ISSN 1229-5418 Implantology 2012; 16(2): 48~59 임플란트즉시식립과조기식립에의한상악전치부의심미적수복증례 황지완, 김재신, 이중석, 정의원, 김창성, 조규성, 채중규, 최성호 연세대학교치과대학치주과학교실, 치주조직재생연구소 Establishment of Esthetics in Maxillary Anterior Region Using Immediate and Early Implant Placement: A Case Report Ji-Wan Hwang, Jae-Shin Kim, Jung-Seok Lee, Ui-Won Jung, Chang-Sung Kim, Kyoo-Sung Cho, Jung-Kiu Chai, Seong-Ho Choi Department of Periodontology, Research Institute of Periodontal Regeneration, College of Dentistry, Yonsei University, Seoul, Korea Abstract In implant dentistry, anterior sites are most likely linked to esthetic expectations and often present a considerable challenge to dental clinicians, because various local risk factors have the potential to compromise the predictability of the results. To attain esthetic results in these compromised patients, careful treatment planning and a delicate clinical approach are important. Immediate implantation has the advantage of maintaining papilla and technical simplicity. However, this technique involves high risk of potential implant dehiscence and gingival recession due to early labial bone resorption. In contrast, early implantation includes the complicated procedure for reconstruction of gingival architecture. Two cases of patients were treated with immediate and early implantation in the maxillary anterior region. All implants appeared to be integrated and were clinically stable. The favorable marginal gingival level and improvement of labial contour were achieved in all cases during the follow-up period. Key Words: dental esthetic, dental implants, maxilla Reprint requests: Seong-Ho Choi Department of Periodontology, Dental Hospital of Yonsei University College of Dentistry, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea Tel: 82-2-2228-3189, Fax: 82-2-392-0398 E-mail: shchoi726@yuhs.ac Received for publication: September 15, 2012 Accepted for publication: September 20, 2012 교신저자 : 최성호 (120-752) 서울시서대문구연세로 50 연세대학교치과병원치주과 Tel: 82-2-2228-3189, Fax: 82-2-392-0398 E-mail: shchoi726@yuhs.ac 원고접수일 : 2012 년 9 월 15 일게재확정일 : 2012 년 9 월 20 일 Copyright 2012. The Korean Academy of Oral & Maxillofacial Implantology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.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. 48 Implantology Vol. 16 No. 2, 2012
I 서론 1969 년 Brånemark 이완전무치악 환자에서임플란트를이용한 수복치료를소개한이래 1 임플 란트를이용한자연치의회복은수복치과에서가장많은진보를이룬영역이며, 다양한임상결과를다룬다수의논문에서높은임플란트생존율과성공률을제시하고있다 2,3. 성공적인임플란트는기능뿐아니라심미를만족시켜야한다. 특히상악전치부는심미적인면이강조되는부분으로임상가들이많은어려움을겪게되는데이는임플란트의목적을만족시키기위해적절한질과양의경조직및연조직이필요하기때문이다. 치아발거후연조직과경조직은일련의적응성변화를유도하여, 무치악부위는전체적으로위축된다. Schropp 등 4 은단일소구치와구치를발거한후 12개월동안일어난골과연조직부피의변화를연구하였다. 처음 3개월동안협-설 / 구개폭경이 30% 감소하였고 12개월후무치악부위는원래너비의 50% 정도감소하였다. 게다가협측골판의높이가감소하여치유 12개월후설 / 구개측골판에비해 1.2 mm 치근단쪽에위치하였다. 이연구결과는개를대상으로한실험인발치후무치악치조제형태에대한 Araújo 와 Lindhe 5 의연구에서도지지된다. 이동물모델에서발치와치유과정중설측에비하여협측골벽에서더욱많은골흡수가일어나는이유는적어도 2가지로정리될수있다. 첫째, 설측에비해협측골벽정상부에치아의존적인조직인다발골이상대적으로많기때문에경조직상실은협측골벽에서더욱현저하다. 둘째로, 발치와의설측골벽은협측에비해현저하게폭이넓기때문에판막거상과골막이골에서분리된결과, 표면흡수가일어나두꺼운설측골벽보다두께가 얇은협측골벽이수직적으로더감소하게된다. 2004 년 Hämmerle 등 6 은발치와치유에나타나는경조직과연조직의변화를반영한임플란트시기의분류를발표하였다. Type 1은발치후즉시임플란트를식립하는경우, Type 2는발치후 4~8주사이에발치와의연조직치유가일어난뒤임플란트를식립하는경우, Type 3 는발치후 12~16 주사이에발치와의연조직뿐아니라경조직의상당한양이치유된후임플란트를식립하는경우, 그리고 Type 4는발치후 6개월이상이경과된후완전히치유된치조제에임플란트를식립하는경우이다. 발치후임플란트즉시식립 (Type 1) 은수술횟수와치료기간의단축, 식립위치결정의용이함등의장점이있다 7. Chen 등 8 은임플란트즉시식립으로발치와치조골의보존이가능하다고제시하였지만최근 Araújo 등 9 은발치후협측다발골의흡수는임플란트의즉시식립과상관없이진행된다고보고하였다. 또한발치후임플란트즉시식립은부족한연조직양으로인해수술부위의일차봉합을이루기어려운경우가있다. 이에반해, 발치와의연조직치유가이루어진후임플란트를식립하는조기식립 (Type 2) 은수술시장력이없는일차봉합을위한판막조절이유리하며심미적위험도가낮은경우부터높은경우까지많은증례에서사용된다. 그러나다근치나치근단쪽골파괴가큰경우는임플란트식립시초기고정을얻기어려운단점이있다. 그러므로심미성을요구하는전치부에서는증례에맞는임플란트식립시기를선택해야하고, 추후협측골흡수및치은퇴축을방지하기위해재생술식등이고려되어야한다. 본임상증례에는상악전치부에서즉시임플란트식립과조기임플란트식립을통해임상적으로양호한결과를나타내었기에이를보고하는바이다. 대한구강악안면임프란트학회지 16 권 2 호, 2012 49
Case Reports II 증례보고 1. 증례 1 2011 년 12월, 18세남환이넘어져서위앞니가부러졌다는주소로연세대학교치과병원보존과에내원하였다. 구강검사및방사선사진검사상 11번치아는복합치관-치근파절상태였고교정적정출을위해발수를시행하였으나설측파절선이치은연하 3~4 mm 선에위치하여예후가불량할것으로판단되어발치후임플란트식립을계획하였다 (Fig. 1). 환자는건강한상태였으며, 특이할만한의학적병력은없었다. 환자는발치후바로임시보철물수복을원하였고, 치료가최대한빨리끝나기를원하였다. 또한임상검사상환자의 gingival biotype 은 probe 를넣었을때비추어보이지않는 thick flat type 으로판단하였고, 수술전 cone beam computed tomography (CT) 검사상, 11번치아의협측골판은 1 mm 두께로 intact 한것을확인할수있었다 (Fig. 2). 따라서즉시임플란트식립을계획하였다. 수술부위에침윤마취를시행하고발치시협측골의손상을최소화하기위해판막을거상하지않고 Periotome (Nobel Biocare, Yorba Linda, CA, USA) 을이용하여조심스럽게 11번치아를발거하였다 (Fig. 3A). 발치와의폭과길이를측정한뒤발치와의구개측벽을따라순차적인 drilling 을시행하였다. 직경 3.3 mm의 final drilling Fig. 1. Preoperative intraoral photographs. A maxillary right central incisor fractured by trauma. (A) Labial view. (B) Occlusal view. Fig. 2. Preoperative radiographs. (A) Periapical view. (B) Cone beam computed tomography crosssectional view. 50 Implantology Vol. 16 No. 2, 2012
을 이용하여 site preparation을 마친 후, 직경 3.8 mm, torque는 40 N이었고 hand wrench를 이용하여 최종 식 길이 12 mm의 Implantium fixture (Dentium, Seoul, 립 깊이를 조절하였다. 식립 후 미리 만들어 놓은 Korea)를 식립하였다(Fig. 3B). 식립 시의 초기 고정 impression jig를 적용하여 impression coping을 채결하 Fig. 3. Intraoral photographs of immediate implant placement. (A) Occlusal view of extraction socket. (B) Occlusal view after implant placement. Fig. 4. Impression taking during surgery. (A) Application of impression jig. (B) Connection of impression coping. (C) Impression taking using pattern resin. Fig. 5. Intraoral photographs after implant placement. (A) Occlusal view after connection of healing abutment. (B) Occlusal view after bone graft material placement. (C) Occlusal view after suturing. 대한구강악안면임프란트학회지 16권 2호, 2012 51
Case Reports 고패턴레진을이용하여인상을채득한후 temporary crown 을제작하였다 (Fig. 4). 식립후임플란트와협측골판사이에 2 mm 간극이발생하여이종골이식재인 Bio- Oss (Geistlich Biomaterials, Wolhusen, Switzerland) 를이식한뒤 temporary crown 을제작하는동안치유지대주를체결한뒤 (Fig. 5) temporary crown 을장착하였다 (Fig. 6). 이식재의탈락을방지하기위해흡수성봉합사 Monosyn 4-0 (Aesculp AG & CO. KG, Tuttlingen, Germany) 로봉합하였다. 술후 cone beam CT 촬영상임플란트는계획했던위치에식립된것을확인할수있었고임플란트와협측골사이의간극부위에이식한이식재도확인할수있었다 (Fig. 7). 술후소독은수술다음날시행하였고수술 1주일후에발사하였으며발사시치유양상에문제는없었다. 수술후한달이경과한뒤치 Fig. 6. Intraoral photograph after provisional prosthesis delivery. Maxillary Anterior Region Using Immediate and Early Fig. 8. Intraoral photograph of provisional prosthesis 4 weeks after implant placement. Maxillary Anterior Region Using Immediate and Early Fig. 7. Postoperative radiographs. (A) Periapical view. (B) Cone beam computed tomography crosssectional view. 52 Implantology Vol. 16 No. 2, 2012
유과정에서특별한점은없었으며임시보철물의 contour 조정을통해 gingival margin 을재형성하였다 (Fig. 8). 술후 3개월에최종보철물을완성하였고, 기능적으로심미적으로만족스러운결과를얻을수있었다 (Fig. 9). 2. 증례 2 2010 년 8월, 22세여환이넘어져서위앞니뿌리가부러졌다는주소로연세대학교치과병원치주과에내원하였다. 구강검사및방사선사진검사상 21번치아는치근파절이확인되어발치후임플란트식립을계획하였 다 (Figs. 11, 12). 임상검사상 gingival biotype 은 medium thick biotype 으로판단하였고환자의심미적요구도가크고술후치은퇴축에대한두려움이큰상황이라 punch technique 를이용한발치와보존술후조기임플란트식립을계획하였다. 수술부위에침윤마취시행후, 발치시협측골의손상을최소화하기위해판막을거상하지않고 Periotome (Nobel Biocare) 을이용하여조심스럽게 21번치아를발 Fig. 9. Intraoral photograph of the final prosthesis placement 16 weeks after implant placement. Maxillary Anterior Region Using Immediate and Early Fig. 10. Periapical radiograph after final prosthesis placement. Maxillary Anterior Region Using Immediate and Early Fig. 11. Preoperative intraoral photographs. A maxillary left central incisor fractured by trauma. (A) Labial view. (B) Occlusal view. 대한구강악안면임프란트학회지 16 권 2 호, 2012 53
Case Reports 거하였다 (Fig. 13). Diamond bur를이용하여치은탈상피화후, 직경 8 mm의 Stiefel biopsy punch (Stiefel, Offenbach, Germany) 를이용하여 20번대구개부측에서직경 8 mm, 두께 3 mm의이식편을채취하였다. 이식편을발치와에적용한뒤, 5-0 흡수성봉합사인 Coated Vicryl (Ethicon Inc., Johnson and Johnson company, Somerville, NJ, USA) 을이용하여봉합을시행하였다 (Fig. 14). 발치후협측골판이완전히남아있어협측연조직소실을막기위한부가적인골이식재이식은시행하지않았다. Fig. 12. Preoperative periapical radiograph. Maxillary Anterior Region Using Immediate and Early 발치와보존술시행 6주후이식편이잘유합되어성숙한점막을보여주고있었고 (Fig. 15) 이시기에임플란트를식립하였다. 수술부위에침윤마취를시행하고 22번치아의원심측선각부위에서하나의수직절개를포함한전측판막을거상하였다 (Fig. 16). 발치와의구개측벽을따라순차적인 drilling 을시행하여 site preparation 을완료하였다. 직경 4.0 mm, 길이 11 mm의 straight type Astra Tech Implant (Astra Tech AB, Mölndal, Sweden) fixture 를식립하였고식립시의초기고정 torque 는 30 N이었다 (Fig. 17A, 17B). 임플란트식립후, 임플란트와협측골판사이의 2 mm의간극과협측골판의외측에 Bio-Oss (Geistlich Biomaterials) 로풍융하게골이식을시행하고흡수성차단막 Bio-Gide (Geistlich Biomaterials) 를적용하여결손부를폐쇄하였다 (Fig. 17C, 17D). 수직절개와감장절개 (releasing incision) 를통하여조직에탄성을부여한후창상의완전한폐쇄를얻을수있었다 (Fig. 18). 1차수술 4개월후 pouch roll tehchnique 10 을사용하여 2차수술을시행하였다. 임플란트식립부위의 cover screw 상방에작은유경판막을형성하고 diamond bur 로상방의치은의탈상피화를시행하였다. Orban knife 를사용하여협측에 pouch 를만들어작은유경판막을말아넣은뒤치유지대주를체결하고봉합은시행하지않았다 (Fig. 19). Fig. 13. Clinical photographs after atraumatic extraction. (A) Labial view. (B) Occlusal view. 54 Implantology Vol. 16 No. 2, 2012
Fig. 14. Soft tissue punch technique. (A) De-epithelization using diamond bur. (B) Havestment of soft tissue from palate. (C) Havested soft tissue. (D) Occlusal view after suturing. Fig. 15. Clinical photographs 6 weeks after the soft tissue punch technique. (A) Buccal view. (B) Occlusal view. Fig. 16. Intraoral photographs of extraction socket after flap reflection. (A) Labial view. (B) Occlusal view. 대한구강악안면임프란트학회지 16권 2호, 2012 55
Case Reports Fig. 17. Intraoral photograghs at implant placement and guided bone regeneration. (A) Labial view after implant placement. (B) Occlusal view after implant placement. (C) Occlusal view after bone graft. (D) Occlusal view after membrane application. Fig. 18. Clinical photograghs after flap closure. (A) Labial view (B) Occlusal view. Fig. 19. Clinical photographs at second surgery. (A) Occlusal view before second surgery. (B) De-epithelization using diamond bur. (C) Connection of healing abutment after the pouch roll technique. 56 Implantology Vol. 16 No. 2, 2012
Fig. 20. Clinical photographs after final prosthesis delivery. (A) Labial view. (B) Occlusal view. Fig. 21. Periapical radiograph after final prosthesis. Maxillary Anterior Region Using Immediate and Early 이차수술후최종보철물을완성하였고보철물주위의 치은형태와교합상태는양호하였으며환자는치료에만족하였다 (Fig. 20, 21). III 총괄및고찰 최근발표한논문들에서발치후즉시임플란트식립은협측골의흡수를피할수없다고보고한다. 특히치조골 벽이얇은전치부는구치부보다임플란트표면이노출될가능성이높으며 Spray 등 11 은협측골판의두께가 1.8 mm 이하일경우골흡수가크다고보고하였다. 부가적치료술식없이자연적인 bone filling 이일어날수있는임플란트표면에서골면까지의임계거리또한중요한데, Jung 등 12 은동물실험을통해 2 mm 이내의 gap defect 에서는자연적인 bone filling 이일어난다고하였다. 뿐만아니라 tissue biotype 또한임플란트의성공률과술후치은퇴축에영향을줄수있다고알려져있다 13. 반면에 Thin, scalloped gingival biotype 은건전한협측골판을가지고있다하더라도협측골판의흡수와변연부치은퇴축의위험도가높기때문에임플란트식립과동시에골재생술식이추천된다. Thick, less scalloped gingival biotype 은치은퇴축과치간유두손실의위험도가상대적으로낮다. 증례 1 환자의경우, 외상으로인해 11번치아의파절로임플란트를식립을계획한경우이다. 술전임상검사에서 thick gingival biotype 으로판단되었고, 술전 cone beam CT 검사상건전한협측골판이확인되었기때문에즉시임플란트식립으로계획하였다. 심미적인결과를위해 Periotome (Nobel Biocare) 을통해무외상성발치를시행하였고절개또한시행하지않았다. 또한임플란트 drilling 과식립시구개측골에기대어협측의 dehiscence defect 나 fenestration defect 를피할수있었다. 임플란트식립후의간극결손부의크기는 2 mm 정도였지 대한구강악안면임프란트학회지 16 권 2 호, 2012 57
Case Reports 만추후얇은치조골벽의흡수를보상하기위해이종골이식재로골이식을시행하였다. 증례 2 환자의경우에도외상으로인한 21번치아의치근파절로발치후임플란트식립을계획하였다. 22세여환으로심미적기대치가매우크고, 임상검사상 medium thick biotype 으로판단하여조기임플란트식립을계획하였다. 치조제보존술 (ridge preservation) 은발치후치조골소실의예방을위해 1985년 Ashman과 Bruins 14 에의해처음고안된술식으로치조제보존이나증대에대한효과는논쟁이되고있지만협측및치간부치은의외형과치간유두높이유지에유리하다고알려져있고, 많은연구가이루어지고있다. 이중 Jung 등 15 이발표한 soft tissue punch technique 을이용한치조제보존술은수술후 6주후유합된이식조직의비율이 99% 에달하며색조면에서도심미적인결과를나타내었다. 이번증례에서도발치후 punch technique 를시행하고 6주가지난후이식된조직은잘유합되어임플란트식립후간극결손부에 guided bone regeneration 을시행한후장력없는일차봉합을얻기에유리했다. 임플란트 2차수술단계에서협측치은의풍융도를위해 pouch roll technique 10 을사용하였다. 이 technique 은협측연조직두께를증강시킴으로써작은수평결손을교정하고협측연조직프로파일을개선시킬수있다. 이는치간유두의형태를보존하고, 시술후불편감을감소시키며연조직치유와심미적결과를증강시키는장점이있다. IV 결론 임플란트의식립시기는치료부위와목적, 발치의원인, 골의형태, 연조직의 biotype 을고려하여결정해야 하며특히상악전치부와같이심미적부위에서는추후골과연조직의변화를고려해야성공적인결과를이룰수있다. 본임상증례에서도이러한사항들을고려하여임플란트식립시기를결정하였고, 발치시외상을최소화하고재생술식을시행하였으며 punch technique, pouch roll technique 등의부가적인술식을동반하여좋은결과를가져올수있었다. 참고문헌 1. Brånemark PI, Adell R, Breine U, et al. Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg. 1969; 3: 81-100. 2. Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-submerged ITI implants. Part 1: 8-year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res. 1997; 8: 161-172. 3. Adell R, Eriksson B, Lekholm U, et al. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants. 1990; 5: 347-359. 4. Schropp L, Wenzel A, Kostopoulos L, et al. Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent. 2003; 23: 313-323. 5. Araújo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol. 2005; 32: 212-218. 6. Hämmerle CH, Chen ST, Wilson TG Jr. Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Implants. 2004; 19 Suppl: 26-28. 7. Lazzara RJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodontics Restorative Dent. 1989; 9: 332-343. 8. Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants. 2004; 19 58 Implantology Vol. 16 No. 2, 2012
Suppl: 12-25. 9. Araújo MG, Wennström JL, Lindhe J. Modeling of the buccal and lingual bone walls of fresh extraction sites following implant installation. Clin Oral Implants Res. 2006; 17: 606-614. 10. Park SH, Wang HL. Pouch roll technique for implant soft tissue augmentation: a variation of the modified roll technique. Int J Periodontics Restorative Dent. 2012; 32: e116-121. 11. Spray JR, Black CG, Morris HF, et al. The influence of bone thickness on facial marginal bone response: stage 1 placement through stage 2 uncovering. Ann Periodontol. 2000; 5: 119-128. 12. Jung UW, Kim CS, Choi SH, et al. Healing of surgically created circumferential gap around non-submerged-type implants in dogs: a histomorphometric study. Clin Oral Implants Res. 2007; 18: 171-178. 13. Lee A, Fu JH, Wang HL. Soft tissue biotype affects implant success. Implant Dent. 2011; 20: e38-47. 14. Ashman A, Bruins P. Prevention of alveolar bone loss postextraction with HTR grafting material. Oral Surg Oral Med Oral Pathol. 1985; 60: 146-153. 15. Jung RE, Siegenthaler DW, Hämmerle CH. Postextraction tissue management: a soft tissue punch technique. Int J Periodontics Restorative Dent. 2004; 24: 545-553. 대한구강악안면임프란트학회지 16 권 2 호, 2012 59