http://dx.doi.org/10.14368/jdras.2016.32.3.149 ISSN 2384-4353 eissn 2384-4272 Review Article Tooth preparation design of dental laminate veneer: a review article Eun-Hye Jo, Kyung-Ho Ko, Chan-Jin Park, Lee-Ra Cho, Yoon-Hyuk Huh* Department of Prosthodontics and Research Institute of Oral Science, Gangneung-Wonju National University, Gangneung, Republic of Korea Tooth preparation design is essential for successful laminate veneer treatment. Preservative tooth preparation limited on enamel, supra-margin advantageous for plaque control, and maintaining contact points known as a standard concept. However, the tooth preparation design has been the controversial issue. In biomechanical considerations, the incisal coverage should be decided on esthetic needs and necessity for the anterior guidance reconstruction. In occasion for sufficient enamel thickness, preparation can prolong to the palatal side but not recommended at palatal concavity. Elongation to contact point is selective option according to the cases. If an old resin restoration located at contact area, laminate veneer should cover over half area of that after surface treatment. The laminate veneer can be also selected at a partially discolored tooth root canal therapy (RCT) and at this occasion, the fiber-reinforced composite (FRC) posts are recommended. (J Dent Rehabil Appl Sci 2016;32(3):149-57) Key words: laminate; tooth preparation; enamel; palatal concavity; contact area 서론 접착치의학의기술적발전과더불어환자들의최소한의치아형성에대한요구가증가함에따라라미네이트는심미치과보철학의대표적인술식중의하나가되었다. 라미네이트의장기적인성공률은교합관계, 치아형성디자인, 접착등에영향을받으며, 1 Burke 2 는법랑질에국한된보존적인치아형성이가장중요한요소라고보고하였다. 라미네이트를위한치아형성에대한개념은시대에따라변화하였다. 초창기에는심미를위한수복물이므로비침습적인접근이적절하다는이유로 무삭제술식 (no preparation technique) 이선호되었다. 그러나과풍융으로인한치주적인문제점들이발생하면서최소침습적접근법 (minimally invasive approach) 에따른치아형성을선호하게되었다. 그후 1990년대열가압도재 (heatpressed ceramic) 가개발된초기에는다소두꺼운두께가필요하여 1.0 mm 정도의깊은삭제를시행하였으나상아질노출에따른문제점들이보고되면서현재최소침습적인치아형성으로개념이재정립되었다. 3 치아형성방법으로는 0.3-0.5 mm의법랑질삭제와치은연선상의 chamfer 변연이추천되나절단면피개에관하여는논쟁의여지가있다. 4 또한라미네이트성공률에관한문헌에서파절 (fracture), 미세누출 (microleakage), 탈락 (debonding) 이주된합병증이며교합양식, 접착실패와더불어치아형성디자인이주요한실패의원인으로지적되고있다. 5-7 본문헌고찰에서는치아형성디자인의정립된부분과논쟁중인의견에대해고찰해보고임상적으로호발하는라미네이트의실패양상을치아형성디자인측면에서논의해보고자한다. *Correspondence to: Yoon-Hyuk Huh Assistant Professor, Department of Prosthodontics, College of Dentistry, Gangneung-Wonju National University, 7 Jukheon-gil, Gangneung, 25457, Republic of Korea Tel: + 82-33-640-2761, Fax: + 82-33-640-3103, E-mail: vino@gwnu.ac.kr Received: September 1, 2016/Last Revision: September 9, 2016/Accepted: September 12, 2016 Copyright 2016 The Korean Academy of Stomatognathic Function and Occlusion. cc It is identical to Creative Commons Non-Commercial License. 149
Jo EH, Ko KH, Park CJ, Cho LR, Huh YH 절단면형성 문헌고찰 라미네이트의절단면피개에관하여상반된연구결과 가존재한다. 절단면피개가더좋은성공률을보인다는 보고와, 8,9 유의한차이가없다고하는보고가있다. 10 절 단면피개시강도에관해서도상반된연구결과가있는데 Hui 등 11 은절단면을피개하지않은경우치아의탄성이 높아서동적응력에더강하다고한반면절단면을피개 한경우라미네이트의기계적강도의증가를보인여러 보고들이존재한다. 12-14 절단면을피개하지않으면라미 네이트의가장큰장점인최소침습적인치아형성이가능 하다. 반면절단면피개의장점으로는접착과유지력이 증가한다는것과수복물의투명도가향상되며적합에유 리하고적절한전방유도의재형성이가능하다는것이다. 절단면피개의디자인으로는 butt joint 형 과 구개 chamfer 형 이있다 (Fig. 1). 이둘의파절강도에관하여도 상반된연구결과가존재한다. 구개 chamfer 형은움직임 이적어서기계적으로안정적이며접착면적이넓고법랑 소주의절단방향이접착에유리하다. 13 또한충격흡수역 할을하는시멘트층이넓으므로응력분산에유리하다. 14 이에반해 butt joint 형은응력이적게발생하는위치에 변연이설계된다는장점이있다. 이차원적유한요소분석을통해라미네이트의응력 분산을연구한 Magne 와 Douglas 13 는구개오목 (palatal A Fig. 1. Schematic diagram of specimen preparation. Butt joint type (A), Palatal chamfer type (B). B concavity) 에변연이위치하는수복물에서높은응력이발생하므로변연을구개오목에근접하지않도록설계하는것을추천하였다. 또한 Magne 등 15 은균열이발생한라미네이트와발생하지않은라미네이트를관찰한결과도재와시멘트자체의두께보다균열의발생에영향을주는것은도재와시멘트의비율이며, 도재 / 시멘트의비율이낮은 (3.0이하) 경우균열의발생이증가한다고보고하였다. 따라서충분하고일정한두께의도재를갖도록치아를형성하는것이중요하지만구개측은법랑질의두께가얇아이러한치아형성이어렵다. 구개 chamfer형은변연이구개오목에근접하며구개측에서의도재 / 시멘트의비율이낮아져균열의발생가능성이높아진다. 구개오목에변연이위치하는경우는흔하지않은데, 인접면을연장하는경우에발생할수있고, 마모가심해짧은치아에서구개 chamfer형으로디자인할경우발생할수있다. 이때는 butt joint형으로디자인하는것이추천된다. 또한구개 chamfer형의단점으로는, 법랑질두께가얇은구개측에서상아질의노출가능성을높이는것이므로법랑질의두께가충분할때만구개 chamfer형의디자인이추천된다. 13 Butt joint형은이외에도치아형성과정및기공과정이더단순하여오차가적다는장점이있으며적합시삽입로가다양하여치아형성과정에서언더컷을남겨도장착이가능하다. 16 Feathered edge형, butt joint형, 구개 chamfer형의파절강도에관한연구들을살펴보면 13,14,17-23 응력분산측면에서, 구개측에하중을가할때 feathered edge형보다구개 chamfer형이유리하다고하였으나 16 butt joint 형을포함하여직접비교한실험은없었다. 파절강도에서 feathered edge형은대부분높게나타났다. 17-20 구개 chamfer형과 butt joint형의파절강도를비슷한실험조건에서직접적으로비교한 2가지연구는서로상반된결과를보였다. 17,22 구개측에수직으로정적인하중을가하였을때 Castelnuovo 등 17 은 butt joint형의파절강도가더높다는결과를얻었고, Schmidt 등 22 은구개 chamfer형의파절강도가더높다고하였다. 이러한상반된결과의원인은두실험에서설정한구개 chamfer형태가서로다르기때문으로판단된다. Schmidt 등 22 의디자인에서는구개 chamfer형의절단면피개면적이더넓어절단면에서전단결합강도를얻을수있었고, 구개측연장부분이기계적인안정성을제공하였을것이다. 따라서적절하게설계된구개 chamfer형은기계적으로도더유리하다고생각된다 (Fig. 2). 150 J Dent Rehabil Appl Sci 2016;32(3):149-57
Tooth preparation design of dental laminate veneer: a review article A B 인접면형성 Fig. 2. (A) Specimen preparation design of Castelnuovo et al., 17 (B) Specimen preparation design of Schmidt et al. 22 문헌고찰을통해라미네이트의성공률을조사한 Shetty 등 24 에따르면절단면을피개하는것이더성공률 이높았다. 그러나 feathered edge 형은치아를더보존적 으로수복할수있다는장점이있으며파절강도가낮다 고해도생리적으로전치가받는힘의최고치 (150-300 N) 을훨씬능가하는파절강도 (527-598 N) 를보였다. 19 따라서절단면의형태나길이수정이필요하지않은경우 에는 feathered edge 형이추천된다. 절단면의수정이필 요한경우에는법랑질의두께가충분하면구개 chamfer 형이, 그렇지않은경우에는 butt joint 형이추천된다. 마 모된치아에서는 butt joint 형이추천된다. 치아마모량이 파절강도에미치는영향에대하여는논쟁의여지가있으 나대부분의연구에서 2 mm 정도까지는라미네이트의 파절강도가높은것으로보고되었다. 25,26 즉, 2 mm 정도 의파절혹은마모된치아에서는라미네이트수복을치 료옵션으로고려할수있다. 인접면까지연장하여라미네이트를형성하는것은변연을숨겨심미성을높이며접착면적을넓혀유지력을증가시키는장점이있다. 라미네이트인접면연장의일반적인적응증으로는위치이상, 정중이개, 치간부검은삼각 (black triangle), 인접면수복물의존재등의경우이며착색이있거나전장관 (full veneer) 과인접한치아의라미네이트수복시에도심미성을위해접촉점을넘어서는치아형성이필요할수있다. 27 어느정도구개측으로연장해야하는지에관해명확한합의는없지만 Rosential 28 은 1 mm를제안하였고, Knight 29 는인접면선각 (line angle) 까지의연장을제안하였으며, 치간공간이클수록보다구개측으로연장할것을추천하였다. 27 Chun 등 30 은상악전치에서순면비니어 ( 두께 0.5 mm), 3/4 비니어 ( 두께 0.5 mm), 전부전장관 ( 두께 1.0 mm) 의파절강도를비교하였을때유의한차이가없다고하였으며변연이상아질에위치하는경우는법랑질에위치하는경우보다파절강도가낮아진다고하였다 (Fig. 3). 3/4 비니어와전부전장관은치아삭제량에서 2배정도차이가나기때문에임상적으로 3/4 비니어의수복이치질보존측면에서더유리할수있다. Guess와 Stappert 31 는동일한두께의 butt joint형의라미네이트와전부전장관라미네이트수복물의 5년간성공률을비교한결과, 전부전장관라미네이트의높은성공률 (100%) 과생존율 (85%) 을보고하였고이는 butt joint형라미네이트의성공률 (97.6%) 과생존율 (72%) 보다높았다. 전통적인라미네이트와전부도재관의중간정도의치아형성을하는전부전장관라미네이트는수복물의변연이설면결절에위치하여발생되는응력이적고접착면적이넓다. A B C D E Fig. 3. Specimen preparation design of Chun et al. 30 (A) labial veneer, (B) 3/4 veneer, enamel, (C) 3/4 veneer, dentin, (D) full veneer, enamel, (E) full veneer, dentin. J Dent Rehabil Appl Sci 2016;32(3):149-57 151
Jo EH, Ko KH, Park CJ, Cho LR, Huh YH 인접면연장을할때구개측으로의연장정도는다양하게할수있는데 Magne와 Douglas 13 에따르면인접면을연장하는경우에응력이높은구개오목에변연이위치하지않도록하는것이필요하다. 따라서구개측으로약간의연장부를가지는, Chun 등 30 의 3/4 비니어디자인이나설면결절에변연이위치하는 Guess와 Stappert 31 의전부전장관디자인이기계적으로유리할것이다. 변연형성심미성과치태조절용이성을위하여가능한치은연선상으로형성하는변연이추천된다. Troedson와 Dérand 32 는라미네이트의응력발생에서치경부변연디자인이미치는영향은크지않으며, 접착의상태가가장중요하고, 변연에서접착이불완전한경우에중앙에서접착이불완전한경우보다큰응력이나타난다고하였다. Seymour 등 16 은 knife-edge, chamfer, shoulder 변연을비교시 knife-edge 변연에서가장작은응력이발생함을보고하였다. Shoulder 변연은날카로운내부선각에응력이집중되어가장큰응력이나타났다. Knife-edge 변연은응력이적으나변연이불명확하며파절가능성이존재한다. 하지만명확한 chamfer 변연은상아질의노출을증가시킬수있다. 33 따라서 knife-edge 와 chamfer의중간형태인 long chamfer 변연이추천되는데, long chamfer 변연은와연우각 (cavosurface angle) 을둔각이되도록하여법랑질소주를노출시켜산부식을용이하게한다. 34 임상적상황에서의고려사항라미네이트의성공률에관한문헌들에따르면실패유형은파절, 미세누출, 탈락등이주로나타난다. 5-7 파절의원인으로는부적절한치아형성, 과하중등이있다. 미세누출은상아질에변연을형성하는경우에증가하며적절한접착을시행하는경우감소할수있다. 지대치의법랑질이부족할경우에는탈락이증가하는데, 접착력이감소하며치아와도재라미네이트의강성도 (stiffness) 차이가커지기때문이다. Burke 35 는라미네이트성공률에관한문헌고찰에서법랑질에국한된치아형성이가장중요한요소라고하였다. Friedman 36 은라미네이트가법랑질에접착될경우접착실패가거의일어나지않으며접착면의 80% 이상이상아질 일경우에탈락이발생함을보고하였고, Peuman 등 37 은치경부에서상아질이노출될경우파절의가능성이높아진다고하였다. 또한상아질의노출시많은문헌에서즉시상아질봉쇄 (immediate dentine sealing) 를시행할것을추천한다. 38-40 이외에도광범위한레진수복물이존재하거나근관치료병력이있는경우라미네이트수복시불리할수있다. Peuman 등 1 은 87개의도재라미네이트의 10년간의경과관찰 (follow-up) 결과대부분의변연의큰결함 (defect) 은기존의레진수복물이존재할경우에발생하였음을보고하였다. 라미네이트변연에레진수복물이존재하는경우레진의중합수축, 낮은마모저항성, 높은열팽창계수, 도재와의낮은접착력등이부정적인영향을미친다. Magne와 Douglas 41 는인접면레진수복물이존재하는전치에서라미네이트수복시레진의중합수축과온도변화에따른체적변화가라미네이트균열발생에미치는영향과인접면연장정도에따른응력발생을조사하였다. 레진의중합수축은도재라미네이트에주로압축력을발생시키며시간에따라수분을흡수하여응력이해소되므로균열발생에치명적인요인이되지못한다. 온도에따른체적변화의영향과레진의중합수축은서로상반되어오히려라미네이트를보호하는효과가있었다. 인접면연장정도는, 레진수복물을피개하지않는경우변연에서가장높은응력이발생하였고인접면을 100% 피개하는경우에가장낮은응력이발생하였다. 만일임상적으로인접면을 100% 피개하는치아형성이어려운경우에는레진수복물을 50% 정도피개하는 medium wrapping 의형태를추천하였다 (Fig. 4). 또한인접면레진수복물이존재하는경우에라미네이트가레진수복물을피개할수도있고, 레진수복물을제거후라미네이트에포함시킬수도있다. Sadiqhpour 등 42 에따르면 Class III 레진수복물이존재하는경우는건전치아와파절강도, 미세누출면에서유의한차이가없었으나기존의레진수복물을제거하고라미네이트를수복하는경우는파절강도가낮아졌다. 또한이경우인접면와동에서시작하는파절유형을보였다 (Fig. 5). Gresniqt 등 43 은기존레진수복물에실리카코팅과실란처리를한경우기존레진수복물에접착된라미네이트가자연치아에접착된라미네이트에비해오히려파절강도가높다고보고하였다. 즉, Class III 레진수복물이존재하는경우표면처리후 50% 이상을피개하는형태의라미네이트로수복할것을추천한다. 152 J Dent Rehabil Appl Sci 2016;32(3):149-57
Tooth preparation design of dental laminate veneer: a review article A B C Fig. 4. The margin location of each veneer. 41 (A) Short wrapping-the veneer was extended only to the facial margin of the preexisting interdental composite. (B) Medium wrapping-the veneer was extended into the bulk of the preexisting composite, penetrating 50% of the interdental area. (C) Long wrapping-the veneer covered the entire interdental area. 하게증가시키는데, 이는섬유강화레진포스트가상아질의탄성계수와유사하며치질에결합하기때문이다. 따라서근관치료가시행된치아에서섬유강화레진포스트와라미네이트로수복하는것을치료옵션중하나로생각해볼수있으나잔존치질의양, 심한변색여부등의임상적상황을주의깊게고려하여야한다. 48 A B 결론 Fig. 5. The design of PLV preparation on tooth with class III composite filling (A), tooth with class IV cavity (B). 42 PLV, porcelain laminate veneer. 근관치료를시행한치아에서라미네이트로수복하는 것은치질보존의측면에서장점이있다. 근관치료병력 이라미네이트수복에미치는영향에관하여는실패율 이증가한다는연구와 44,45 성공률과큰상관관계가없다 는보고가함께존재한다. 46 D Arcangelo 등 47 의연구에 따르면라미네이트치아형성과근관치료는상악전치의 파절저항성에는유의한영향을미치지않으나치아의휨 (deflection) 을유의하게증가시킨다. 이는법랑질의두께 가감소하기때문이다. 파절은높은저작력이가해질때 일어나는드문일이지만치아의휨은낮은저작력이가 해질때발생할수있으므로더중요한지표이다. 라미네 이트접착후에파절강도는유의하게증가하며치아의 휨은유의하게감소하여건전치아와비슷해진다. 또한 섬유강화레진포스트의수복은치아의파절강도를유의 여러문헌을고찰한결과라미네이트치아형성에관하여다음과같은사항들이추천된다. 전방유도를재설정해야하는경우혹은심미적요구로인해절단면길이를증가시켜야하는경우에절단면피개를시행하며법랑질의두께가충분한경우에는구개 chamfer 형으로, 불충분한경우에는 butt joint형으로한다. 2 mm 정도파절혹은마모된치아에서라미네이트수복을치료옵션으로고려할수있으며, 변연이구개오목에위치하는것을피할수있는치아형성디자인을선택한다. 치경부변연은치은연선상에, long chamfer 변연을형성한다. 위치이상, 정중이개, 착색등의증례에서인접면연장을시행하며인접면에레진수복물존재시표면처리후레진수복물의절반이상을피개하는형태의라미네이트로수복한다. 변색이심하지않은근관치료를시행한치아에서라미네이트수복시에는섬유강화레진포스트의사용을추천한다. J Dent Rehabil Appl Sci 2016;32(3):149-57 153
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Review Article 라미네이트치아형성디자인에관한문헌고찰 조은혜, 고경호, 박찬진, 조리라, 허윤혁 * 강릉원주대학교치과대학치과보철학교실및구강과학연구소 성공적인라미네이트치료를위해서는치아형성방법이매우중요하다. 법랑질에국한된보존적인치아형성, 치태조절이용이한치은연선상 (equigingival) 변연, 가능한존재하는접촉점의유지등의조건이일반적으로알려져있으나구체적인치아형성디자인에관하여는논쟁의여지가존재한다. 생역학적으로고려해볼때, 다음과같은사항들이추천된다. 절단면피개는심미적요구와전방유도의재설정필요여부측면에서결정해야하며, 법랑질두께가충분한경우에는구개측연장을하는것이좋으나응력집중이큰구개오목 (palatal concavity) 에변연이위치하는것은부적절하다. 인접면연장은증례에따라선택적으로시행하며, 인접면에레진수복물이존재하는경우에는표면처리후레진수복물을절반이상피개하는형태의라미네이트로수복한다. 변색이심하지않은근관치료가시행된치아의경우라미네이트수복을고려해볼수있으며, 이때섬유강화레진포스트를사용하는것을추천한다. ( 구강회복응용과학지 2016;32(3):149-57) 주요어 : 라미네이트 ; 치아형성 ; 법랑질 ; 구개오목 ; 인접면 * 교신저자 : 허윤혁 (25457) 강원도강릉시죽헌길 7 강릉원주대학교치과대학치과보철학교실 Tel: 033-640-2761 Fax: 033-640-3103 E-mail: vino@gwnu.ac.kr 접수일 : 2016 년 9 월 1 일 수정일 : 2016 년 9 월 9 일 채택일 : 2016 년 9 월 12 일 157