J Korean Acad Pediatr Dent 39(1) 2012 http://dx.doi.org/10.5933/jkapd.2012.39.1.84 하악전치부에발생한치근낭종의치험례 김선하 최성철 박재홍 김광철 경희대학교치과대학소아치과학교실 국문초록치근낭은가장흔한치성기원낭으로치수감염, 치수실활, 외상으로인한이차감염또는치아우식에의해발생한다. 보통치근낭은무증상이나이차감염이발생할경우통증, 부종, 발적등을유발할수있으며, 크기가커질수록치근낭은인접한신경을압박하여안면비대칭또는마비증세를일으킬수있다. 치료는보존적신경치료또는외과적처치를요하며, 낭의크기가크거나인접조직의침범을야기할가능성이있는경우에는낭적출술을시행해야한다. 대부분의증례에서완벽한치료가가능하고재발율이낮다. 본증례의환아들은하악전치부낭을주소로내원하여임상검사에서일부하악전치가괴사되었음을발견하였으므로근관치료를시행한후전신마취하에치근단절제술및치근낭적출술을시행하였다. 이후컴퓨터단층촬영을시행하여이환부의골생성및재발여부를관찰하였으며성공적인결과를보였기에이를보고하는바이다. 주요어 : 치근낭, 근관치료, 치근낭적출술 Ⅰ. 서론치근낭 (radicular cyst) 은악골에발생하는흔한치성기원낭으로, 치수의실활이나치수감염등에의해발생한다. 원인으로는치아우식증, 직접적인외상, 우연한치수의노출과잔존치근등을생각할수있다. 20대에서호발하나전연령대에서보고되며모든치아의치근부위에서발생가능하나주로전상악부에서호발하는것으로알려져있다 1-4). 일반적으로감염이없는치근낭은무증상이지만감염이발생하면통증과부종, 발적등염증이나감염경과에따른다양한증상을보이고, 크기가커지면서안면의비대칭이나신경압박에의한감각이상등도나타날수있다 2,3,5,6). 치근낭의치료법으로는보존적인근관치료나조대술, 외과적적출술이있는데낭이크거나인접한구조물에합병증이동반된경우는외과적적출술의적응증이된다 7-9). 낭이클때 (0.5 cm 이상 ) 에는발치와를통한소파술만으로는병소부의모든부위에접근할수없으므로낭벽의완전한제거가어려워재발의위험이많다 10). 감염된낭은골에밀접히부착되어있으며인접치가낭내에포함되어있는경우가있으므로생활력검사를하여건전한치아는보존해야하며, 외부로누공이형성되어있을경우괴사된치아의근관치료및치근단절제술등과함께낭적출술을시행하여야한다. 상악동이나비강및하악관의천공위험이있거나노인환자나소모성질환이있는환자에서는조대술을시행한다. 어떠한방법을사용하더라도골의재생이완전히이루어질때까지 3개월이내 6개월간격으로주기적인 x-선검사를하여야한다. 본증례들은하악전치부의치근낭으로인해강동경희대학교치과병원소아치과에내원한환아들로치근낭적출술을사용하여병소의제거및골의재생이효과적으로이루어지는결과를얻었기에이를보고하는바이다. 교신저자 : 김광철서울특별시동대문구회기동 1 / 경희대학교치과대학소아치과학교실 / 02-440-6207 / juniordent@yahoo.ac.kr 원고접수일 : 2011 년 10 월 10 일 / 원고최종수정일 : 2011 년 12 월 23 일 / 원고채택일 : 2012 년 01 월 05 일 84
대한소아치과학회지 39(1) 2012 Ⅱ. 증례보고 1. 증례 1(Fig. 1-7) 13세남아로하악전치부의낭을주소로개인치과의원에서의뢰되었다. 특이한전신병력은없었으며초진시임상소견으로 #31, #41 순측부위에염증성육아조직이증식되어있었고누공이존재하였다. 치아우식소견은보이지않았고환자가기억하는별다른외상병력은없었으며약 6개월전에입술과해당부위잇몸이많이부었던경험이있다고하였다. 방사선사진에서하악좌측견치에서하악우측견치까지지름약 2.5 cm의명 확한방사선투과성병소가존재하였고, 컴퓨터단층촬영사진에서는역시동일부위의피질골이현저히파괴된모습을보여주었다. 임상검사및전기치수검사를통해 #31, #41 치아의괴사를확인하였으므로술전에근관치료를시행하였다. 이후외래에서국소마취하에전층판막절개를시행한후치근낭적출술시행하였으며치주조직재생유도재인 Teruplug(Atelo- Collagen sponge) 를삽입하였다. 이후주기적인 X-선검사를시행하였으며술후 2년이된현재골재생이일어난모습을나타내고있다. Fig. 1. Inflammatory granulation tissue grows on the labial side of #31, #41 area, and fistula was made. Fig. 4. 24 months after operation: Radiolucent lesion became radiopaque. Dental CT view Fig. 2. 24 months after operation: Fistula and radiolucent lesion was disappeared. Fig. 5. Cortical bone destuction on the labial side of #31-#33, #41,-#43. Dental CT view Fig. 3. Initial panoramic view: Well defined radiolucent lesion on the apical area of #31-#33, #41,-#43. Fig. 6. 24 months after the operation, new bone formation was made. 85
J Korean Acad Pediatr Dent 39(1) 2012 Fig. 7. Cyst enucleation: 1. #31, #41: root canal treatment was completed before surgery(#31, #41-pulp necrosis was found), 2. Under local anesthesia, full mucoperiosteal flap incision, 3. Cyst enucleation, 4. Teruplug(Atelo-Collagen Sponge) insertion, 5. Suture with 3-0 B/S. 2. 증례 2(Fig. 8-12) 15세남아로하악전치부의통증을주소로내원하였다. 치과병력은약 5년전상악유전치를발거하는중에 #42 치아치관부의파절이발생하였다고하였으며전신적특이병력은없었다. 치아우식등의소견은보이지않았으므로외상으로인한치수의감염에의해치근낭이발생한것으로판단되었다. 임상검사에서 #42 Mo(++), #41 Mo(+) 의치아동요도를보였으며 #42 치아는타진반응이있었고, #41, #42 순측부위 의촉진시압통이존재하였다. 방사선사진상에서는 #31, #32, #41 주변의명확한경계의방사선투과성부위가존재하였으며 #42 주변으로 periapical rarefaction이존재하였다. #32, #42 치아의치조백선의연속성이상실되었다. 치료는치수괴사가확인된 #32, #42 치아의신경치료를먼저시행하였고, 본증례는전신마취하에전층판막을절개한후 microsaw를사용하여 cortical bone osteotomy를시행하였다. 이후낭적출술을시행하고 bone graft material인 Osteon Fig. 8. Periapical cyst on #31, #32, #41 area and periapical rarefaction on #42 area. Loss of lamina dura continuity on #32, #42. Fig. 10. Initial panoramic view: Periapical cyst on #31, #32, #41 area and periapical rarefaction on #42 area. Loss of lamina dura continuity on #32, #42. Fig. 9. 24 months after the operation, new bone formation was made. Fig. 11. 24 months after operation: Radiolucent lesion become radiopaque. 86
대한소아치과학회지 39(1) 2012 Fig. 12. Cyst enucleation: 1. #32, #42: root canal treatment was completed before surgery(#32, #42-pulp necrosis was found), 2. Under general anesthesia, full mucoperiosteal flap incision, 3. Cortical bone osteotomy using microsaw, 4. Cyst enucleation, 5. Osteon (bone graft material) insertion, 6. Cortical bone fixation with 4-hole absorbable plates and screws, 7. Suture with 3-0 B/S. 을삽입하였다. 이후 4-hole absorbable plates and screw로피질골고정을시행하였다. 이후주기적인 X-선검사를시행하였으며술후 2년이된현재골재생이일어난모습을보여준다. Ⅲ. 총괄및고찰치근낭 (radicular cyst) 은전체악골낭의 52~68% 를차지하는가장흔한형태의치성낭으로치근단낭 (periapical cyst) 과근단치주낭 (apical periodontal cyst) 으로도불리운다 11,15). 치근낭의발생기전은치아우식증이나외상에의한치관부치수의염증이치근단으로파급된후염증과괴사조직이치근단공을통해유출되어치근단주위에염증성육아종 (granuloma) 을형성하게되는데, 염증반응이지속되면육아종의상피세포 (Malassez 상피잔사에서유래 ) 가염증성자극에의해활성화되어과형성되며, 후에세포의변성으로낭이형성된다. 이러한낭은모든방향으로팽창되어주위골을흡수하며계속커진다 10). 낭은 x-선촬영시우연히발견되는경우가많으며, 감염에의해동통이나타나거나측방팽창에의한뚜렷한변형이나타날때까지증상은현저하지않다. 이번증례와같이하악에서는순측및협측으로의팽창이현저하며상악에서는외측으로팽창되나, 후방으로경사된측절치의치근이나제2소구치및대구치의구개측치근주위의얇은골을팽창시켜구개측조직의변형을나타내기도한다 6). 낭이감염되었을때에는구강내누공을통하여농이나갈색의액체가유출되며, 안면부나경부로누공이형성되기도한다. 낭이침범된치아는타진시양성반응을나타내며, 치아가전위되기도한다 10). X-선소견으로는원형또는타원형의방사선투과성부위가뚜렷한방사선불투과성의선으로둘러싸여있으며, 이러한낭주위의방사선불투과성의선은원인치의치조백선과연결되어있다. 낭내함몰된부위의치근주위에는백선이관찰되지않으며, 유치의치근단에발생시하방의영구치배에발생된함치성낭으로오진될수있다 12). 첫번째와두번째증례모두원인치의치조백선과연결되거나치조백선의소실을보였으며전기치수검사를통해치수의괴사를확인한후근관치료를시행하였다. 치근단농양이나육아종과비슷하여작은치근낭의경우감별이어려우며, 이를감별하기위한정확한방법은없으나실활치의치근단병소가 1cm 이상일때낭으로의심할수있다 13). 낭의액체는밀짚색깔로 cholesterol 결정이진주빛을띈다. 단백질량은적으며, keratin을일부가지고있다. 감염시농, 장액성또는혈농성액체를볼수있으나, 시간이지남에따라치즈모양의물질이나온다 10). 낭의병리조직학적소견은낭벽은중층편평상피세포로되어있으며, 급성및만성염증세포의침윤이관찰된다 12,13). 치근낭의처치법으로는낭의일부를제거하여배액하는조대술 (marsupialization) 이나낭적출술 (enucleation) 을흔히사용하고있다. 낭적출술의경우낭의크기가너무크지않아서수술적접근이가능하고, 주위해부학적구조물과의분리가가능한경우또는일차적조대술적출후에이차수술로시행할수있다. 조대술은골내낭의크기가너무커서낭적출술을시행하기어려운경우나주위의중요한해부학적구조물에손상을줄우려가있을때에시행하는방법이다 7,18). 이번두증례에서는수술적접근이가능하고주변해부학적구조물과의분리가가능하다고판단되어치근낭적출술을시행하였다. 낭의크기가큰경우이차적골결손부에골이식을선호하기도하나, 낭의조건에따라골이식없이도양호한치유를보이는경우도흔히관찰할수있다. 낭의치유양상에영향을미치는요소로는낭의크기, 위치, 매복치의유무, 주위골의양과상태, 연조직결손부의여부, 환자의전신상태, 술전염증상태, 치근단병소의존재여부등을들수있다 14). 치근낭의치료에서는근관치료후낭의적출과동시에치근단절제술을시행하여이환된치아를보존할수있다 9,15). 이번증례에서는치수의괴사로인해근관치료를시행한치아들의 87
J Korean Acad Pediatr Dent 39(1) 2012 치근단절제술이낭적출술과함께동시에이루어졌으며, 첫번째증례에서는치주조직재생유도재인 Teruplug 를삽입하였고, 두번째증례에서는신선자가골이식을시행하였다. 골이식의시행여부는술자의기호에의존하는경우가많으며근거에기반한표준적인치료방침은확립되어있지않으나, 골이식을시행한경우대부분양호한골치유양상을보이며자발적인골치유를도와준다고알려져있다 16). 이번증례에서사용한치주조직재생유도재및골이식모두성공적인결과를보였으며, 치유기간및예후모두큰차이를보이지않았다. 술자의나이및비용, 입원치료의어려움등을고려할때비교적저침습적인술식을선택하는것이좋을것으로사료된다. 낭의치료로이밖에흡인법과자연적인치유를생각할수있다. 흡인법은낭내액체를주기적으로흡인하여낭내의팽창력을감소시켜성장을억제할뿐아니라병소의발육을저해하게하는방법인데치유기간이길고, 낭조직의병리검사가불가능하며개구부가쉽게막히는단점이있으며일부낭이잔존되어재발의위험성도있으므로주의해야한다. Worth는치근낭이작은경우원인치의발거나발치와를통한소파술만으로병소부의외과적처치없이치료가가능하다고하였으나반대로 Marker등은발치와는폐쇄되고병소는잔존됨으로써후에잔존낭또는농양의발생등지속적인병발증이나타나는경우가많다고하였다 17). 따라서술후정기적인구강검사및 X-선사진촬영등의 follow-up이필요하다. 본증례들은수술후재발이나합병증없이양호한결과를얻었으며지속적인경과를관찰중이다. Ⅳ. 요약치근낭의치료에서성공적인결과를얻기위해서는감염된치아의신경치료와치근단절제술및낭적출술을통해염증조직을완전히제거해야한다. 일반적으로외과적수술이제대로이루어지면, 치근낭의재발이나종양으로의전환이일어나지않는다. 그러나지속적인술후 follow-up과 X-선검사를통해염증의재발이나남아있는잔존낭의여부를확인해야할것이다. 참고문헌 1. Nair PN. New perspectives in radicular cysts: Do they heal? Int Endod J, 31:155-60, 1998. 2. Shear M. Cysts of the oral regions, 3rd ed. Wright: Oxford; 136-70,1992. 3. Peter E. Larsen, Arden K. Hegtvedt. odontogenesis and odontogenic cysts and tumors. In: Cummings Otolaryngology-Head and Neck Surgery. 4th ed. Elsevier Mosby: Philadelphia; 1511-43, 2004. 4. Simon JH. Incidence of periapical cysts in relation to root canal. J Endod, 6:845-8, 1980. 5. Meningaud JP, Oprean N, Pitak-Arnnop P, et al. Odontogenic cysts: A clinical study of 695 cases. J Oral Sci, 48:59-62, 2006. 6. Kim KW, Lee JH. Clinical study of cysts in the jaws. J Korean Assoc Maxillofac Plast Reconstr Surg, 21:166-73, 1999. 7. Johann AC, Gomes Cde O, Mesquita RA. Radicular cyst: a case report treated with conservative therapy. J Clin Pediatr Dent, 31(1):66-7, 2006. 8. Caliskan MK. Prognosis of large cyst-like periapical lesions following nonsurgical root canal treatment: a clinical review. Int Endod J, 37:408-16, 2004. 9. Maddalone M, Gagliani M. Periapical endodontic surgery: A 3-year follow-up study. Int Endod J, 36: 193-8, 2003. 10. 이상철, 김여갑저. 구강악안면영역의소수술. 의치학사, 서울, 315-318, 1993. 11. Kyung Tae, MD, Hyun Jung Lee, MD, Li A Ryu, MD, et al. Treatment of radicular cyst in maxilla. Korean J Otorhinolaryngol-Head Neck Surg, 50: 789-94, 2007. 12. Kurger, G.O. Textbook of Oral Surgery. 6th ed., C.V. Mosby Co., St. Louis, Toronto, 1984. 13. Laskin, D.M. Oral and Maxillofacial Surgery. Vol II., C.V. Mosby Co., St. Louis, 1980. 14. Kim YD, Chang KY, Cho JS, et al. Transnasal marsupialization of large infected radicular cyst in immunocompromised patients : A case report. Korean J Otolaryngol-Head Neck Surg, 44:1168-70, 2001. 15. Lee SJ, Sohn HK, Kim SO, et al. Case report for treatment of periapical lesion by using apicoectomy. J Korean Acad Pediatr Dent, 24:575-80, 1997. 16. Ricucci D, Lin LM, Spa Wngberg LS. Wound healing of apical tissues after root canal therapy: a longterm clinical, radiographic, and histopathologic observation study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 108:609-21, 2009. 17. Marker P, Br ndum N, Clausen PP, et al. Treatment of large odontogenic keratocysts by decompression and later cystectomy: a long-term follow-up and a histologic study of 23 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 82:122-31, 1996. 18. Cha YH, Kim HJ, Cha IH, et al. Treatment of huge mandibular cyst with enucleation after decompression under local anesthesia. J Korean Assoc Oral Maxillofac Surg, 36:286-90, 2010. 88
대한소아치과학회지 39(1) 2012 Abstract RADICULAR CYST ENUCLEATION ON MANDIBULAR ANTERIOR REGION Sun ha Kim, Sung Chul Choi, Jae Hong Park, Kwang Chul Kim Department of Pediatric Dentistry and Institute of Oral biology, School of Dentistry, Kyung Hee University, Seoul, Korea The radicular cyst is the most common odontogenic cyst which is caused by pulpal inflammation, pulp death, and secondary to trauma or dental caries. Usually, the radicular cyst is asymptomatic, but a secondary inflammation can cause pain, swelling and redness. Getting larger, the radicular cyst can cause facial asymmetry and paresthesia by pressure on nerves. It requires conservative endodontic treatment or surgical approach. When the size of cyst is large or invasion of the adjacent tissue is not expected, cyst enucleation is carried out. And most of the case can be completely cured and shows low recurrence. In these radicular cysts cases, by cyst enucleation or apicoectomy after root canal treatment simultaneously, the infected teeth can be preserved successfully. Key words : Radicular cyst, Endodontic treatment, Cyst enucleation 89