Vol. 33 No. 3, December 2014 Bio-col 테크닉을이용한상악전치부임플란트의식립증례 서정민, 박현경, 박우현, 이영빈, 윤현경 국립경찰병원통합치과전문임상의과 A case of maxillary anterior implant placement using a Bio-col technique Jeong-Min Seo, Hyun-Kyung Park, Woo-Hyun Park, Yung-Bin Lee, Hyun-Kyung Yun Department of Dentistry, National Police Hospital, Seoul, Korea Maxillary anterior implants should be both aesthetically perfect and functionally successful. To achieve aesthetic success in anterior maxillary implants, immediate implant placement after tooth extraction to prevent bone resorption, and flapless implant surgery to minimize soft tissue trauma, can be considered as treatment options. Immediate implant placement, however, cannot be performed easily when infection occurs in extraction sockets. Extensive flap elevation is necessary in compromised bone height or width areas. The entire treatment procedure, from tooth extraction and implant placement to final prosthesis fabrication, takes a lot of effort in terms of obtaining the proper esthetic results in the anterior maxillary implants. If massive bone resorption occurs, guided bone regeneration and tissue graft surgery is performed. In such cases, provisional restoration can be used to initiate guided soft tissue healing for natural looking, esthetically pleasing soft tissue contours. This paper presents the case of a patient who needed implant treatment following trauma to both maxillary central incisors. In this case, infection in an extraction socket impeded immediate implant placement, which led to the use of the Bio-Col alveolar ridge preservation technique suggested by Sclar in 2003 to obtain the best possible esthetic results. Using the Bio-Col technique, interim provisional restoration was used to prepare extraction sockets for implant placement. Flapless implant surgery to preserve the scalloped-shaped gingiva was originally planned. However, buccal bone resorption was observed during surgery, which led to flap elevation and guided bone regeneration, resulting in limited esthetic results. Provisional restorations were customized to guide natural soft tissue architecture following implant placement. Four months after provisional restoration, the contour of the gingiva was stabilized enough for additional gingival recession not to occur. Therefore, the final restorations were delivered using zirconia abutments and crowns. (JOURNAL OF DENTAL IMPLANT RESEARCH 2014;33(3):73-77) Key Words: Bio-col, Delayed implantation, Anterior implant placement 서론 Branemark에의해골유착의개념이도입된뒤 1), 임플란트는완전무치악환자에서장기적인성공률을보였으며 2), 단일치아에대한수복에서도상당한안정성을보여왔다 3). 그중에서상악전치부는임플란트보철물의기능적회복뿐아니라심미적요구가중요한부위이다. 상악전치부임플란트식립시심미성의재현을위해여러가지고려해야할점이있는데, 첫번째로는발치하게될치아의위치, 두번째로는식립부위의치은의유형, 세번째로는수직적상악골골결손량, 네번째로는인접치아의치조골높이등이있다 4). 1. 상악전치부임플란트식립시고려사항 1) 치아위치의이상심미적인결과가요구되는부위의치아에추후임플란트식립을해야하는경우교정과치료를시행하여인접치아의치간유두부위의재생을유도할수있다. 특히교정적정출을통해서인접치열의골및연조직의부피를적절하게회복시킬수있다. 2) 치은의유형 (1) 두께가얇은치주조직 (Thin, scallopped periodontium) 부착치은의양이적고, 하방의치조골두께가얇아서자연치를 Received November 20, 2014, Revised December 1, 2014, Accepted December 10, 2014. cc This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creative commons.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. 교신저자 : 윤현경, 138-708, 서울시송파구가락본동 58, 경찰병원치과 Correspondence to: Hyun-Kyung Yun, Department of Dentistry, National Police Hospital, 58, Garakbon-dong, Songpa-gu, Seoul 138-708, Korea. Tel: +82-2-3400-1287, Fax: +82-2-3400-1111, E-mail: petera73@hanmail.net JOURNAL OF DENTAL IMPLANT RESEARCH www.kaidimplant.or.kr
74 서정민등 : Bio-col 테크닉을이용한상악전치부임플란트의식립증례 덮는치조골에천공이나열개가존재하고, 연조직이유약하며치아의형태는일반적으로삼각형의외형을가지고있다. 이러한유형의치주조직을가진환자의경우임플란트를식립하게되면치은의퇴축이발생하고치조골에골개조반응이골흡수의형태로발생하게된다. 따라서심미적인연조직의회복이어려워상악전치부등심미적인결과가요구되는부위에임플란트를식립하고보철물을제작할때치간유두의압박을막고, 보철물의형태가치은변연을잘지지하여퇴축을최소화할수있어야한다. 예방적인결합조직이식술등이필요할수있다. (2) 두께가두꺼운치주조직 (Thick, flat periodontium) 연조직의외형이평평하고, 많은양의부착조직을가지는치밀한섬유성연조직을가지는경우이며, 흡수에저항하는두꺼운골형태를가지고있고, 치아의형태는일반적으로사각형의외형이다. 섬유성인연조직특성으로인해판막을거상할때절개선에반흔조직이발생하여비심미적으로나타날수있다. 따라서절개선을가능한숨기는방향으로하여 1~2개치아의임플란트를식립하는경우에는조직천공 (tissue punching) 방법이나구개측으로부터접근하는 peninsular flap을형성하는것이도움이된다. 3) 수직적상악골결손수직적골결손은상악중절치사이치관유두의끝에서전비극에이르는거리가 10 mm 이하인경우를말하는것으로, 재생에필요한연조직의부족으로인해 site-development 심미적인결과를얻기어렵다. 또한임플란트식립후판막의수동적인적합이어려워연조직이치근단으로이동하려는성향이있어치은퇴축이발생할수있다. 연조직의치근단퇴축을막기위해과장된경사절개및골막절개등을이용하여긴장이없는판막형성을하는것이필요하다. 4) 인접치아의골높이인접치아의치간골이상실되면필연적으로치간유두의상실이수 반되므로임플란트인접자연치의치간골높이도임플란트의심미에영향을미치게된다. 그러나인접골소실의양은연조직에의해가려져있으므로정밀한평가를위해서방사선촬영및 bone sounding 이필요하며인접골소실이많이심한경우에는교정적정출을이용하여수직적골높이를증가시킬수있다. 2. Bio-col technique을이용한치조와보존술식 Sclar는 2003년임플란트의연조직과심미 (Soft tissue and esthetic considerations in implant therapy) 라고하는저서를통해 Bio-col이라는치조제보존술식을소개했다 5). 이개념은심미적인치료결과가요구되는부위에자연스러운치조제외형을보존하거나형성하여최종적으로자연치의해부학적인골외형과연조직형태를임플란트에재연하고자하는노력이다. Bio-col 술식은첫번째로발치시외상을줄여골조직의흡수를최소화하는것으로시작한다. 그다음발치와에즉시임플란트를식립하고빈공간에골이식재를채운뒤콜라겐차폐막을사용하여골흡수에저항할수있도록격리한다. 그뒤임시치아또는치아외형을본뜬해부학적치유지대주 (anatomic healing abutment) 를사용하여치간유두를유지하고골외형및연조직의형태를보존하고자한다. 만일협측치조골에골결손이있고치아의동요도가심하고감염소견이있는경우지연식립을하기도하는데치조골결손폭이인접치아근원심폭경의 1/3을넘어가게되면골재생에기여하는잔존골의골량부족으로인해치유가불량해질수있다 4). 현재임플란트를식립해야하는부위에연조직의결손이있다면, 임플란트식립과동시에혹은 2차수술시에상피하결합조직이식술을시행하고임시치아를이용하여연조직의치유를유도한다. 연조직의결손뿐아니라골의결손까지발생된경우에는자가골이나이종골이식을시행하게되는데이때연조직이식술도수반이된다. Bio-col 술식에서임시치아는심미적인보철물제작에있어서중요한역할을하게되는데, 임시치아의형태에따라서연조직의치유가유도되기때문이다. 임플란트수술당일에임시치아또는해부학 Fig. 1. 치아파절사진, 순면. Fig. 2. 치아파절사진, 설면.
Seo JM, et al: A case of maxillary anterior implant placement using a Bio-col technique 75 적맞춤지대주 (anatomic custom healing abutment) 를사용하는것이추후심미적인임플란트보철물제작을위해필요하다. 본증례는상악전치부위의외상을주소로내원하여발치 3개월후임플란트를지연식립한환자에서발치직후인공치아를사용하여자연스러운치은조직의치유를유도하고, 임플란트를식립한뒤에는임시치아를이용, 자연치의치은외형을형성한뒤최종보철물을완성하는 Bio-col 술식을적용하였다. 증례보고 환자는 20세의경으로 2014년 2월훈련중얼굴에외상을받아상악좌, 우측중절치의파절이발생하여본원에내원하였다.(Figs. 1, 2) 방사선사진결과좌, 우측중절치의치근 1/3과 2/3 부위에횡적파절이관찰되어발치를결정하였다. 최소한의외상을주어발치를하고자시도하였다. 외상을받은지 1주일이상경과되어본원에내원하는과정에서발치와에농이형성되어있어즉시임플란트를식립할경우감염이우려되었다. 따라서임플란트를 3개월뒤지연식립하기로결정하고발치와에콜라겐차폐막 (Collatape, Zimmer dental, USA) 을삽입한뒤봉합하였다.(Figs. 3, 4) 인공치아의치은쪽형태를발치와 3 mm내로삽입이되도록조정하여발치와의치은변연을지탱할수있도록유도하였다.(fig. 5) 이렇게인공치아의형태를조정한결과 3개월뒤자연치의치은과유사한형태로치유가일어났다.(Fig. 6) 3개월뒤 2개의임플란트 (Dentium, 4.3 10 mm) 를식립하였다. 인공치아를이용하여치은의형태를형성하였으므로판막을열지않고치은을천공하여임플란트를식립하고자하였으나협측골의골흡수가예상보다심각하여판막을열고골유도재생술을시행하기로결정했다. 초기고정은양호하였으나임플란트의 2/3이노출되어이종골 (Bio-Oss) 이식을시행하고흡수성차폐막 (Bio-gide) 을사용하여마무리하였다.(Fig. 7, 8) 임플란트식립직후임시치아용지대주 (plastic temporary abutment, Dentium, Korea) 를이용하여임시치아를제작하고연결한뒤치주조직의치유를유도하였다. 결합조직이식술은임플란트주위조직이치유되는양상을지켜보면서추후결정하기로하였다. 3개월간관찰결과임플란트식립부위가약간튀어나온것같고이물감이느껴진다는환자의의견이있어서추가적인결합조직이식술은시행하지않기로하고 zirconia abutment Fig. 3. 발치된치아. Fig. 5. 발치와에 Bio-col technique 을응용하여임시치아부착. Fig. 4. 발치후 collatape 을치조와에삽입. Fig. 6. 발치 3 개월후자연스러운치은외형형성.
76 서정민등 : Bio-col 테크닉을이용한상악전치부임플란트의식립증례 Fig. 7. 임플란트식립시골이식술시행. Fig. 9. 최종보철물장착. Fig. 8. 임플란트수술. (Zirconia abutment, Acucera Co, Korea) 및 zirconia crown 으로최종보철을마무리하였다.(Fig. 9) 고찰 상악전치부위의임플란트는부족한가용골로인해심미적인수복에많은제약이따른다. 상악전치부의경우결손과동시에치근상방협측골의일부혹은전부의소실이시작되게되며처음일년내에 25% 의협구개측골양의감소가, 그리고 30-40% 의급속한감소가 3년내발생한다 6,7). 이에골유도재생술등으로가용골의양을늘리고연조직이식을부가적으로실시하기도한다. 골유도재생술은골표면적을늘릴수있으며초기임플란트안정성을높이고새로형성된골의성숙도가높으며임플란트표면의골침착을향상시킬수있다 8,9). 상악전치부위임플란트의심미적인수복을위해골유도재생술이외에도 Bio-col 술식을통해치은의심미적치유를유도할수있다. Bio-col 술식은 Sclar 5) 가 2003년임플란트의연조직과심미 (Soft tissue and esthetic considerations in implant therapy, Quintessence Inc.) 를통해제안한치조제재건술식으 로이술식에는임플란트식립전에치은의형태를조정하는것과, 임플란트식립후임시치아및해부학적맞춤형지대주를이용하여자연치와유사하게협측보다치간유두의높이가높은 scallope 형태를가진치은의치유를유도하는것이포함된다. 본증례의환자의경우상악중절치의외상으로발치후임플란트식립을계획하였으나, 외상후시간이경과되어발치와가감염이되어불가피하게 3개월후임플란트를식립하게되었다. 가능한심미적인임플란트보철수복을위해임플란트식립전임시치아를이용하여발치와의치은을자연치와유사한형태로치유되도록유도하는 Bio-col 술식을적용하였다. 골량이충분할경우전체판막을형성하지않고치은을천공하여외상을최소화한뒤임플란트를식립하려고계획하였다. 그러나환자의치주조직이얇고 3개월의발치와치유기간동안협측골의흡수가임플란트전체길이의 2/3 가량발생하여전체판막을열어임플란트를식립해야했고처음계획했던심미적인임플란트수복에어려움이있었다. 부족한골을위해수술과정에서는골유도재생술을시행하였고, 임플란트식립직후임시치아를제작하여치은의치유를유도하였다. 상악전치부의임플란트는 96 97% 의성공률을보이는예지성있는치료방법이지만 10), 임플란트의기능적측면외에심미성이높게요구되는부위이므로임플란트의심미성을높이기위한여러가지시도및고려가필요하다고사료된다. 결론 본증례에서는발치후임플란트의지연식립을계획한환자에서상악전치부의심미적인수복을위해골유도재생술및자연스러운치은의치유를위해 Bio-col 술식을임플란트식립전후에적용하였다. 발치후임플란트식립전에인공치아의치은면을치근과유사하게조정하여발치와에 3 mm 정도삽입되게하고치유를유도했다. 그리고임플란트식립후에는임시치아를이용하여자연치와유사한치은의형태로치유될수있도록하였다. 임플란트식립전까지인공
Seo JM, et al: A case of maxillary anterior implant placement using a Bio-col technique 77 치아로자연치와유사한치은의형태를형성하였으므로판막을열지않고치은을천공하여임플란트를식립할계획이었으나임플란트식립직전에촬영한 CT 분석결과협측골흡수가빠르게진행되어판막을광범위하게열고골유도재생술등의술식을시행하게되었다. 이러한외상성수술방식때문에연조직의최대한의심미적인결과를얻는데제한이있었다. 최종보철은연조직의치유가안정된상태에서제작할때추후치은퇴축등의변수가발생할가능성이낮을것으로생각되어임시치아를장착하고 3개월후에제작하였다. References 1. Branemark PI, Breine U, Adell R, et al. Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969;3:81-100. 2. Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Sur 1981;10:387-416. 3. Schmitt A, Zarb GA. The longitudinal clinical effectiveness of osseointegrated dental implants for single-tooth replacement. Int J Oral Implantol 1993;6:197-202. 4. Sclar A. Strategies for management of single-tooth extraction sites in aesthetic implant therapy. J Oral Maxillofac Surg 2004;62(suppl 2):90-105. 5. Sclar A. Soft Tssue and Esthetic Considerations in Implant Therapy. Chicago, IL, Quitessence, 2003. 6. Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wearers: a mixed longitudinal study covering 5 years. J Prosthet Dent 1979;17:120-32. 7. Misch E. Divisions of available bone in implant dentistry. Int J Oral Implantol 1990;7:9-17. 8. Buser D, Bragger U, Lang NP, et al. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clin Oral Implants Res 1990;1:22-32. 9. Nevins R, Mellonig JT. The advantages of localized ridge augmentation prior to implant placement: a staged event. Int J Periodont Res Dent 1995;15:11-29. 10. Schincaglia GP, Nowazri H. Surgical treatment planning for the single-unit implant in aesthetic areas. Periodontol 2000 2001;27:262-82.