http://dx.doi.org/10.5933/jkapd.2011.38.4.435 대한소아치과학회지 38(4) 2011 자가이식을이용한매복견치의치험례 : 증례보고 고윤식 김지연 박기태 성균관대학교의과대학삼성서울병원치과진료부소아치과 국문초록상악견치의매복은소아치과의사가흔히접할수있는맹출장애이며, 이를방치하였을경우인접치의치근흡수, 낭종형성등의임상적인문제점을유발할수있다. 이에대한치료는간단한유치발치에서부터매복치아의교정적견인, 외과적자가이식등다양한방법을고려할수있다. 이중자가이식은매복치아가교정적견인술을시행하기어려운위치에존재하거나재위치시키는데실패했을경우에매복치아의발거에앞서고려할수있으며, 그예후는치근의완성도, 환자연령, 외과적술식, 근관치료시기, 치아고정기간등에의해결정된다. 본두증례들은혼합치열기말기에상악견치가매복된환자에서그매복위치가자발적인맹출유도나교정적견인및배열이어렵다고판단된경우이며, 자가이식후근관치료와교정치료를시행하고현재까지성공적으로유지되고있어보고하는바이다. 주요어 : 상악견치, 자가이식, 매복 Ⅰ. 서론상악영구견치의매복은소아치과의사가흔히접할수있는맹출장애이다. 매복이발생할수있는전신적인원인으로는내분비장애가있거나방사선조사를받았을경우, 비타민 D의결핍, 열질환 (febrile disease) 등이있으며, 국소적인원인으로는영구치배의위치가비정상이거나치아크기와악궁크기간의부조화가있을경우, 유견치가만기잔존하거나조기상실하였을경우, 구개파열부의존재, 유착, 과잉치, 낭종및종양, 치근의만곡, 치아맹출순서의이상등이있다 1). 발생빈도는일반적으로 1~3% 정도로보고되고있으며 2-4), 하악에비해상악이 3~6배호발하고 1), 성별로는여성과남성이 2대1의비율로발생한다 3). 매복위치에따라서는구개측매복이순측매복에비해 2~3배호발하며, 구개측에위치할경우에는두꺼운피질골로인해수술적처치없이는자발적맹출이어렵다 1). 매복된견치를그냥방치하였을경우에는매복치아의변위가심해지거나인접치의이동, 악궁길이의감소, 내흡수및외흡 수, 낭종형성, 연관통등여러합병증을야기할수있다 1). 따라서매복을조기진단하고적절한시기에필요한처치를시행하여매복을예방해주는것이중요하다. 매복이발생하였을경우에는매복치아의위치와방향, 치근의형성단계, 맹출가능한공간의존재여부등을고려하여외과적노출후교정적으로견인을하거나자가이식, 매복치아를발치하는방법등을선택할수있다 1,5). 이들방법중자가이식이란해당치아를발거하여동일한개체의발치와나외과적으로형성한수용부에재위치시키는술식이다 6). 이에대한적응증으로는매복된치아가교정력을가할수없는위치에존재하거나다른방법을사용할수없는경우를들수있으며 7), 해당치아를발치하기에앞서시행해볼수있다. 하지만, 외과적술식에의한치근면과치주인대의손상가능성이존재하며, 이식할치아의치근발달정도와치주인대의재부착여부, 치조골이재생되는정도등여러요인이술식의성공에영향을미친다 8). 본두증례는상악견치의매복증례로서자가이식을동반한교정치료와근관치료를시행하여심미적, 기능적으로양호한결과를얻었기에보고하는바이다. 교신저자 : 박기태서울특별시강남구일원동 50 / 성균관대학교의과대학삼성서울병원치과진료부소아치과 / 02-3410-2426 / park2426@skku.edu 원고접수일 : 2011 년 08 월 05 일 / 원고최종수정일 : 2011 년 10 월 18 일 / 원고채택일 : 2011 년 11 월 14 일 435
J Korean Acad Pediatr Dent 38(4) 2011 Ⅱ. 증례보고 1. 증례 1 12세 5개월된여자환아가 송곳니가나오지않는다 를주소로내원하였다. 구강검사결과상악좌측영구견치가맹출하지않은상태였으며전반적인교합상태는양호한편이었다. 방사선사진상에서상악좌측영구견치가수평으로매복되어있었고, 치관은중절치치근에근접해있었으며이로인한측절치의치근흡수가의심되었다. 매복견치의치근은완성된상태였으며경미한치근만곡이의심되었다 (Fig. 1). 심한수평매복과치근만곡으로교정적견인이곤란하다고판단하여자가이식을시행하기로하였다. 먼저고정성교정장치를이용하여상악견치가배열될공간을형성하고, 중절치와측절치치근이원심경사될경우치근흡수가발생할수있으므로상악전치부에는 standard bracket을사용하여치근의원심경사 로인한치근흡수를예방하고자하였다. 자가이식은구강악안면외과에의뢰되어시행되었으며, 이식된견치는 0.016인치 NiTi교정용 wire와복합레진을이용하여고정하였다 (Fig. 2). 이식된치아의치근단이완성된상태였으므로치근의염증성흡수를예방하기위해근관치료가필요하다고판단되었지만치아의동요도가지속되어바로시행하지는않았으며, 그전까지는정기적으로방사선사진을촬영하여염증성치근흡수여부를확인하였다. 동요도가감소하고치수생활력검사에서 3회의음성판정이나온후에근관치료를시행하고수산화칼슘을이용하여임시충전하였다. 11개월후의방사선사진에서치근흡수없이주변치조골이재생되는것을확인할수있었다 (Fig. 3). 교정장치를제거한후에근관치료를완료하였으며근관입구를복합레진으로수복하였다. 자가이식 4년경과후까지해당치아는임상적및방사선사진상에서성공적으로유지되고있다 (Fig. 4). Fig. 1. A pretreatment panoramic radiograph showed that maxillary left canine was impacted horizontally. Its crown was located near the apex of central incisor and seems to have caused root resorption of lateral incisor. Fig. 3. a) After 7 months, there was no root resorption of the canine, but apical lesion was detected. Root canal treatment was initiated. b) After 11 months, the size of periapical radiolucency decreased significantly. Fig. 2. Four weeks after autotransplantation. A bony defect was shown near the apex of maxillary left canine, but no pathologic change was shown. Fig. 4. Posttreatment follow up of 4 years after autotransplantation. The transplanted tooth was aligned well, and no sign of root resorption was observed. 436
대한소아치과학회지 38(4) 2011 2. 증례 2 13세 11개월된남자환아가 유치가남아있다 를주소로내원하였다. 구강검사결과상악좌측유견치가만기잔존하였으며, 방사선사진및 3D dental-ct상에서잔존한유견치치근단부위에치아종이발견되었고상악좌측영구견치는중절치와측절치의구개측에매복된상태였다 (Fig. 5). 매복된위치는교정적견인이가능한위치였으나보호자는교정적견인을원하지않아자가이식을시행하기로하였다. 치료전에보호자와환아에게부가적인신경치료를해야한다는것과치근흡수가능성이있다는것을설명하였으며, 이에대해동의를얻은후에치료를시작하였다. 증례 1에서와같이고정성교정장치를이용하여 4개월간상악견치의이식을위한공간을확보하고, 구강악안면외과에의뢰하여유견치와치아종을제거한뒤자가이식을시행하였다. 0.018인치스테인레스스틸교정용 wire를이용하여 2개월간고정하였으며, 이때주변치아들은교정용 bracket을부착하여고정기간동안이식한치아에기능력이가해지도록하였다. 자가이식후 4주가지났을때는방사선사진상에서치근흡수가발견되지않았으나 (Fig. 6), 8주후방사선사진상에서는염증성치근흡수가발견되었다. 치근흡수가더진행하는것을예방하기위해치수를제거하고수산화칼슘으로근관을임시충전하였으며 (Fig. 7), 이후염증성치근흡수는더진행되지않았다. 자가이식 1년후, 치아배열이완료되었고동요도가정상으로회복되었으며방사선사진상에서도정상적인치유가확인되어교정장치를제거하였다 (Fig. 8). 그후근관치료를완료하고근관입구는글래스아이오노머와복합레진으로충전하였다. 해당치아는자가이식 2년후까지임상적및방사선사진상에서병적소견없이성공적으로유지되고있다 (Fig. 9). Fig. 5. Pretreatment panoramic radiograph and 3D dental CT. The crown of maxillary left canine is located palatally near the apex of left central and lateral incisors, and complex type odontoma is located near the apex of maxillary left deciduous canine. Fig. 7. After 2 months, external root resorption was detected. Root canal treatment was initiated and the canal was filled by calcium hydroxide paste. Fig. 6. Four weeks after autotransplantation. The radiographs show that the odontoma and the deciduous canine was removed, and the impacted canine was transplanted successfully. 437
J Korean Acad Pediatr Dent 38(4) 2011 Fig. 8. After 1 year, the transplanted tooth is aligned normally and orthodontic brackets were removed. Fig. 9. Posttreatment follow up of 2 years after autotransplantation. The radiographs showed that the canine was retained well without any periapical pathologic changes. Ⅲ. 총괄및고찰자가이식을시행한치아의예후는이식할시기의치근발육정도와외과적술식에의한백악질과치주인대의손상유무, 수용부의치주인대존재유무와치조골의상태, 치아고정방법및기간, 그리고근관치료시작시기에따라달라지게되는데 9), 자가이식을시행하기가장좋은시기는전체치근길이의 1/2~3/4정도로치근이발육된시기이다 10-12). 미성숙된치근과넓은근단공을가지는경우에는재혈관화의가능성이높지만완성된치근을가진치아는치수괴사가많이발생한다. 그러나미성숙된치근일수록치수생활력이상실될경우급격한치근흡수가발생되기때문에더빈번한방사선학적평가가필요하다. 본두증례는모두내원당시치근발육이거의끝난상태였으며, 자가이식술시행이후모두치수괴사가발생하였으므로근관치료를시행해주었다. 이식할치아의백악질과치주인대를보호하기위해서는발거시외상을최소화해야하며, 수용부를형성할때에도가급적외상을줄여서수용부치근막을잔존시키는것이예후에더유리하다 13). 또한, 이식상태에맞는고정방법을선택하는것과적절한시기에고정을제거하는것도중요하다. 고정방법과기간은이식할치아와수용부의적합도에따라좌우되며, 고정의목적은이 식치아의치유를돕는것이어야한다 14). 초기적합도가양호한경우에는봉합고정과같은약한형태의고정을시행하고, 초기적합도가불량한경우에는 resin wire splint등의견고한고정이필요하다 15). Andreasen은장기간견고한고정을시행하면치근흡수를증가시키고치아유착의빈도가증가하여이식치아의예후에나쁜영향을미친다고보고하였고, 1~2주정도의짧은고정으로치아유착을예방할것을권하였다 8). 증례 1, 2 모두교정용 wire를이용하여 resin wire splint를시행하였으나증례 1의경우는 0.016인치 NiTi wire를사용하여 5주간, 증례 2의경우는 0.018인치스테인레스스틸 wire를사용하여 2개월간고정을시행하였다. 두증례모두주변치아에 bracket을부착하여고정기간동안에도기능력이가해지도록하였으며이로인해치아유착을예방할수있었다. 치근이완전히발육된매복치아의경우는자가이식후치근흡수가발생할수있으므로적절한시기에근관치료를시작해야한다. 완전히발육된치아는이식후에재혈관화가능성이낮으며치수의괴사가능성이높아진다. 따라서이식될치아가접근가능할경우에는치아이식전에근관치료가완료되어야하며매복치아와같이접근이어려운경우에는치아이식후, 치근흡수가발생하기전에근관치료가시작되어야한다. 이식후너무빨리근관치료를시행하면회복중인치주인대에부가적인손상이가해질수있으며, 반면너무늦게시행할경우에는치 438
대한소아치과학회지 38(4) 2011 근흡수가일어날수있다. 근관치료를이식 2주후에시작해야한다는의견이있지만 16), Schwarz와 Andreasen은완성된치근단을가진치아의경우는이식 3주경에실시하는것이적절하다고하였고 17), Kugelberg는 4주이내에근관치료를해야한다고주장하였다 18). 근관치료를이식직후시작할경우에는결과가좋지않았는데, 3주경에근관치료를시행하였을때치근흡수가 13.5% 만발생하는것과비교하여이식직후시작한경우에는 50% 에서치근흡수가발생하였다 19,20). 반면 Siers등은치근단형성이완료된치아의경우에도주기적으로임상적및방사선학적검사를하여서병적인징후가발견되었을경우에만근관치료를시행해야한다고보고하였다 21). 증례 1의경우는시기상으로는이식후 7개월이경과한후근관치료를시작하였으나그사이에정기적인임상적, 방사선학적검사를통하여염증성치근흡수를예방할수있었다. 증례 2의경우는치근단부위에치근흡수가발생하였으나, 치근흡수가발생한직후바로수산화칼슘을이용한근관치료를시작하여치근흡수의진행을예방할수있었다. Ⅳ. 요약본증례는치근형성이완료된상악견치가매복된경우교정적처치와근관치료를동반한자가이식술을통하여성공적으로치료될수있음을보여주었다. 따라서매복의정도가심하여교정적견인등의치료가불가능할경우견치의자가이식이좋은치료의대안이될수있음을보여준다. 참고문헌 1. Bishara SE : Impacted maxillary canines: a review. Am J Orthod Dentofacial Orthop, 101:159-171, 1992. 2. Dachi SF, Howell FV : A survey of 3, 874 routine full-month radiographs. II. A study of impacted teeth. Oral Surg Oral Med Oral Pathol, 14:1165-1169, 1961. 3. Ericson S, Kurol J : Radiographic assessment of maxillary canine eruption in children with clinical signs of eruption disturbance. Eur J Orthod, 8:133-140, 1986. 4. Thilander B, Myrberg N : The prevalence of malocclusion in Swedish schoolchildren. Scand J Dent Res, 81:12-21, 1973. 5. Kohavi D, Becker A, Zilberman Y : Surgical exposure, orthodontic movement, and final tooth position as factors in periodontal breakdown of treated palatally impacted canines. Am J Orthod, 85:72-77, 1984. 6. Boyne PJ : Transplantation, implantation, and grafts. Dent Clin North Am, 15:433-453, 1971. 7. Joshi MR : Transmigrant mandibular canines: a record of 28 cases and a retrospective review of the literature. Angle Orthod, 71:12-22, 2001. 8. Andreasen JO : Atlas of replantation and transplantation of teeth. Munksgaard, 177-222. 1992. 9. 김명래 : 치아재식및자가치아이식에의한보존. 대한치과의사협회지, 31:557-584, 1993. 10. Kahnberg KE : Autotransplantation of teeth (I). Indications for transplantation with a follow-up of 51 cases. Int J Oral Maxillofac Surg, 16:577-585, 1987. 11. Kristerson L : Autotransplantation of human premolars. A clinical and radiographic study of 100 teeth. Int J Oral Surg, 14:200-213, 1985. 12. Lagerstrom L, Kristerson L : Influence of orthodontic treatment on root development of autotransplanted premolars. Am J Orthod, 89:146-150, 1986. 13. Andreasen JO : Periodontal healing after replantation and autotransplantation of incisors in monkeys. Int J Oral Surg, 10:54-61, 1981. 14. 김수경, 백병주, 김재곤등 : 자가이식을이용한상악매복견치의치료. 대한소아치과학회지. 34:481-488, 2007. 15. Bauss O, Schilke R, Fenske C, et al.: Autotransplantation of immature third molars: influence of different splinting methods and fixation periods. Dent Traumatol, 18:322-328, 2002. 16. Tsukiboshi M : Autotransplantation of teeth: requirements for predictable success. Dent Traumatol, 18:157-180, 2002. 17. Schwartz O, Andreasen JO : Allotransplantation and autotransplantation of mature teeth in monkeys: the influence of endodontic treatment. J Oral Maxillofac Surg, 46:672-681, 1988. 18. Kugelberg R, Tegsjo U, Malmgren O : Autotransplantation of 45 teeth to the upper incisor region in adolescents. Swed Dent J, 18:165-172, 1994. 19. Andreasen JO, Paulsen HU, Yu Z, et al. : A longterm study of 370 autotransplanted premolars. Eur J Orthod, 12:14-50, 1990. 20. Gardiner GT : The autogenous transplantation of maxillary canine teeth. A review of 100 consecutive cases. Br Dent J, 146:382-385, 1979. 21. Siers ML, Willemsen WL, Gulabivala K : Monitoring pulp vitality after transplantation of teeth with mature roots: a case report. Int Endod J, 35:289-294, 2002. 439
J Korean Acad Pediatr Dent 38(4) 2011 Abstract AUTOTANSPLANTATION OF IMPACTED MAXILLARY CANINES: CASE REPORTS Yoonsik Ko, Ji-Yeon Kim, Ki-Tae Park Department of Pediatric Dentistry, Samsung Medical Center, Sungkyunkwan University School of Medicine Maxillary canine impaction is a common eruption problem in children. Impaction frequently involves further complications such as root resorption of adjacent teeth, cyst formation and migration of the neighboring teeth, etc. Various treatment modalities include extraction of preceding deciduous canine, orthodontic traction, and surgical extraction followed by immediate replantation of the extracted tooth at the proper position(autotransplantation). Autotransplantation is considered as the treatment of choice when surgical exposure and subsequent orthodontic traction are difficult or impossible due to unfavorable impacted position. The prognosis of autotransplantation is affected by the degree of apex formation, surgical procedures performed, timing of root canal treatment, and length of stabilization period. In these two cases presented, the patients with unerupted maxillary canine were treated with autotransplantation. One case was thought that guidance of eruption by orthodontic traction was difficult because of its unfavorable impacted position. In the other case, parents didn t agree to treat by orthodontic traction, therefore autotransplantation was done. In both cases, autotransplantation was carried out following root canal treatment and orthodontic treatment, and both cases have demonstrated to be successful to this day. Key words : Maxillary canine, Autotransplantation, Impaction 440