린이 - 이전의교정치료경험이없고, 영구치발거경험이없는환아 - 매복이나전위등이없는정상치아를가진환아 - 과거에안면이나수부에외상경험이없는환아위의조건을만족하는 7세에서 16세사이의여아 154명, 남아 179명, 총 333명을연구대상으로하였다. 2. 연구방법 1) 치아의석회화단계분석파노라마방사선사진상에서환자의하악좌측견치, 제 1소구치, 제 2소구치, 제 2대구치의석회화단계를 Dermijian 등 33) 이기술한방법에따라평가하였다 (Fig. 1). 상악치아의경우파노라마방사선사진상중첩으로인해정확한평가가어려워제외하였고, 하악전치부와제 1대구치의경우이미치근단이완성된경우가대부분이어서평가에서제외하였다. 2) 수완부골성숙도평가수완부방사선사진상에서 Fishman 6) 이제시한 SMI(Skeletal maturity indicators) 11단계중 SMI 1, 2, 4, 6, 8, 10 으로평가하였다 (Fig. 2). 3) 경추골성숙도평가측모두부규격방사선사진상에서제 2,3,4번경추의성장 244

대한소아치과학회지 35(2) 2008 Fig. 1. The stages of tooth calcification (From Dermijian, 1978 33) ). C stage : Enamel formation is complete at the occlusal surface. Dentinal deposition has commenced.

The pulp chamber in the uniradicular teeth is curved, being concave toward the cervical region. In the molars the pulp chamber has a trapezoid form. The pulp horns are beginning to differentiate.

In molars the radicular bifurcation is visible. F stage : The walls of the pulp chamber now form an isosceles triangle. The apex ends in a funnel shape.

3 대한소아치과학회지 35(2) 2008 Fig. 1. The stages of tooth calcification (From Dermijian, ) ). C stage : Enamel formation is complete at the occlusal surface. Dentinal deposition has commenced. The outlines of the pulp chamber are curved. D stage : Crown formation is complete to the cementoenamel junction. The pulp chamber in the uniradicular teeth is curved, being concave toward the cervical region. In the molars the pulp chamber has a trapezoid form. The pulp horns are beginning to differentiate. Root formation is seen. E stage : The walls of the pulp chamber are straight and the pulp horns are more differentiated. The root length is less than the crown height. In molars the radicular bifurcation is visible. F stage : The walls of the pulp chamber now form an isosceles triangle. The apex ends in a funnel shape. The root length is equal to or greater than the crown height. In molars the bifurcation has developed sufficiently to give the roots a distinct outline with funnel shaped endings. G stage : The walls of the root canal are now parallel and its apical end is still partially open (distal root in molars). H stage : The apical end of the root canal is completely closed (distal root in molars). The periodontal membrane has a uniform width around the root and the apex. Fig. 2. Skeletal maturity indicators (From Fishman, ) ). PP3 (SMI 1) : the proximal phalanx of the third finger, the epiphysis equals its diaphysis MP3 (SMI 2) : the middle phalanx of the third finger, the epiphysis equals its diaphysis S (SMI 4) : the first mineralization of the ulnar sesamoid bone MP3cap (SMI 6) : the middle phalanx of the third finger, the epiphysis caps its diaphysis DP3μ(SMI 8) : the distal phalanx of the third finger, complete epiphyseal union MP3μ(SMI 10) : the middle phalanx of the third finger, complete epiphyseal union 245

J Korean Acad Pediatr Dent 35(2) 2008 Fig. 3. Cervical vertebral maturation stages (From Baccetti, et al. 2002 27) ).

4 J Korean Acad Pediatr Dent 35(2) 2008 Fig. 3. Cervical vertebral maturation stages (From Baccetti, et al ) ). CVMS Ⅰ : The lower borders of all the three vertebrae are flat, with the possible exception of a concavity at the lower border of C2 in almost half of the cases. The bodies of both C3 and C4 are trapezoid in shape (the superior border of the vertebral body is tapered from posterior to anterior). The peak in mandibular growth will occur not earlier than one year after this stage. CVMS Ⅱ : Concavities at the lower borders of both C2 and C3 are present. The bodies of C3 and C4 may be either trapezoid or rectangular horizontal in shape. The peak in the mandibular growth will occur within one year after this stage. CVMS Ⅲ : Concavities at the lower borders of C2, C3, and C4 now are persent. The bodies of both C3 and C4 are rectangular horizontal in shape. The peak in mandibular growth has occurred within one or two years before this stage. CVMS Ⅳ : The concavities at the lower borders of C2, C3, and C4 still are present. At least one of the bodies of C3 and C4 is squared in shape. If not squared, the body of the other cervical vertebra still is rectangular horizontal. The peak in mandibular growth has occurred not later than one year before this stage. CVMS Ⅴ : The concavities at the lower borders of C2, C3, and C4 still are evident. At least one of the bodies of C3 and C4 is rectangular vertical in shape. If not rectangular vertical, the body of the other cervical vertebra is squared. The peak in mandibular growth has occurred not later than two years before this stage. 양상에따라 5단계로분류한 Baccetti 등 27) 이제시한 CVMS(Cervical Vertebral Maturation Stages) 평가방법을이용하였다 (Fig. 3). - 골성숙도 ( 수완부골, 경추골 ) 단계별각치아의석회화단계의분포도를조사하였다. - Kappa value : 평가자의재현성을검정하였다. 3. 평가방법 Ⅲ. 연구성적 3명의평가자 ( 교정과의사 2명, 소아치과의사 1명 ) 에의해시행되었으며일치하지않는항목에대해서는토의를거쳐의견일치를보았다. 평가자의재현성검증을위해한달의간격을두고 20명을무작위로선정하여재평가를하였다. 4. 통계분석 - SPSS statistical package : 경추골및수완부골성숙단계별평균연령과표준편차를구하고남녀별유의성을분석하였다. - The Spearman rank order correlation coefficient : 치아석회화단계, 수완부골성숙도, 경추골성숙도간의상관관계를분석하였다. 1. 연구대상의연령분포이번연구대상자의연령분포는 Table 1과같다. 2. 골성숙도단계별역연령의분포 Table 2는골성숙도단계별남녀의인원과평균역연령을보여준다. Table 2-1의수완부골결과에서는모든단계에서여아가남아에비해작게나타났으며통계적유의성도모든단계에서존재하였다. 경추골결과에서도마지막단계인 CVMS Ⅴ 단계를제외하고모든단계에서통계적으로유의한차이를보였다. CVMS Ⅴ 단계에서도통계학적으로유의하진않지만여아에서약 9개월앞서나타났다 (Table 2). 246

5 대한소아치과학회지 35(2) 2008 Table 1. Number of subjects used in this study 총합 Female male Table 2-1. Distribution of chronological ages for all subjects grouped by SMI Maturation Number of Chronological age Difference Sex stages subjects Mean ± SD (mon.) (mon.) P-value PP3 F ± M ± MP3 F ± <.0001 M ± S F ± <.0001 M ± MP3cap F ± <.0001 M ± DP3μ F ± M ± MP3μ F ± M ± Table 2-2. Distribution of chronological ages for all subjects grouped by CVMS Maturation Number of Chronological age Difference Sex stages subjects Mean ± SD (mon.) (mon.) P-value CVMS Ⅰ F ± M ± CVMS Ⅱ F ± M ± CVMS Ⅲ F ± M ± CVMS Ⅳ F ± M ± CVMS Ⅴ F ± M ± 수완부골성숙도와치아석회화단계사이의상관관계수완부골성숙도와치아석회화단계사이의상관관계는남녀모두에서높은수치를보였다. 여아의경우하악견치는 0.877, 하악제 1소구치 0.901, 하악제 2소구치는 0.891, 하악제 2 대구치 0.918의결과를보였고, 남아의경우하악견치는 0.865, 하악제 1소구치 0.894, 하악제 2소구치는 0.902, 하악제 2대구치 0.905의결과를보였다. 남녀모두동일하게하악제 2대구치에서가장높은상관관계를나타내었다 (Table 3). 4. 수완부골성숙도단계별각치아의석회화단계의분포도조사 1. PP3 단계 PP3 단계에서는남녀모두하악견치와하악제 1소구치는대부분 E 단계이상의치아석회화도를보였고하악제 2대구치는대부분 D 단계를나타내었다 (Fig. 4). 2. MP3 단계 MP3 단계에서는여아의경우하악견치 F 단계가 88.46%, 하악제 1 소구치 F 단계 76.92% 로높게나타났으며. 남아의 247

6 J Korean Acad Pediatr Dent 35(2) 2008 Table 3. Correlation coefficients between SMI and dental calcification stages Correlation Coefficients Tooth Female Male r Significance r Significance Canine.877 ***.865 *** First premolar.901 ***.894 *** Second premolar.891 ***.902 *** Second molar.918 ***.905 *** Fig. 4. Percentage distribution of calcification stages at the PP3 stage. Fig. 5. Percentage distribution of calcification stages at the MP3 stage. 경우는하악견치, 하악제 1, 2소구치는대부분 F 단계이상의석회화도를보였다 (Fig. 5). 3. S 단계 S 단계에서는여아는하악견치, 하악제 1소구치는 F 단계이상의석회화도를보였고하악제 2소구치의 F 단계가 70.59% 로가장높은분포를보였다. 남아는대체적으로분산된분포를보였다 (Fig. 6). 4. MP3cap 단계 MP3cap 단계에서는남녀모두하악견치의 70% 이상이이미치근완성단계를보였으며하악제 2대구치의 G 단계가여아 53.85%, 남아 81.82% 로높게분포하였다 (Fig. 7). 5. DP3μ단계 DP3μ단계에서는여아의경우하악제 2대구치의 G 단계가 86.69% 로높게분포하였으며남아는대상치아대부분이치근완료단계를나타내었다 (Fig. 8). 248

7 대한소아치과학회지 35(2) 2008 Fig. 6. Percentage distribution of calcification stages at the S stage. Fig. 7. Distribution of calcification stages at the MP3 cap stage. Fig. 8. Distribution of calcification stages at the DP3 μstage. 6. MP3μ단계 MP3μ단계에서는대부분의대상치아가치근완성단계의석회화도를나타내었다 (Fig. 9). 5. 경추골성숙도와치아석회화단계사이의상관관계경추골성숙도와치아석회화단계사이의상관관계또한모든치아에서비교적높은상관관계를보였지만, 수완부골에비해수치가다소낮았으며특히남아의결과에서좀더낮은수치 249

8 J Korean Acad Pediatr Dent 35(2) 2008 를보였다. 여아의경우하악제 2대구치 (0.897), 남아의경우하악제 1소구치 (0.782) 에서가장높은상관관계를보였다 (Table 4). 6. 경추골성숙도단계별각치아의석회화단계의분포도조사 Fig 은경추골성숙도단계에따른각치아석회화단계의분포도를도표로나타내었다. Fig. 9. Distribution of calcification stages at the MP3μstage. Table 4. Correlation coefficients between CVMS and dental calcification stages Correlation Coefficients Tooth Female Male r Significance r Significance Canine.864 ***.773 *** First premolar.869 ***.782 *** Second premolar.854 ***.763 *** Second molar.897 ***.778 *** 1. CVMS Ⅰ 단계 (Fig. 10) Fig. 10. Distribution of calcification stages at the CVMS Ⅰ stage. 250

9 대한소아치과학회지 35(2) CVMS Ⅱ 단계 (Fig. 11) Fig. 11. Distribution of calcification stages at the CVMS Ⅱ stage. 3. CVMS Ⅲ 단계 (Fig. 12) Fig. 12. Distribution of calcification stages at the CVMS Ⅲ stage. 4. CVMS Ⅳ 단계 (Fig. 13) Fig. 13. Distribution of calcification stages at the CVMS Ⅳ stage. 251

10 J Korean Acad Pediatr Dent 35(2) CVMS Ⅴ 단계 (Fig. 14) Fig. 14. Distribution of calcification stages at the CVMS Ⅴ stage. 7. 수완부골성숙도와경추골성숙도의상관관계 8. 평가자의재현성검증 경추골과수완부골성숙도간의상관관계는여아 0.925, 남아 0.821로남녀모두높은상관관계를나타내었다 (Table 5). 평가자의재현성검증은 으로전반적으로재현성이아주높았으며경추골성숙도 ( ) 가치아의석회화단계 ( ) 와수완부골성숙도평가 (0.98) 보다다소낮은수치를보였다 (Table 6). Table 5. Correlation coefficients between SMI and CVMS Correlation Coefficients Female Male r Significance r Significance *** *** Table 6. Reproducibility of the assessment #33 #34 #35 #37 SMI CVMS Observer A Observer B Observer C

11 대한소아치과학회지 35(2) 2008 Ⅳ. 고찰성장기어린이의교정치료시양호한치료결과를얻기위해서는최대성장시기를정확히예측하여치료시기를결정하고치료계획을수립하는것이필요하다 1-4). 사춘기성장은인종과성별그리고각개인마다그개시기, 기간, 최대성장기에있어많은차이가존재하므로역연령자체만으로평가하는것은많은문제점을지니고있다 9,22,40). 따라서사춘기성장의평가에는신체성숙도, 골성숙도, 치아성숙도, 성적성숙도평가등의다양한방법들이시도되어왔다. 본연구는 7-16세의성장기어린이를대상으로성장평가의여러가지방법중치아석회화단계와경추골및수완부골의골성숙도간의상관관계를평가하였다. 먼저본연구에서이용한평가방법중수완부골성숙도평가방법인 Fishman 6) 이제시한 SMI는수완부골의여섯부위에서 11단계로구분되어있으며성장발육평가에가장널리이용되는방법으로평가가매우용이하고재현성이높은장점이있다. SMI의 11단계는경추골성숙도의 5단계및치아석회화단계의 6단계와수적으로많은차이를보였기때문에임상적으로중요한의미를지니는 PP3, MP3, S, MP3cap, DP3μ, MP3μ 의6 단계를선택하여평가하였다. 각평가단계의임상적의미를살펴보면 PP3는성장가속화시작하기전단계이며 sesamoid 골의골화단계는최대성장시점보다약 1년먼저나타나고, MP3cap 단계는최대성장시점과일치하며 MP3μ 단계는거의성장이완료되었음을의미한다. 경추골성숙도는 Baccetti 등 27) 이제시한 2, 3, 4번경추의변화에따른 CVMS를이용하여평가하였다. 첫번째단계인 CVMS Ⅰ 단계은성장이시작되는시기이며, CVMS Ⅱ 단계는성장가속화시작단계로 1년이내에최대성장시기가일어남을의미하며, CVMS Ⅲ 단계는최대성장기가이시기의 1년이내에일어났음을의미한다. 그리고 CVMS Ⅳ 단계는성장감속화시기를, CVMS Ⅴ 단계는성장이완료되었음을의미한다. 이평가방법에서사용되는 2, 3, 4번경추는측모두부규격방사선사진에서모두확인이가능하고객관화된지표를제시하여평가가용이한방법이다. Dermijian 33) 은치배에서석회화가시작되는시기부터치근단이폐쇄되는시기까지 8단계로구분하였고, Nolla 34) 는치아의발육단계를미석회화기부터근단폐쇄기까지 10단계로구분하여치아석회화정도에따른치아성숙도를평가하였다. 본연구에서는치아석회화단계의평가방법으로 Dermijian이제시한방법을이용하였는데, 그이유는평가항목이치관에대한상대적인길이를이용하여치근길이의비율과형태를기준으로한명확한세부항목으로구성되어있기때문이다. 그러므로발육중인치아의상이축소되거나확대되어도평가의신뢰도에영향을미치지않는장점이있다. 치아석회화단계의평가는파노라마방사선사진을이용하여하악견치와하악제 1소구치, 하악제 2소구치, 하악제 2대구치를평가하였다. 파노라마 방사선사진은교정진단뿐아니라성장기어린이의치과진료시일반적인촬영법으로널리사용되고있으며본연구에서는교정진단을위해촬영한파노라마방사선사진을이용하였다. 전치부와제 1대구치의경우이른시기에발육이완료되기때문에평가에서제외하였고, 상악치아의경우파노라마방사선사진상여러해부학적구조물의중첩에의해정확한평가가어려워제외하였다. 그리고제 3대구치의경우선천적결손이많고발육의변이가심하여평가대상에서제외하였다. 골성숙을의미하는경화부위들이출현하는시기에있어서남녀성별차이가있음이보고되어왔으며, 초기골성숙단계에서는여아가남아보다 2년이상빠른성숙을보이고성장완료기에는그차이가줄어드는것으로알려져있다 41-44). 본연구에서도수완부골성숙도에서는모든단계에서통계적으로남녀가유의한차이를보였으며, 경추골성숙도에서는마지막단계인 CVMS Ⅴ 단계를제외한모든단계에서통계적으로유의하게여아가남아보다빠른골성숙을보였다. 그양상은이전의연구와동일하게사춘기성장이활발한시기에서많은차이를보이다가성장감속기에서그차이가감소되었다. 수완부골성숙도와경추골성숙도의상관관계분석에서도이전의연구와유사하게높은상관성을나타내었다. 이는경추골성숙도는수완부골성숙도처럼악골의성장평가에유용하다고것을의미한다. 특히최근발표된 CVMS를이용한경추골성숙도평가는이전의방법보다객관화된지표를제시하여보다용이하게적용할수있어임상적으로큰유효성을지니리라판단된다. 본연구에서치아석회화단계와수완부골성숙도사이의상관관계를검정한결과평가대상이된모든치아에서높은상관관계를보였다. 남녀모두수완부골성숙도와하악제 2대구치의석회화단계가가장높은상관관계를보였는데, 이는견치와높은상관관계를보인이전의연구 36,37) 와는차이가있었으며이는하악제 2대구치가하악견치나하악소구치보다다소늦게석회화가이루어지기때문으로사료된다. 그리고경추골성숙도또한치아의석회화단계와통계적으로유의한상관관계를보였다. 하지만수완부골에비해서는다소낮은상관관계를나타내었다. 이또한경추골성숙도가수완부골성숙도보다좀더느리게이루어져치아석회화단계와시기적으로더큰차이를보이기때문인것으로생각된다. 치아석회화단계와골성숙도단계의관계를좀더명확히알기위해수완부골성숙도단계별치아석회화단계의분포도를분석하였다. 전반적으로동일한골성숙도에서여아가남아보다이른치아석회화단계를나타내었다. 사춘기성장가속화시작단계인 MP3 단계에서는여아의경우하악견치와하악제 1소구치가대부분 F 단계이상의석회화단계를보였으며, 남아의경우하악견치, 하악제 1, 2소구치가 F 단계이상의석회화단계를나타내었다. 즉남녀모두하악견치 F 단계이후에사춘기성장이시작될것으로생각된다. 그리고사춘기최대성장시점의약 1년전인 S 단계에서는여아의경우하악제 2 253

J Korean Acad Pediatr Dent 35(2) 2008 대구치가대부분 E 단계나 F 단계의석회화단계를보였으며, 남아는하악제 2대구치가대부분 F 단계나 G 단계에분포하였다.

최대성장시점과일치하는 MP3cap 단계에서는남녀모두하악견치와하악제 1소구치가비교적높은비율로치근단완성단계를보였으며, 특히남아에서하악제 2대구치 G 단계의비율이매우높게나타났다.

Schematic diagram between skeletal maturity and dental calcification stage at 1-year before maximum growth period. Fig. 16.

12 J Korean Acad Pediatr Dent 35(2) 2008 대구치가대부분 E 단계나 F 단계의석회화단계를보였으며, 남아는하악제 2대구치가대부분 F 단계나 G 단계에분포하였다. 이결과의의미를살펴보면교정치료시악정형적효과를얻기위해서는 S 단계이전에치료를고려해야하는데, 파노라마방사선사진상에서하악제 2대구치의석회화단계가여아는 F 단계, 남아는 G 단계에도달하기이전에는교정치료시작을고려해야함을의미한다. 최대성장시점과일치하는 MP3cap 단계에서는남녀모두하악견치와하악제 1소구치가비교적높은비율로치근단완성단계를보였으며, 특히남아에서하악제 2대구치 G 단계의비율이매우높게나타났다. 이시기이후는최대성장시기가지남으로인해서악골성장에의한악정형적효과는기대하기힘들고, 대부분치아이동에의한교정치료가이루어지게된다. 수완부골성숙도, 경추골성숙도, 치아석회화단계의분포를 Fig. 15. Schematic diagram between skeletal maturity and dental calcification stage at 1-year before maximum growth period. Fig. 16. Schematic diagram between skeletal maturity and dental calcification stage at the maximum growth period. Fig. 17. Schematic diagram between skeletal maturity and dental calcification stage at growth completion period. 254

13 대한소아치과학회지 35(2) 2008 분석하여임상적으로중요한의미를지니는성장시점의표준화된지표를제시해볼수있다 (Fig.15 17). 최대성장 1년전과일치하는 sesamoid 골이출현하는 SMI 4(S) 단계는 CVMS Ⅱ 단계와유사하다. 이시기의치아석회화단계에있어서여아는하악제 2소구치가 F 단계, 하악제 2대구치는 E 또는 F 단계의석회화도를나타내었고, 남아의경우는하악제 2소구치가 G 단계를보이고하악제 2대구치는대부분 F 또는 G 단계의석회화도를보였다 (Fig. 15). 최대성장시점인 SMI 6(MP3cap) 단계에서여아의경우는하악견치가이미성장이완료되었으며하악제 2소구치와하악제 2대구치는 G 단계가비교적높게분포하였고, 남아는하악견치와하악제 1소구치가치근단완성단계에도달하며하악제 2대구치는 G 단계의석회화도를나타내었다 (Fig. 16). 대부분의성장이완료된 SMI 10(MP3μ) 단계에서는경추골은 CVMS Ⅴ 단계와일치하며남녀모두하악견치, 하악제 1, 2소구치및하악제 2대구치가대부분치근단완성이이루어졌다 (Fig. 17). 치아석회화단계를이용한성장의평가방법은골성숙도에비해표준화된지표의제시가힘들고치아의성장이골의성장에비해빠르게진행되어완료되기때문에성장평가에서정확한판단의기준으로적용하기에는한계가존재한다. 하지만본연구에서치아석회화단계와골성숙도단계간의상관관계와분포도를분석해본결과, 파노라마방사선사진을이용한치아석회화단계평가방법이성장에대한유용한임상적정보를제공할수있으리라판단된다. 평가항목의재현성을검증하기위해연구대상자중 20명을성별과역연령을고려한후무작위로선정하여첫평가에서 1 달후재평가를실시하였다. Kappa value를이용한검증에서 으로전반적으로높은재현성을보였다. 경추골성숙도가치아의석회화단계와수완부골성숙도평가보다다소낮은수치를보였는데, 이는측모두부규격방사선사진이수완부방사선사진이나파노라마방사선사진보다선명도가낮고경추골의중첩으로인해서하연의오목함의평가에서모호한경우가있었기때문으로생각된다. Ⅴ. 결론본연구는성장중인부정교합환자의진단이나치료계획의수립, 치료방법및시기, 예후등을결정하는데중요한판단의지침이되는치아석회화단계와경추및수완부골성숙도의상호간의연관성을규명하여개인의보다정확하고효율적인사춘기성장정도를평가하기위해시행하였다. 전신질환이없고교정치료경험이없는 7-16세의여아 154명, 남아 179명, 총 333명의파노라마방사선사진, 측모두부규격방사선사진, 수완부방사선사진을분석하여평가함으로써다음의결론을얻었다. 1. 여아가남아보다빠른골성숙을보이며사춘기성장이활발한시기에서큰차이를보이다가성장감속기에서그차 이가감소된다. 2. 남녀모두에서수완부골성숙도와경추골성숙도사이에높은상관관계존재하였다. 3. 남녀모두에서하악견치, 하악제 1소구치, 하악제 2소구치, 하악제 2대구치의석회화단계는수완부골과경추골성숙도와통계적으로유의한상관관계가있었다. 4. 남녀모두하악제 2대구치가수완부골성숙도와가장높은상관관계를보였다. 5. 골성숙도 ( 수완부골, 경추골 ) 단계별각치아의석회화단계의분포도를조사하였다. 이상을종합해볼때, 파노라마방사선사진의치아석회화단계를통하여사춘기성장정도를평가하는것은부정교합환자의진단및치료계획을수립하는데임상적으로유용한정보를제공할수있을것으로사료된다. 참고문헌 1. Bishara SE, Jamison JE, Peterson LC, et al. : Longitudinal changes in standing height and mandibular parameters between the ages 8 and 17 years. Am J Orthod, 80: , Fishaman LS : Maturational patterns and prediction during adolescence. Angle Orthod, 57: , Pancherz H, Hägg U : Dentofacial orthopedics in relation to somatic maturation. An analysis of 70 consecutive cases treated with the Herbst appliance. Am J Orthod, 88: , Singer J : Physiologic timing of orthodontic treatment. Angle Orthod, 50: , Moore RN, Moyer BA, Dubois LM : Skeletal maturation and craniofacial growth. Am J Orthod Dentofac Orthop, 98:33-40, Fishman LS : Radiographic evaluation of skeletal maturation. A clinically oriented method based on hand-wrist films. Angle Orthod, 52:88-112, Björk A : A timing of interceptive orthodontic measures based on stages of maturation. Trans Eur Orthod Soc, 48:61-74, Johnston FE, Hufham HP, Moreschi AF, et al. : Skeletal maturation and cephalofacial development. Angle Orthod, 35:1-11, Björk A, Helm S : Prediction of the age of maximum pubertal growth in body height. Angle Orthod, 37: , Dermijian A, Buschang PH, Tanguay R, et al. : Interrelationships among measures of somatic, 255

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15 대한소아치과학회지 35(2) :97-112, Bowden BD : Epiphyseal changes in the hand-wrist area as indicators of adolescent stage. Aust Orthod J, 4:87-104, Eklöf O, Ringertz H : A method for assessment of skeletal maturity. Ann Radiol, 10: , 이미라, 이상호 : 한국인사춘기성성장기에서의수완부골성숙도와치아발육에관한연구. 대한소아치과학회지, 19: , 김선미 : 정상교합자의악골성장과수완부골성숙단계에관한연구. 대한소아치과학회지, 23:9-17,

16 J Korean Acad Pediatr Dent 35(2) 2008 Abstract RELATIONSHIP BETWEEN DENTAL CALCIFICATION STAGES AND SKELETAL MATURITY INDICATORS IN KOREAN INDIVIDUAL Dong-Gyun Kang, Tae-Wan Kim, Soon-Hyeun Nam, Young-Jin Kim, Hyun-Jung Kim Department of Pediatric Dentistry, College of Dentistry, Kyungpook National University The purpose of this study was to investigate the relationship between the stages of calcification of various teeth and skeletal maturity stages among Korean individuals. The study subjects consisted 154 female and 179 male ranging from 7 years to 16 years of age. A total of 333 hand-wrist, cephalo-lateral and panoramic radiographs were obtained and analyzed. The tooth development of the mandibular canines, first, second premolars, and second molars were assessed according to the Dermijian s system. Skeletal maturity stages were determined from hand-wrist radiographs by using the SMI system and cephalo-lateral radiographs by using the CVMS, respectively. The results were as follows. 1. The mean ages of each stage of skeletal maturity were consistently younger in female subjects. 2. There was a high correlation between skeletal maturity of hand-wrist and cervical vertebrae in the both sexes. 3. There was a high correlation between skeletal maturity and dental calcification stage of mandibular canines, first premolar, second premolars, and second molar. 4. The mandibular second molar was tooth showing the highest correlation. 5. Percent distributions of the relationship between calcification stages of individual teeth and stages of skeletal maturity were obtained in both sexes. In summary, this suggests that tooth calcification stages from panoramic radiographs might be clinically useful as a maturity indicator of the pubertal growth period. Key words : Pubertal growth, Dental calcification stage, Skeletal maturity of hand-wrist, Skeletal maturity of cervical vertebrae 258

J Korean Acad Pediatr Dent 35(2) 2008 도사이상관성이낮다고보고하였다. 국내에서는차와서 13), 오와양 14), 이와이 15), 정과양 16) 이치아석회화과정과골성숙도에관한연구를보고하였다. 부정교합의형태에따른골성숙도의연구로는김과정 17) 의보

J Korean Acad Pediatr Dent 35(2) 2008 도사이상관성이낮다고보고하였다. 국내에서는차와서 13), 오와양 14), 이와이 15), 정과양 16) 이치아석회화과정과골성숙도에관한연구를보고하였다. 부정교합의형태에따른골성숙도의연구로는김과정 17) 의보 대한소아치과학회지 35(2) 2008 Ⅲ 급부정교합어린이의수완부골성숙과하악제 3 대구치발육에대한연구 강근영 양규호 최남기 김선미 전남대학교치의학전문대학원소아치과학교실, 치의학연구소및 2 단계 BK21 사업단 국문초록 본연구는 Ⅰ급부정교합과 Ⅲ급부정교합어린이의수완부골성숙단계와하악제3대구치발육을비교 평가하고자하였다. 이를위해전남대학교병원소아치과에내원한환자들로 8세부터