CASE REPORT http://dx.doi.org/10.4047/jkap.2012.50.4.330 유재욱 허성주 김성균 곽재영 * 서울대학교치의학대학원치과보철학교실 Shortened dental arch(sda) 개념은여러현실적인이유로적절한대안이없을경우제 2 소구치까지만수복이이루어져도안정적인교합과저작력을얻을수있다는것으로자연치와임플란트를이용한수복시공히적용되는개념이다. 본증례는 2 급지적장애로인해치료시협조를구할수없으며우식으로인해다수의치아가상실된환자로대구치부위의심한골흡수와상악동의함기화및상악동염으로인해제 2 대구치까지의수복이용이하지않아가급적위험요인을줄이면서최소한의전신마취로치료를종결하기위해 SDA 개념을적용, 제 2 소구치까지만수복이이루어졌다. 치료결과심미적, 기능적으로만족할만한향상이이루어졌고추가적인저작력의요구는없었으며주기적인재내원으로구강위생이강화되었다. ( 대한치과보철학회지 2012;50:330-5) 주요단어 : SDA; 2 급지적장애 ; 완전구강회복술 서론 2 급지적장애는지능지수와사회성숙지수가 35 이상 49 이하인사람으로일상생활의단순한행동을훈련시킬수있고, 어느정도의감독과도움을받으면복잡하지아니하고특수기술을요하지아니하는직업을가질수있는사람으로정의된다. 본증례의환자는지적장애 2 급판정을받은 29 세의여자환자로구강위생관리가전혀이루어지지않아대부분의치아가상실된채내원하였으며, 상실기간이길어상, 하악대구치부위의치조골흡수가많이진행되어잔존골이심하게부족한상태였다. 본증례의환자는치료협조를구하기어려워전신마취하에치료가진행되었으며위험부담이적은최소한의치료를위하여 shortened dental arch (SDA) 개념을적용하여치료가이루어졌다. Shortened dental arch (SDA) 는 1981 년 Arnd Käyser 에의해최초로소개된개념으로온전한상, 하악 6 전치와함께최소한 4 개의 occlusal unit 만으로저작활동에무리가없으며안정된교합을이룰수있다는것이다. 1 Occlusal unit 은상, 하악소구치한쌍을의미하며대구치한쌍은 2 개의 occlusal unit 으로계산된다. 하지만일반적으로는대구치를포함하지않고제 2 소구치까지수복하는것을의미한다. 1992 년 WHO 는전치부와소구치를포함하는최소 20 개의치아는기능과심미를만족시켜줄수있는최소의치아개수로좋은치료목표가될수있다고제시한바있으며 Solow 는 implant 를이용하여 SDA 로수복하여도자연치와같은결과를얻을수있다고보고하였다. 2-5 증례보고 환자는심한우식으로인해대부분의치아가상실된채내원하였으며남아있는치아들도대부분치근만남아있어수직고경이확립되지않은상태였다 (Figs. 1-3) 또한상악의경우골흡수, 상악동의함기화뿐만아니라상악동염에의해임플란트식립이곤란한상황이었다. 2 개월간임시의치를사용해본결과의치의관리가힘들뿐만아니라의치를두번잃어버리기까지하였다. 또한진료협조부족으로간단한알지네이트인상외에는대부분의진료가불가능하여전신마취하에시술이이루어져야했기에임플란트를이용한고정성으로수복하되실패확율이높은대구치부위는수복하지않고 SDA 개념을적용하여제 2 소구치까지만수복하기로결정하였다. 가급적전신마취횟수를줄이기위해철저한사전계획과준비하에진료가진행되어임플란트식립을포함하여최종보철까지총 5 회의전신마취로치료가마무리되었다. 보철과에처음내원시상, 하악대구치부위심한골흡수양상을보였으며 #15 치아의정출, 하악전치부의치아 - 치조골정출이관찰되었다. #41 치근단염증으로인해누공이형성되어있었으며하악전치부의임상치관길이가충분하지않아수복시생물학적폭경이침범될우려가있었다 (Figs. 1-3). 진단왁스업시행결과필요한최소한의거상량은전치부 1-1.5 mm 정도로파악되었으며 #15 치아는의도적근관치료후교합평면을낮추고치관확장술, #23 치아치은절제술, 하악전 * 교신저자 : 곽재영 110-749 서울시종로구연건동 28 서울대학교치의학대학원치과보철학교실 02-2072-2661: e-mail, young21c@snu.ac.kr 원고접수일 : 2012 년 9 월 27 일 / 원고최종수정일 : 2012 년 10 월 12 일 / 원고채택일 : 2012 년 10 월 14 일 c 2012 대한치과보철학회 cc 이글은크리에이티브커먼즈코리아저작자표시-비영리3.0 대한민국라이선스에따라이용하실수있습니다. *This research was supported by the Bio & Medical Technology Development Program of the National Research Foundation (NRF) funded by the Korean government (MEST) (No. 2011-0027790). 330 대한치과보철학회지 2012 년 50 권 4 호
A B Fig. 1. Initial photo (frontal view). Loss of VD, supraeruption of #15, dento-alveolar protrusion and severe resorption of mandibular molar region can be observed. Fig. 2.Initial photo (upper and lower occlusal view. A: maxilla, B: mandible). Bucco-lingual resorption of edentulous region, remaining caries of mandibular anterior teeth and the fistula in the labial gingiva of #42 can be observed. Fig. 3. Initial panoramic view. Resorption of alveolar bone and maxillary sinus pneumatization can be observed. Fig. 4. Diagnostic wax-up. Supraeuption of #15 and dentoalveolar protrusion of mandibular anterior teeth could be identified and the necessity of gingivectomy of #23 and CLP of #15, 31, 32, 33, 41 was verified. 치부치관확장술이필요하다고판단되었다 (Fig. 4). CT 촬영결과역학적으로유리한 #14 위치의경우부족한골폭과골높이, 상악동염으로인해상악동거상술시높은실패의위험이따르기에식립에불리한위치로판단되며, 상대적으로골폭과골높이가좋고상악동거상술이필요없는 #13 위치에식립하여 #14 부위는캔틸레버로처리하는것이유리하다고판단되었다 (Figs. 5, 6). 이에치료계획을정리하면, 상악의경우 #12, 13 부위에임플란트식립후 #12, 13 연결고정하고 #14 부위는캔틸레버처리, #15 치아는근관치료후조화로운교합평면을갖도록치아길이를짧게삭제한후치관확장술시행, #23 치아치은절제술후 #11, 23, 25 를지대치로하여 #11-25 를연결하는 6 본계속가공의치수복. 하악은 #41 치아발치후 #31, 32, 33, 42 치아치관확장술및 #31, 32, 33, 42 를지대치로하여 #33-42 를연결하는 5 본계속가공의치수복및 #34, 35, 43, 45 부위임플란트식립하기로하였다. 이모든과정을최소한의전신마취로진행하기위해서치료첫째날에임플란트식립하고둘째날은근관치료, 치관확장술, 치은절제술및 fixture-level 에서인상채득, 셋째날에는치아삭제및임시수복, 교합채득및인상채득. 넷째날에는코핑시적, 마지막다섯째날에는최종보철물수복으로총 5 회의전신마취를계획하였다. Fig. 5. CT image of maxilla. Narrow ridge and inadequate length of height around #14 and maxillary sinusitis can be observed. 대한치과보철학회지 2012 년 50 권 4 호 331
Fig. 6. CT image of mandible. Despite enough height, narrow width of alveolar bone made GBR necessary. Fig. 7. Implant surgery. GBR was done at both maxilla and mandible (A: maxilla, B: mandible). Fig. 8. Gingevectomy of #23, CLP of #15, 31, 32, 33, 42 and extraction of #42. Fig. 9. Healing after gingivectomy and CLP. Relatively regular gingival height and enough clinical crown length of mandibular anterior teeth were attained. Fig. 10. Tooth preparation and customized abutment. 계획대로첫째날전신마취하에임플란트식립하였다 (Fig. 7). 이때전신마취는비강삽관을통한가스마취 (desflurane) 로이루어졌다. 둘째날, #15 근관치료및치관확장술, #41 발치, #31, 32, 33, 42 치아근관치료후섬유강화형포스트와레진코어및치관확장술, #23 치아치은절제술시행하였다. 또한이때 fixture-level 에서인상채득하여 titanium customized abutment 제작하 였다 (Fig. 8). 임플란트식립후 10 주, 치관확장술시행 4 주후에치은높이가어느정도균일해지고하악전치부의충분한임상치관길이가확보되었다 (Fig. 9). 셋째날치아형성및 customized abutment 체결, 인상채득, 일차교합채득하였고임시수복이이루어졌다 (Figs. 10, 11). 이때의교합은임플란트 customized abutment 를연결한상태에서시행한 2 차진단왁스업상에서제 332 대한치과보철학회지 2012 년 50 권 4 호
Fig. 11. Provisional restoration. Fig. 12. Bite registration. Pattern resin copings which were relined by bite material at one side were connected remaining provisional restorations at the other side and vice versa. Fig. 13. Coping try-in. Fig. 14. Final restoration (frontal view). Fig. 15. Final restoration (upper and lower occlusal view). 작된임시수복물을기준으로미리제작한코핑을이용하여채득하였다. 먼저좌측에임시수복물을장착하고우측은코핑을장착한상태로 CR 유도하여상, 하악코핑을연결고정하고, 반대로우측에임시수복물장착하고좌측에코핑을장착한상태로한번더 CR 유도하여상, 하악코핑을연결고정하였는데이렇게함으로써임시보철물로확립된수직고경이기록된안정적인교합을채득할수있었다 (Fig. 12). 전신마취하였기에 CR 유도는용이하게이루어질수있었다. 이후임시수복에얼마나적응하는지평가가이루어졌는데, 임시수복물장착후적절한 lip support 및안모의개선이이루어졌고 clicking sound 또는측두하악관절의불편감이없었으며구강주위근육의과긴장 도관찰되지않았고저작, 발음시불편감도없는등임시수복에잘적응하여일차로채득한교합을그대로최종보철에이용하기로하였다. 넷째날코핑시적시행하고 (Fig. 13), 마지막다섯째날최종최종보철물수복하여치료가종결되었다 (Figs. 14, 15). 이로써 SDA 개념을적용하여전악수복이이루어졌으며만족할만한결과를얻게되었다. 환자는심미적, 기능적으로만족하였으며추가적인저작력의요구는없었다. 또한주기적인재내원을통한구강위생강화교육으로구강위생또한증진되었다. 대한치과보철학회지 2012 년 50 권 4 호 333
고찰 본증례의경우심한치조골흡수와상악동의함기화, 상악동염, 경제적문제등으로대구치부위임플란트식립이용이하지않았으며모든진료가전신마취하에이루어져야했기에실패에대한부담도컸다. 또한임시의치의사용결과저작력에대한요구는크지않다고판단되어 SDA 개념을적용하여전악수복이이루어졌다. 실제로치료후와여러차례의재내원과정중에환자는만족할만한저작력을보고하였으며추가적인저작력의요구는없었고교합은안정적으로유지되었다. 치료전전치한개정도만대합되어거의저작되지않은상태로섭취가이루어져위장관계문제를많이겪던것에비교해치료후위장관계문제가거의없이원하는음식을섭취할수있었다. 또한관리가어려웠던가철성임시의치에비해고정성으로전악수복이이루어져더편안하고강한저작력을얻을수있었다. 조금더나은결과를위해 #11 치아의치은절제술도동반되었으면하는아쉬움이남지만전반적으로는심미적인결과를얻었으며환자와보호자모두심미적으로만족하였다. 참고문헌 1. Kanno T, Carlsson GE. A review of the shortened dental arch concept focusing on the work by the Käyser/Nijmegen group. J Oral Rehabil 2006;33:850-62. 2. Witter DJ, De Haan AF, Käyser AF, Van Rossum GM. A 6-year follow-up study of oral function in shortened dental arches. Part II: Craniomandibular dysfunction and oral comfort. J Oral Rehabil 1994;21:353-66. 3. Witter DJ, de Haan AF, Käyser AF, van Rossum GM. A 6-year follow-up study of oral function in shortened dental arches. Part I: Occlusal stability. J Oral Rehabil 1994;21:113-25. 4. Solow RA. Comprehensive implant restoration and the shortened dental arch. Gen Dent 2010;58:390-9. 5. Armellini D, von Fraunhofer JA. The shortened dental arch: a review of the literature. J Prosthet Dent 2004;92:531-5. 334 대한치과보철학회지 2012 년 50 권 4 호
CASE REPORT Full mouth rehabilitation of an oligodontia patient with intellectual disability based on shortened dental arch concept: a case report Jae-Wook You, DDS, MSD, Seong-Joo Heo, DDS, MSD, PhD, Seong-Kyun Kim, DDS, MSD, PhD, Jai-Young Koak, DDS, MSD, PhD Department of Prosthodontics, School of Dentistry, Seoul National University, Seoul, Korea Shortened dental arch (SDA) as a treatment goal is the concept that stable occlusion and enough masticatory force can be achieved by restoration to the second premolars when the situation is not favorable. SDA could be applied both natural teeth and implant supported fixed prostheses. This case dealt with a patient who has grade 2 intellectual disability and a lot of missing teeth. Because of intellectual disability, patient cooperation during treatment could not be expected. Therefore every treatment should be done under general anesthesia. In addition to that, ridge resorption around molar area was severe and there were maxillary sinus pneumatization and maxillary sinusitis which increased failure probability. SDA concept was adopted to reduce risk factor and minimize general anesthesia. After the treatment, functional and esthetic improvement was achieved and oral hygiene was fortified by periodic recall check and education. (J Korean Acad Prosthodont 2012;50:330-5) Key words: SDA; Intellectual disability; Full mouth rehabilitation *Corresponding Author: Jai-Young Koak Department of Prosthodontics, School of Dentistry, Seoul National University 28 Yeongun-Dong, Chongro-Gu, Seoul, 110-749, Korea +82 2 2072 2661: e-mail, young21c@snu.ac.kr Article history Received September 27, 2012 / Last Revision October 12, 2012 / Accepted October 14, 2012 c cc 2012 The Korean Academy of Prosthodontics 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. 대한치과보철학회지 2012 년 50 권 4 호 335