매복된상악전치의교정적치료 : 증례보고 김해리 오소희 김영희 한림대학교성심병원소아치과 국문초록 상악전치의매복은제3대구치, 상악견치, 상하악제2소구치에비해서드물지만, 정중과잉치, 외상, 치근만곡등의치근형성의변이가높은빈도로나타나기때문에다른전치부에비해서는매복되는비율이높고, 보통약 8세이후의초기혼합치열기의아동에서관찰된다. 상악중절치의매복으로인한인접치아의이동으로공간상실과함께정중선변이가나타날수있고낭종등이발생할수있으므로, 정확한위치를확인하고적절한치료계획을세우는것이중요하다. 치료방법으로는외과적발거, 자발적맹출의관찰, 교정적견인등이있으나, 매복치의병적변화가없고, 치근의발육이양호하다면기능과심미성의회복을위해교정적견인을시행한다. 이에매복된상악전치들을교정적견인을통해정상적인맹출방향으로유도하여양호한치료결과를얻었기에보고하는바이다. 주요어 : 매복치, 교정적견인, 치근만곡 Ⅰ. 서론 매복치란일종의치아맹출장애이며, 맹출로의물리적장애또는악골내치아의비정상적인위치로인한치아의맹출정지 1) 를말한다. 원인으로과잉치, 점막성장애물, 복합종과같은골성장애물, 유치의외상으로인한계승영구치의치배손상, 골격과치아크기의부조화나유치의인접면우식증등으로인한치열궁길이의부족, 치배의회전, 치아맹출순서의이상, 치근의조기폐쇄등이있을수있다 2). 매복치아중상악영구전치의매복의원인은정중과잉치, 상악유전치부의외상, 치근만곡등의치근형성의변이가있는데, 교신저자 : 오소희 경기도안양시동안구평촌동 896 번지한림대학교성심병원소아치과 Tel : 031-380-3870 E-mail : pedopia@chol.com 그중외상이영구치의형태이상을유발하는주된원인이다 3,4). 발생빈도는제3대구치 (98%), 상악견치 (1.33%), 제1소구치 (0.22%), 제2소구치 (0.11%) 다음 (0.06-0.2%) 으로발생하며 5), 심미적인문제를야기하기때문에비교적쉽게발견되고, 구개측보다순측매복의빈도가높다 6). 매복치아는우선임상적으로좌우치아의맹출시기가다른것으로판단할수있다 7). 이후위치확인을위해촉진과방사선사진검사를시행하는데, 임상적으로약 8세이후에상악중절치의매복이관찰가능하며, 이시기에는측절치가먼저맹출되어있다 1). 매복치아의합병증으로는인접치의이동으로인한악궁의공간상실, 낭종형성, 인접치아의치근흡수, 부분맹출에의한감염, 전위맹출, 전치부의경우심미적인문제를야기할수있다 8-10). 본증례는매복된상악전치를주소로내원한환아에서매복치의외과적노출후교정적견인을통하여양호한맹출양상을보였기에보고하는바이다. 709
J Korean Acad Pediatr Dent 34(4) 2007 Ⅱ. 증례보고 < 증례 1> 성명 : 이 나이 : 8세 10개월성별 : 여주소 : 상악좌측전치부의매복전신상태 : 건강구강내소견 : 초진시상악좌측중절치와측절치의미맹출양상을보였으며, 파노라마방사선사진과치근단방사선사진 (Fig. 1), CT 촬영 (Fig. 2) 결과상악좌측측절치의치배위치의이상으로인해중절치의맹출장애가발생한것으로사료되었다. 또한상악좌측견치치배의위치이상을확인할수있었다. 치료과정 : Window opening 후 modified transpalatal arch(tpa) with loop을이용하여상악좌측측절치와견치의교정적견인을시행하였다 (Fig. 3). 교정적견인약 5개월후매복되어있던상악좌측측절치와견치모두치관의 1/2이상맹출되었으며, 교정적견인을시행하지않았던상악좌측중절치에서도측절치의위치변화로인해자발적맹출이일어났다. 이후의상악좌측전치부배열에필요한공간확보를위해 Pendulum appliance를이용하였다 (Fig. 4). 교정적견인약 12개월후에는상악좌측중절치와견치의 leveling이이루어졌다 (Fig. 5). 그로부터약 5개월후에는측절치의 leveling까지이루어졌으며 (Fig. 6), 당시촬영한치근단방사선사진상에서상악좌측중절치의치근만곡이확인되었다 (Fig. 7). Fig. 1. Panoramic and periapical view : First visit. Fig. 2. CT - Axial and sagittal view: First visit. 710
Fig. 3. Orthodontic traction : Modified TPA with loop. Fig. 4. Space reganing : Pendulum appliance. Fig. 5. Leveling and alignment : 12 months after orthodontic traction. Fig. 6. Leveling and alignment : 17 months after orthodontic traction. Fig. 7. Periapical view : 17 months after orthodontic traction (Root dilaceration on #21). 711
J Korean Acad Pediatr Dent 34(4) 2007 < 증례 2> 성명 : 박 나이 : 9세 2개월성별 : 여주소 : 상악우측중절치의맹출지연전신상태 : 건강치과기왕력 : 개인치과의원에서의뢰된환아로이전정중과잉치발거경험있음. 구강내소견 : 처음내원시상악우측중절치의미맹출양상이관찰되었으며 (Fig. 8), 방사선사진에서미맹출된치아의치근은미완성상태였다 (Fig. 9). 치료과정 : Window opening 후 resin wire splint with loop을이용한교정적견인을시행하였으며 (Fig. 10), 교정적견인약 3개월후에 2x4 appliance를이용한 leveling and alignment를교정적견인과동시에시행하였다 (Fig. 11). 견인후약 2개월 (Fig. 12), 3개월 (Fig. 13), 8개월 (Fig. 14) 에촬영한치근단방사선사진상에서치근단이상이관찰되었으며, 계속적인관찰후근관치료여부를결정하기로하였다. 교정적견인약 10개월후상악우측중절치가좌측중절치와같은수준으로위치되었으며 (Fig. 15), 그로부터약 1개월후에 debonding을시행하였다 (Fig. 16). Fig. 8. Intraoral view : First visit Fig. 9. Panoramic and periapical view : First visit. Fig. 10. Orthodontic traction : Resin wire splint with loop. Fig. 11. Leveling and alignment : 3 months after orthodontic traction. 712
Fig. 12. Periapical view : 2 months after orthodontic traction. Fig. 13. Periapical view : 3 months after orthodontic traction. Fig. 14. Periapical view : 8 months after orthodontic traction. Fig. 15. Leveling and alignment : 10 months after orthodontic traction. Fig. 16. Debonding : 11 months after orthodontic traction. < 증례 3> 성명 : 손 나이 : 10세 7개월성별 : 남주소 : 상악좌측중절치의맹출지연전신상태 : 건강구강내소견 : 초진시구강내소견으로상악좌측중절치가미맹출상태이고 (Fig. 17), 방사선사진소견상 (Fig. 18) 상악좌측중절치의치근발육은거의완성되었으나매복된양상으로보아, 치근의자발적맹출력이거의상실된것으로사료되었다. 치료과정 : Window opening 후 resin wire splint with loop을이용한교정적견인을시행하였고 (Fig. 19), 교정적견인약 3개월후치관이약 1/2 정도맹출되었다 (Fig. 20). 교정적견인약 4개월후에 2 4 appliance를이용하여 leveling and alignment를시행하였으며 (Fig. 21), 교정적견인약 7개월후 high canine의해소를위해 open coil spring을사용하였다 (Fig. 22). 교정적견인약 11개월후상악좌측중절치치관의대부분이맹출되었고, 그동안보였던반대교합도해소되었다 (Fig. 23). 713
J Korean Acad Pediatr Dent 34(4) 2007 Fig. 17. Intraoral view : First visit. Fig. 18. Panoramic and periapical view : First visit. Fig. 19. Orthodontic traction : Resin wire splint with loop. Fig. 20. 3 months after orthodontic traction. Fig. 21. Leveling and alignment : 4 months after orthodontic traction. Fig. 22. Open coil spring : 7 months after orthodontic traction. 714
Fig. 23. 7 months after orthodontic traction. Fig. 24. 11 months after orthodontic traction. Ⅲ. 총괄및고찰상악중절치가매복되는중요한원인중하나인상악중절치의만곡은치아가굽어있는형태로치아의중앙부, 즉치관과치근의경계부에서굽어있는경우가흔하다. 만곡의형태는순설측치근만곡과측방치근만곡으로구분할수있다 11). 만곡의원인으로먼저유치에가해진외상을들수있는데, Ravn은유치의외상과계승치의만곡의연관성에대해보고하였으며 12), 치근만곡에미치는영향의정도는외상을받은시기와계승치아의형성정도에의해달라질수있다 13). 다른원인으로는치배의이소성발육이있는데, Stewart는외상의기왕력이없는어린이의계승치순측만곡에관한연구 14) 에서그가능성을제시하였다. 그외에도낭종이나과오종, 쇄골두개이골증 15) 과같은전신질환등이원인이될수있으나아직까지는많은논란이있다. 매복치아의치료시기는인접치의이동으로인한부정교합의발생을예방하기위해가능한빠를수록좋으며, 이는소아심리발달의측면에서도그러하다 16). 맹출지연시상악은 4개월, 하악은 12개월까지정상으로간주하며, 그이후에도맹출하지않는경우치료를시작하는것이바람직하다. 매복된치아의치근형성이 1/2 미만인경우에는자발적인맹출을유도하며 17), 같은악궁의반대측치아가맹출되는시기로서치근이 2/3 정도완성된때부터치근단폐쇄시기까지는교정적견인을고려해야한다 18). 매복치아의치료시에는매복치의위치와상태, 치근만곡도, 맹출공간의존재여부및부정교합의정도, 환자의나이, 요구도등도고려해야한다 19). 치료방법으로는우선맹출방향이정상으로보이는경우맹출로상의장애물을제거한후자발적맹출을유도한다. 이는단기간에환자협조도만으로만족할만한치료효과를볼수있는반면, 결과적으로치축이비정상적일수있으며, 인접치와치은 연의높이가다를수있다는단점이있다 20). 매복치아의치근만곡이심하거나맹출방향에이상이있을때는발치를시행한다. 맹출방향이정상이며, 치근이완성된경우교정적견인을시행한다. 매복치의교정적견인동안치수혈류량의변화로인한치수석회화가일어날수있고 21), 과도한힘과빠른치아이동은매복치의유착과지지조직의손상을일으킬수있다 22). 따라서 30-80gm의힘으로 interrupted tooth movement를시켜합병증을예방한다. 치료기간의단축을위해외과적시술을병용하는데 23), 순측매복된상악전치의외과적접근시전층판막술을이용한 closed method를시행하여점막의불필요한절제로인한부착치은의감소와심미적인결함을예방해야한다 20). 매복치의심한위치이상으로교정적견인이어려운경우, 발거가능성을감수한환아의나이와심미성을고려하여외과적재식술을고려할수있다. 외과적재식술은시술후즉시심미성이향상되고치료기간을단축시키며비용을절감할수있다. 치조골의폭경과높이를정상적으로유지할수있고, 치은변연의형성을위한치주적처치가필요하지않다 24). 재식은치근이약 3/4~4/5 정도형성되었을때시행하며, 매복치의발거시치근막손상에주의하고즉시식립하는것이이식의성공률을높일수있다 25). Ⅳ. 요약한림대학교성심병원소아치과에상악전치부의매복을주소로내원한환아들에서, 외과적노출을동반한교정적견인을시행하여매복되었던치아를정상수준으로맹출시키는데만족할만한결과를얻었다. 교정적견인을시행하기전에공간에대한평가가선행되어야하며필요하다면공간확보를위한치료를해야한다. 매복되어있던만곡치에대해서는주기적으로생활력을관찰하여향후근관치료여부를결정한다. 715
J Korean Acad Pediatr Dent 34(4) 2007 참고문헌 1. Andreasen JO, Petersen JK, Lasin DM : Textbook and atlas of tooth impactions. 1st ed., Munksgaard, Copenhagen, 114-123, 1997. 2. Bishara SE, Kommer DD, McNeil MH, et al. : Management of impacted canines. Am J Orthod, 69:371-387, 1976. 3. Cangialosi TJ : Management of a maxillary central incisor impacted by a supernumerary tooth. J Am Dent Assoc, 105:812-814, 1982. 4. Di Biase DD : The effect of variation in tooth morphology and position on eruption. Dent Pract Dent Rec, 22:95-108, 1971. 5. Grover PS, Lorton L : The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol, 59:420-425, 1985. 6. Gunter JH : Concerning impacted teeth. Am J Orthod, 28:642-649, 1942. 7. Kapala JT : Interceptive orthodontics and management of space problems. Textbook of Pediatric dentistry, Williams & Wilkins, Baltimore, 372-328, 1980. 8. McCormick J, Filostrat DJ : Injury to the teeth of succession by abscess of the temporary teeth. J Dent Child, 34:501-504, 1967. 9. Vanarsdall RL, Corn H : Soft tissue management of labially positioned unerupted teeth. Am J Orthod, 72:53-64, 1977. 10. Neville BW, Damm DD, Allen CM, et al. : Oral and maxillofacial pathology. Saunders Co., Philadelphia, 58-59, 1995. 11. Andreasen JO, Andreasen FM : Textbook and color atlas of traumatic injuries to the teeth. 3rd ed., Mosby, Missouri, 470-479, 1994. 12. Ravn JJ : Sequelae of acute mechanical trauma in the primary dentition, A clinical study. ASDC J Dent Child, 35:281-289, 1968. 13. Shafer, Hine, Levy : A textbook of oral pathology. 4th ed., Saunders, Philadelphia, 40-41, 1983. 14. Stewart DJ : Dilacerate unerupted maxillary central incisors. Brit Dent J, 145:229-233, 1978. 15. Winter GR : Dental conditions in Cleidocracial dysostosis. Am J Orthod, 29:61-89, 1943. 16. Bishara SE : Treatment of unerupted incisors. Am J Orthod, 59:443-447, 1971. 17. Kim YH : Treatment of unusually impacted permanent maxillary central incisor. J Am Dent Assoc, 69:596-600, 1964. 18. Lin YT : Treatment of an impacted dilacerated maxillary central incisor. Am J Orthod Dentofacial Orthop, 115:406-409, 1999. 19. 이기수, 박영국 : 상악중절치에만곡치근을가진환자의교정치료에대한치험예. 대한치과의사협회지, 26:1131-1135, 1988. 20. Kokich VG, Mathews DP : Surgical and orthodontic management of impacted teeth. Dent Clin North Am, 37:181-204, 1993. 21. Mostafa YA, Iskander KG, El-Mangoury NH : Iatrogenic pulpal reactions to orthodontic extrusion. Am J Orthod Dentofacial Orthop, 99:30-34, 1991. 22. Proffit WR : Contemporary orthodontics. 3rd ed., Mosby, Missouri, 483-484, 2000. 23. Di Salvo NA : Evaluation of unerupted teeth: orthodontic viewpoint. J Am Dent Assoc, 82:829-835, 1971. 24. Tasi TP : Surgical repositioning of an impacted dilacerated incisor in mixed dentition. JADA, 133:61-66, 2002. 25. Andreasen JO : Atlas of replantation and transplantation of teeth. Mediglobe, 111-138, 1992. 716
Abstract ORTHODONTIC TREATMENT OF IMPACTED MAXILLARY INCISOR : A CASE REPORT Hae-Ri Kim, So-Hee Oh, Young-Hee Kim Department of Pediatric Dentistry, Hallym University Sacred Heart Hospital Impaction of maxillary incisor is rare than the third molar and canine, but its rate is higher than the other anterior teeth due to frequent mesiodens, trauma and variation of root formation (root dilaceration etc.). It is often observed in the dental age of about eight years and over. It will be occurred that the space loss, midline deviation and cyst formation due to the impaction of maxillary incisor. So it is important to evaluate the precise location of impacted tooth and to make appropriate treatment plan. Treatment would be surgical extraction or expectation for spontaneous eruption. If the impacted tooth has no pathologic change and development of the root is favorable, orthodontic traction is recommended for recovery of function and esthetics. In these cases, we performed orthodontic traction for the eruption of impacted maxillary incisors, and obtained satisfactory results. Key words : Impacted teeth, Orthodontic traction, Root dilaceration 717