CASE REPORT http://dx.doi.org/10.4047/jkap.2012.50.3.191 이재영 김지환 한동후 * 연세대학교치과대학보철학교실 상악전치부는심미적회복이강조되는부위다. 발치후치유될때까지기다린다면치조골흡수와치간유두수축을방지할수없다. 일단흡수된조직을재생하기위해서는추가적인외과적술식이필요하고치료기간도많이소요된다. 발치전치조골과치은조직이건강하다면치주조직을보존유지하기위해발치와동시에즉시임플란트식립을고려할수있다. 특히건전한발치와에서의즉시임플란트식립은여러논문에서성공적인결과를보였다. 치근단병소가존재하는치아의발치후즉시임플란트식립에대해서는부정적인반응을보이는연구가많았으나, 최근에는확실한발치와의육아조직제거와전신적항생제투여시성공률이높다는결과도보고되고있다. 본증례는 73 세여환으로상악좌측중절치의포스트 - 코어와금속도재관이탈락되었으며임플란트치료를받고싶다는주소로내원하였다. 치근단병소와수직적치근파절이존재하였으나치근단병소가있는치아에서도즉시임플란트식립의성공사례가여러차례보고되어발치및즉시임플란트식립을계획하였다. 발치후발치와육아조직제거와클로르헥시딘용액소독및 tetracycline 용액으로 soaking 을시행한후임플란트를식립하였으며식립전후로전신적항생제를투여하였다. 임플란트를식립하면서인상채득하여 2 일뒤임시보철물을장착하였다. 약 6 개월뒤치경부형태를재연하여최종인상채득하였으며최종보철물을장착하였다. 보철물장착후 2 년까지치은선이인접치아와조화를이루고변연골흡수없이심미적으로만족할만한결과를얻었기에보고하는바이다. ( 대한치과보철학회지 2012;50:191-7) 주요단어 : 즉시임플란트 ; 치근단병소 ; 상악전치부 서론 상악전치부는기능회복보다심미적회복이더중요한부위지만발치후치유기간동안일어나는치조골흡수와치간치은의소실은심미성을저해하게된다. 그러므로발치전치조골과치은조직이건강하다면이를유지하기위하여발치와동시에즉시임플란트식립을고려할수있다. 즉시임플란트식립은치료시간과치료술식을단축시킬수있고이상적인위치인자연치아의위치에임플란트식립할수있다는장점이있으며주변골을보존하고연조직심미성면에서도유리하다. 1 Chen 등 1 은즉시와지연임플란트식립의단기생존률에는큰차이가없다하였고, Tan 등 2 은즉시임플란트식립시 2 년생존률은 98.4% 에이른다고하였다. 이렇듯이이미여러연구를통해서즉시임플란트의높은생존률이보고되어왔다. 하지만즉시임플란트식립이모든경우에가능한것은아니며 Schwartz-Arad 등 3 이발표한논문을비롯하여여러연구에서감염원이존재하는부위에즉시임플란트식립은상대적금기 증이라하였다. 4 또한 Peñarrocha 등 5 은급성치근단염증이있는부위에서의즉시식립은절대적금기증이라하였다. 이에대한근거로 Quirynen 등 6 은잔존육아조직과임플란트접촉시다시병소가활성화될수있으며, 상악 426 개, 하악 113 개의단일임플란트를추적검사한결과, 상악과하악각각 1.6%, 2.7% 의 retrograde peri-implantitis 발생률을발표한바있다. 7 최근까지도치근단병변이존재하는부위의즉시임플란트식립은금기시되어왔으나, 근래들어육아조직제거나전신적항생제투여등을동반한경우만성치근단병소가존재하더라도즉시임플란트식립이가능하다는임상증례가보고되고있다. 8-12 그러나상악전치부의심미적결과에대한증례보고는많지않다. 본증례는치근단병소가존재하는상악좌측중절치부위에발치직후피판형성없이임플란트를식립한후즉시임시보철물을이용하여연조직재형성을시행하고최종보철물장착후 2 년간관찰한바만족스러운심미적결과를얻었기에이를보고하고자한다. * 교신저자 : 한동후 120-752 서울서대문구연세로 50 연세대학교치과대학보철학교실 02-2228-3163: e-mail, DONGHOOHAN@yuhs.ac 원고접수일 : 2012 년 7 월 6 일 / 원고최종수정일 : 2012 년 7 월 16 일 / 원고채택일 : 2012 년 7 월 23 일 대한치과보철학회지 2012 년 50 권 3 호 191
증례보고 Diagnosis and Treatment plan 본환자는 73 세여환으로상악좌측중절치의보철물이빠졌으며해당부위임플란트식립을하고싶다는주소로내원하였다. 전신병력으로는고혈압이있었으며치과적병력으로는약 30 년전해당치아의포스트 - 코어와금속도재관치료를받은적이있었다. 내원당시상악좌측중절치는포스트 - 코어와금속도재관이탈락되어치근만남은상태였으며임상과방사선검사결과수직치근파절과치근단병소가관찰되었다 (Fig. 1). 발치후즉시임플란트식립을계획하였다. Surgical Procedure 비외상적발치후발치와의결손형태와주변해부학적구조를검사하였고그결과손상된벽은존재하지않았다. 순측에서변연치은으로부터변연골까지의거리를치주탐침으로측정한결과 3 mm 하방에감지되었다. 발치후발치와육아조직제거, 소파술, 클로르헥시딘용액세척그리고 tetracycline soaking 을시행하여기존감염원을완전히제거하고자하였다 (Fig. 2). 또한술전 1 시간전과수술후 5 일간하루 3 번페니실린계항생제 ( 목시클정, 375 mg, 대웅제약 ) 및진통제 ( 근화소말겐정, 370 mg, 근화제약 ) 를복용하도록지시하였다. 발치와처치후피판형성없이 bone-level SLA (Straumann Dental Fig. 1. Intraoral photos and periapical radiograph at first visit. A: Maxillary left central incisor from labial view, B: Maxillary left central incisor from incisal view, C: Periapical radiograph of maxillary left central incisor with periapical radiolucent area. Fig. 2. Post-extraction procedures. A: Assessment of extraction socket, B: Measurement of distance between marginal gingival and marginal bone with probe, C: Chlorhexidine irrigation, D: Tetracycline soaking. 192 대한치과보철학회지 2012 년 50 권 3 호
Implants, Basel, Switzerland) 임플란트직경 4.8 mm 길이 14 mm 를제조사에서제시한술식에맞춰식립하였다. 순측치조골에손상을주지않도록주의하면서구개벽쪽으로드릴링과태핑한후, 임플란트를구개벽과밀착되게식립하였으며순측 bone plate 의내벽과는 1-1.5 mm 의공간을남겨두어신생골이채워지도록하였다. 임플란트상단은치은변연하방 3 mm, 변연골과같은높이에위치시켰다 (Fig. 3). 술후방사선사진촬영하여임플란트의방향과위치를확인하였다. Prosthetic procedure 즉시임시보철물을위하여인상채득시행하였으며창상감염을방지하기위해통상적인트레이와인상재없이인상용 지그와패턴레진을이용하였다. 임시보철물을제작하여 2 일뒤장착하였으며과도한교합력이가해지지않도록조정하였다 (Fig. 4). 주기적으로임시보철물을검사하고조정하여주변연조직의변화를관찰하였으며술후 6 개월째최종인상을채득하였다. 최종인상채득에앞서출현윤곽을인기하기위해기공용아날로그를임시치관에연결한후퍼티를사용하여치관치경부의형태를기록하였다. 임시치관대신인상용코핑을연결한후그공간을패턴레진으로채웠다. 치경부형태가재현된인상용코핑을구강내에연결한후인상을채득하였다 (Fig. 5). 작업모형에서도재를축성한맞춤지대주를제작하였고도재금속관을제작하였다. 구강내에서시적하고조정한뒤임시시멘트를사용하여도재금속관을합착하였다 (Fig. 6). Fig. 3. Surgical procedures. A: Drilling towards apical and palatal directions, B: Tapping, C: Implant installation, D: 1-1.5 mm of gap exists between implant fixture and labial bone plate. Fig. 4. A: Impression taking for immediate provisional restoration, B: Initial placement of immediate provisional restoration. 대한치과보철학회지 2012 년 50 권 3 호 193
Follow-up 보철물장착후매 6 개월마다정기검사를시행하였으며 2 년 후중절치사이의치간유두공극이치간유두로거의채워져서심미적으로만족할만한결과를보였다. 방사선사진에서도임플란트주위의변연골흡수없이잘유지되고있었다 (Fig. 7). Fig. 5. Impression taking for definitive restoration. A: Registration of emergence profile of provisional restoration using putty index, B: Reproduction of emergence profile on impression coping, C: Connection of customized impression coping. Fig. 6. Definitive restoration. A: Customized abutment on definitive model, B: Metal-ceramic restoration on definitive model, C: Initial placement of metal-ceramic restoration. Fig. 7. A: Intraoral photo and periapical radiograph 6 months after initial placement, B: Intraoral photo and periapical radiograph 2 years after initial placement. 194 대한치과보철학회지 2012 년 50 권 3 호
고찰 이미다수의증례보고에서치근단병소가존재하는부위에육아조직제거와전신적항생제투여등을시행하고즉시임플란트식립했을때에도감염이존재하지않는부위에시행하였을때와같이높은생존률을보고하였다. 8-12 Villa 와 Rangert 8 는 20 명환자에서 97 개의근관또는치주감염이존재하는치아를발치와동시에임플란트식립하여 15 개월에서 44 개월까지추적한결과 100% 생존률을보였으며, Bell 등 9 은환자기록검토를통하여평균 19.75 개월추적한결과 285 개의치근단병소존재하던치아에서의즉시임플란트식립은 97.5%, 637 개의대조군에서는 98.7% 의성공률을보여그차가통계적으로의미가없다고하였다. Casap 등 13 은감염이존재하는치아의발치및즉시임플란트식립한 30 개의증례를 1 년에서 6 년간추적한결과 97.7% 의성공률을보였다고하였으며, Fugazzotto 10 는 418 개의임플란트를최소 2 년간추적한결과 97.8% 의높은성공률을보고하였다. 이렇게여러성공적인결과가보고되고있으나아직까지는증례보고나후향적연구를통한결과가대부분이다. 이전의모든연구에서감염이존재하는부위에임플란트식립시발치후감염원제거의중요성을강조하였으며, 그방법으로발치와처치및전신적항생제투여를언급하였다. 특히상악전치부의순측 bone plate 는상당히얇기때문에임플란트시술후잔존육아조직이다시활성화되어염증으로인한골괴사가야기된다면치은퇴축으로인해심미적으로만족스러운결과를얻을수없다. 14 그러므로비외상적발치후감염조직을제거하기위하여확실한육아조직제거가반드시필요하며식염수나클로르헥시딘을이용한발치와세척, 그리고항생제세척 (antibiotic irrigation) 을시행할수있다. 본증례에서도이를적용하여발치와처치를시행하였다. 전신적항생제투여에대하여 Waasdorp 등 15 은항생제투여가육아조직제거후에도남아있을수있는잔존감염억제나술전에세균의양을줄이는역할을하는것으로예상된다고하였다. Esposito 등 16 은술전 1 시간전페니실린계통의항생제를투여시초기임플란트실패를줄인다고보고하였으며, 술후투여기간에대하여짧은기간투여할것을권하였다. 하지만 Mazzocchi 등 17 은술전후항생제투여없이술후항염증제만복용한 437 명의환자의 736 개의임플란트식립증례에서 96.2% 의생존률을보였음을보고하며, 건강한환자에서술자가정확한시술을행하고철저한술후관리를한다면항생제투여가불필요하다고언급하였다. 치과치료에있어전신적항생제투여는무작위대조연구나전향적연구가아직은부족하며, 15 실제로앞서언급한연구에서도항생제종류및투여기간은다양하였다. 본증례에서는술전 1 시간전페니실린계통의항생제 ( 목시클정, 375 mg, 대웅제약 ) 를처방하였고술후 5 일동안에도항생제투여를지시하였다. Fugazzotto 10 는발치후평가해야할항목으로발치와의 defect 형태, 주변해부학적구조, 그리고이상적위치에임플란트를 안정적으로심을수있는가대하여언급하였으며, 본증례의환자에서검사결과손상된벽은존재하지않았고, 안정적인발치와형태를가지고있었다. 즉시임플란트식립시순측 bone plate 와임플란트사이의 1-1.5 mm 공간이자연적으로신생골이채워지도록하였으며, Becker 등 18 은증례보고를통하여골이식없이즉시임플란트식립하여도장기적으로성공률이높다고보고한바있다. Botticelli 등 19,20 은동물실험과다수의증례를통해별다른골유도재생술식없이도임플란트와순측또는구개측 bone plate 의내벽사이의공간이신생골로채워질수있다고하였으며, 이러한경조직의형성은한정된측방결손부에응괴가잘차오를때가능하다고하였다. Covani 등 21 도 2 mm 이내의공간은골유도막없이도한정된협설측공간에신생골이채워질수있다고보고하였다. 임플란트식립후 48 시간내에보철물장착하는것을즉시보철물이라하며, 22 De Rouck 등 23 은즉시임시보철물시행시 midfacial 부위의심미적인면에서유리하며치간유두소실도제한적으로일어난다고보고한바있다. 그러므로즉시임시보철물장착후주변연조직의변화를관찰하고그에맞게임시보철물을조정하는과정이필요하다. 퍼티와패턴레진을이용함으로써임시보철물에인기된연조직형태를재현할수있으며이는최종인상채득시이용할수있다. 본증례는비록 2 년의단기간의추적검사를시행하였다는한계가있으나, 치근단병소가존재하는부위에서도적절한술전과술후관리가이루어지고수술과정을잘이행한다면즉시임플란트식립시기능적으로도심미적으로도만족할만한결과를얻을수있음을보여준다. 결론 치근단병소를동반한상악중절치를발치한후육아조직제거와발치와소독및항생제세척을시행하고즉시임플란트를식립하였다. 보철물장착후 2 년간관찰한결과, 심미적으로만족할만한결과를얻었다. 참고문헌 1. 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;19:12-25. 2. Tan WL, Wong TL, Wong MC, Lang NP. A systematic review of post-extractional alveolar hard and soft tissue dimensional changes in humans. Clin Oral Implants Res 2012;23:1-21. 3. Schwartz-Arad D, Chaushu G. The ways and wherefores of immediate placement of implants into fresh extraction sites: a literature review. J Periodontol 1997;68:915-23. 4. Novaes AB Jr, Vidigal Ju nior GM, Novaes AB, Grisi MF, Polloni S, Rosa A. Immediate implants placed into infected sites: a histomorphometric study in dogs. Int J Oral Maxillofac 대한치과보철학회지 2012 년 50 권 3 호 195
Implants 1998;13:422-7. 5. Peñarrocha M, Uribe R, Balaguer J. Immediate implants after extraction. A review of the current situation. Med Oral 2004;9:234-42. 6. Quirynen M, Gijbels F, Jacobs R. An infected jawbone site compromising successful osseointegration. Periodontol 2000 2003;33:129-44. 7. Quirynen M, Vogels R, Alsaadi G, Naert I, Jacobs R, van Steenberghe D. Predisposing conditions for retrograde periimplantitis, and treatment suggestions. Clin Oral Implants Res 2005;16:599-608. 8. Villa R, Rangert B. Early loading of interforaminal implants immediately installed after extraction of teeth presenting endodontic and periodontal lesions. Clin Implant Dent Relat Res 2005;7:S28-35. 9. Bell CL, Diehl D, Bell BM, Bell RE. The immediate placement of dental implants into extraction sites with periapical lesions: a retrospective chart review. J Oral Maxillofac Surg 2011;69: 1623-7. 10. Fugazzotto P. A retrospective analysis of immediately placed implants in 418 sites exhibiting periapical pathology: results and clinical considerations. Int J Oral Maxillofac Implants 2012;27:194-202. 11. Siegenthaler DW, Jung RE, Holderegger C, Roos M, Hämmerle CH. Replacement of teeth exhibiting periapical pathology by immediate implants: a prospective, controlled clinical trial. Clin Oral Implants Res 2007;18:727-37. 12. Del Fabbro M, Boggian C, Taschieri S. Immediate implant placement into fresh extraction sites with chronic periapical pathologic features combined with plasma rich in growth factors: preliminary results of single-cohort study. J Oral Maxillofac Surg 2009;67:2476-84. 13. Casap N, Zeltser C, Wexler A, Tarazi E, Zeltser R. Immediate placement of dental implants into debrided infected dentoalveolar sockets. J Oral Maxillofac Surg 2007;65:384-92. 14. Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 2008;19:73-80. 15. Waasdorp JA, Evian CI, Mandracchia M. Immediate placement of implants into infected sites: a systematic review of the literature. J Periodontol 2010;81:801-8. 16. Esposito M, Grusovin MG, Talati M, Coulthard P, Oliver R, Worthington HV. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database Syst Rev 2008;(3):CD004152. 17. Mazzocchi A, Passi L, Moretti R. Retrospective analysis of 736 implants inserted without antibiotic therapy. J Oral Maxillofac Surg 2007;65:2321-3. 18. Becker BE, Becker W, Ricci A, Geurs N. A prospective clinical trial of endosseous screw-shaped implants placed at the time of tooth extraction without augmentation. J Periodontol 1998;69: 920-6. 19. Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820-8. 20. Botticelli D, Berglundh T, Lindhe J. Resolution of bone defects of varying dimension and configuration in the marginal portion of the peri-implant bone. An experimental study in the dog. J Clin Periodontol 2004;31:309-17. 21. Covani U, Cornelini R, Barone A. Bucco-lingual bone remodeling around implants placed into immediate extraction sockets: a case series. J Periodontol 2003;74:268-73. 22. Degidi M, Piattelli A. Immediate functional and non-functional loading of dental implants: a 2- to 60-month follow-up study of 646 titanium implants. J Periodontol 2003;74:225-41. 23. De Rouck T, Collys K, Cosyn J. Single-tooth replacement in the anterior maxilla by means of immediate implantation and provisionalization: a review. Int J Oral Maxillofac Implants 2008;23:897-904. 196 대한치과보철학회지 2012 년 50 권 3 호
CASE REPORT Immediate implant placement into extraction sites with periapical lesions in the esthetic zone: a case report Jae-Young Yi, DDS, Jee-Hwan Kim, DDS, MSD, PhD, Dong-Hoo Han*, DDS, MSD, PhD Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea Esthetics is important in restoring maxillary anterior area. Alveolar bone resorption and loss of interdental papilla may be minimized by immediate implantation. Previous studies showed successful results with the immediate implantation in healthy extraction socket, while many of these studies objected the immediate implantation into extraction sites with periapical lesions. Recent studies, however, reported successful results of the immediate implantation into extraction sites with periapical lesions with careful debridement of extraction sockets and general medication of antibiotics prior to implantation. A 73-year-old female visited the department of Prosthodontics in University Dental Hospital with the chief complaint of fallen post-core and crown on left maxillary incisor. Although the incisor was with vertical root fracture and periapical lesion, the immediate implantation following the extraction of tooth was planned. Thorough socket debridement, irrigation with chlorhexidine, and tetracycline soaking were followed by immediate implantation. The general medication of antibiotics (Moxicle Tab., 375 mg) was prescribed before and after the surgery. Immediate provisional restoration was delivered two days after the surgery, and the definitive metal-ceramic restoration was placed about six months later after reproducing the emergence profile from the provisional restoration. This case presents satisfying result esthetically and functionally upto two years after the placement of prosthesis with the harmonious gingival line and no loss of marginal bone. (J Korean Acad Prosthodont 2012;50:191-7) Key words: Immediate implantation; Periapical lesion; Maxillary anterior tooth *Corresponding Author: Dong-Hoo Han Department of Prodthodontics, College of Dentistry, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea +82 2 2228 3163: e-mail, DONGHOOHAN@yuhs.ac Article history Received July 6, 2012 / Last Revision July 16, 2012 / Accepted July 23, 2012 대한치과보철학회지 2012 년 50 권 3 호 197