ISSN 1229-5418 Implantology 2016; 20(2): 72~79 양측상악중절치임플란트수복시 Computer Guided Surgical Stent 의이용 이강희 1, 김기덕 2, 김근희 2, 김민유 1, 박원서 1 1 연세해담치과, 2 연세대학교치과대학통합진료학과 The Use of Computer Guided Surgical Stent in Dental Implant of Maxilla Central Incisor Kang-Hee Lee 1, Kee-Doeg Kim 2, Keunhee Kim 2, Minyu Kim 1, Wonse Park 2 1 Yonsei Haedam Dental Clinic, Seoul, Korea 2 Department of Advanced General Dentistry, Yonsei University College of Dentistry, Seoul, Korea Abstract Implant placement for the upper anterior teeth is difficult compared to the posterior teeth, therefore careful consideration by the dental practitioner is necessary. To achieve successive implant placement, it is very important to place the implant fixture in the proper position. An implant prosthesis connected to a properly placed implant fixture can be expected to yield good results with regard to function as well as aesthetics. On the contrary, improper positioning of an implant can result in an unaesthetic, non-functional and weak implant with no bite force. In this case report, the upper central incisor was extracted due to severe root resorption and was restored with a dental implant. During the surgery, the implant placement was performed with a computer guided stent. After surgery, the aesthetics of the gingiva was adjusted and improved with a provisional restoration. Finally, additional gingival plastic surgery and gingival bleaching was performed and successful aesthetic treatment of the Maxilla central incisor was accomplished. With this case report, we hope to determine the position of implant fixture for functional and aesthetically ideal prosthesis implants and to evaluate the use of computer guided stents to promote the positioning of implants. Key Words: central incisor, computer guided stent, dental implant, implant location, root resorption Reprint requests: Wonse Park Department of Advanced General Dentistry, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: 82-2-2228-8980, Fax: 82-2-2227-8906 E-mail: wonse@yuhs.ac Received for publication: June 17, 2016 Revised for publication: June 21, 2016 Accepted for publication: June 22, 2016 교신저자 : 박원서 (03722) 서울시서대문구연세로 50-1 연세대학교치과대학통합진료학과 Tel: 82-2-2228-8980, Fax: 82-2-2227-8906 E-mail: wonse@yuhs.ac 원고접수일 : 2016 년 6 월 17 일원고수정일 : 2016 년 6 월 21 일게재확정일 : 2016 년 6 월 22 일 Copyright 2016. The Korean Academy of Oral & Maxillofacial Implantology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 72 Implantology Vol. 20 No. 2, 2016
I 서론 임플란트는상실된치아를대체하는인공치아로서그기능과안정성을인정받아, 고정성보철치료를대체하는훌륭한대안으로인정받고있다 1,2. 하지만임플란트는수술적처치가필요하며, 치조골의형태와치은의성상에따라술후결과에제한을받는다 3. 또식립시에임플란트가이상적인위치에식립되지않으면차후보철이올라가는과정에서어느정도보완을한다하여도원하는결과를얻기어려울수있다는단점이있다. 적합하지않은위치에식립된임플란트치료는치간부음식물함입, 치은염증, 임플란트- 골계면의응력, 교합력분산실패등을발생시킨다. 전치부에서는기능적인문제외에도비심미적인치아형태와치은변연, 비정상적인치아비율과간격등의심미적문제를일으킨다 4. 따라서보철물의기반이되는임플란트를이상적인위치에식립하는것은심미보철, 연조직형성, 유지관리등추후모든치료를성공적으로진행함에있어매우중요한과정이다. 임플란트를정확한위치에심기위한노력은여러방식으로시도되어왔다. 가장보편적인방식은치아가상실된악궁을인기한석고모형상에레진인공치나왁스모형등을위치시킨뒤, 배열된치아의축을따라드릴삽입로를설정하고아크릴스텐트를제작하여수술시보조장치로사용하는것이다. 하지만이러한방식의수술스텐트는치조골의실제위치를모르는상태에서계획하고제작된다. 그러므로이스텐트를이용해수술하게되면계획한임플란트의위치와실제치조골의위치가달라서치조골의열개, 천공, 고정실패등의문제가발생하고, 따라서수술중술자의역량으로대량의수정 이불가피한경우가대부분이었다. Computer guided surgical stent 는 1990년대소개된이후계속적인기술개발에힘입어정확도와편의성이점점개선되어가고있는기술이다. 또 cone-beam computed tomography (CBCT), laser scanner, threedimensional (3D) printer 같은주변기기의보편화에힘입어대중성을얻어가고있다. 수년전만해도외국유명임플란트회사들만이서비스를제공하였기때문에고비용, 제작기간소요, 언어소통의어려움등의문제로접근성이떨어졌지만최근에는국내유수임플란트회사들뿐아니라, computer guided surgical stent 만을제작하고지원하는전문업체들이점점늘어가고있는추세이다. Computed tomography (CT) 촬영으로얻어진환자의 3D skull model 상에서진단, 계획하여제작된 computer guided surgical stent 를이용하면실제골의위치와계획된임플란트의위치가같아위와같은문제를해결할수있다. 또주변치아와의간격, 잔존협측골의두께를고려할수있을뿐아니라식립깊이조절을통해제작될보철물의출현치은변연 (emergence profile) 의두께와각도, 치은낭의깊이까지도조절할수있다는장점이있다. 본연구는 computer guided surgical stent 를이용해상악중절치 (#11, #21) 를회복한증례를통해스텐트의유용성을평가하고, 심미적이고기능적인전치부임플란트치료를위해정확한임플란트의위치가가지는중요성을논의하고자한다. II 증례보고 2004년 10월 12일의과적병력이없는 16세남성환자가상악중절치가아래로내려온다는것을주소로연세 대한구강악안면임프란트학회지 20 권 2 호, 2016 73
Case Report Fig. 2. Extracted right maxilla central incisor (#21), severe external root resorption extended to cementum, dentin and pulp canal can be seen. Fig. 1. Maxilla cental incisor of 21-year-old man. There was the past trauma history, and root canal therapy was done. But severe external root resoprtion can be observed. The treatment plan is extraction of central incisor and implant surgery at this site after Orthodontic treatment of adjacent teeth. 대학교 치과병원에 내원하였다. 주소 치아는 수년 전 외 상에 의한 탈락과 재식립 병력이 있었다. 치근 외흡수 소 견이 보여 근관치료 후 5년간 경과 관찰을 하였으나 외흡 수가 멈추지 않고 계속하여 진행되는 것이 관찰되었고, 따라서 주소 치아 발치와 교정을 동반한 임플란트 처치 가 추천되었다(Fig. 1). 발치 후 교정 치료를 진행할 경우 교정 치료 기간 동안 발치 부위의 치조골, 특히 순측골의 흡수 가능성이 높기 때문에, 치조골을 유지하기 위하여 상악 좌우 중절치의 발치를 가능한 한 연기하면서 교정 치료를 우선 시행하였고, 임플란트는 악골 성장이 완료 Fig. 3. The occlusal view of extracted central incisor after 1 year of orthodontic treatment. At the same time of extraction, socket preservation with collagen matrix was done but narrow alveolar bone was seen due to buccal bone resorption. 되는 만 20세 이후 식립하는 것을 계획하였다. 교정을 통해 상하악 치아를 배열하면서 상악좌측중절 의 흡수를 최대한 예방하고 치조골 재형성을 돕기 위해 치(#21; 2011. 11. 7), 상악우측중절치(#11; 2012. 7. 31) 발 서 발치와 내의 육아 조직을 소파한 후, collagen matrix 치를 순차적으로 시행하였다. 침윤마취(lidocaine 2%, (Teruplug; Olympus Terumo Biomaterials, Tokyo, 1:100,00 epinephrine)하에 발치를 시행하였으며 순측골 Japan)를 넣고 봉합하였다. 발치된 치아는 백악질과 상 74 Implantology Vol. 20 No. 2, 2016
Fig. 4. Cone-beam computed tomography, cross-sectional view at the implant placement site (#21, maxilla left central incisor). Kang-Hee Lee et al. : The Use of Computer Guided Surgical Stent in Dental Implant of Maxilla Central Incisor. Implantology 2016 아질을포함하여치수관을침범하는흡수양상을보였고 (Fig. 2), 외흡수요인평가를위해발치부위조직생검실험을의뢰였으나특이소견을발견할수없었다. 이후교정처치마무리를진행하였고, 2013년 8월 12일임플란트식립을위한 CT 촬영과구강검사를시행하였다. 검사결과순설측치조골흡수로폭경이좁아심미적보철치료가어려울것으로예상되었다 (Fig. 3, 4). 치조골의재형성과정교한임플란트식립을위해서동종골과흡수성차폐막을사용하는골유도재생술을동반한 computer guided implant surgery를계획하였다. In2Guide program (CyberMed, Seoul, Korea) 을사용하여 CT로얻은 3D skull model 상에 implant surgery planning을하였다 (Fig. 5). 계획된임플란트는수직적으로인접치의 cement-enalmel junction 보다 1 mm 하방에 implant coronal top이위치하며, 협설로치조골을벗어나지않고 1 mm 구개측에위치하여순측으로충분한치조골과치은을남겨야자연스러운치은형태를얻고이후 saucerization 을예방할수있다 4. 3D printer로아크릴재질의 computer guided surgical stent 를제작하였다 (Fig. 6). 2013년 9월 26일, In2Guide surgical stent (CyberMed) 를사용하여임플란트 (Dentium superline FX4010SE; Dentium, Seoul, Korea) 를식립하였고, 식립부위순측치조골흡수가예상되는부위에동종골과흡수성차폐막을사용하여골이식을시행했다 (Fig. 7). 2013년 11월 29일, 식립체와지대주를연결하기위한임플란트 2차수술을시행했으며, 동시에레진임시치관을장착하여환자의심미성과기능성을회복하였고치은 대한구강악안면임프란트학회지 20 권 2 호, 2016 75
Case Report Fig. 5. Implant placement planning was done using various images, In2Guide implant planning progam (CyberMed, Seoul, Korea). 3D skull, cross-sectional view, horizontal view, etc., with consideration of width and depth of the alveolar bone, length of abutment, a relationship with lower teeth and gingival thickness. Fig. 6. A computer guided surgical stent made of acryl using three-dimensional print. 형성을유도하였다. 치간유두의재형성을유도하기위해서치조골의높이와치은의두께를고려해임시치관의인접면접촉점을치조골 5 mm 상방에형성하였다 4,5. 1개월간격으로순측치은변연과치간유두의높이와형태를확인하고레진임시치관을계속해서수정하여서심미적인치은형태가얻어지도록노력하였다 (Fig. 8). 2차수술 4개월차에잘유도된치은형태에따라맞춤지대주 (custom abutment) 와심미보철물 (porcelain fused zirconia crown) 을제작하여장착하였다 (Fig. 9). 2014년 6월 3일에환자가치아와치은의심미, 기능에대해만족하였으나치은착색에대해개선을요구하여 76 Implantology Vol. 20 No. 2, 2016
Fig. 7. Cone-beam computed tomography, cross-sectional view of implanted right maxilla central incisor using surgical guide stent. Within narrow alveolar ridge, placement of implant was seen without any invasion of adjacent structure. Bone graft was done at the buccal site, to compensate narrow alveolar ridge. Kang-Hee Lee et al. : The Use of Computer Guided Surgical Stent in Dental Implant of Maxilla Central Incisor. Implantology 2016 Fig. 8. Clinical photo with installation of abutment and resin temporary crown after second surgery. There is a black triangle due to recession of an incisive papilla, and irregular and thin marginal gingiva can be observed. Fig. 9. After gingival molding, gingival impression taking and Installation of the custom abutment and porcelain fused zirconia crown was done. The black triangle was successfully filled, and symmetrical marginal gingiva was achieved. At the upper attached gingiva, stains due to smoking and postoperative scar can be observed. 대한구강악안면임프란트학회지 20 권 2 호, 2016 77
Case Report Fig. 10. One month check-up after gingival plastic surgery and bleaching. The pinkish-red and smooth attached gingiva can be seen, and proper preservation of interproximal papillae and marginal gingiva was observed. 반흔조직제거와치은미백을위한 2차치은성형수술을한차례시행하였다. 치은성형수술 1주일후반흔과착색이현저히감소되었으며후에도계속해서유지되고있다 (Fig. 10). III 총괄및고찰 상악중절치의상실은환자에게심미적, 기능적장애를발생시킬뿐아니라그로인해심미적장애가동반될수도있다. 임플란트치료는상실된치아를대체하는아주좋은치료이지만식립체가일단식립되고나면제거나교체가어렵다는단점이있다. 전치부치료에서부적절한위치에식립된임플란트식립체는비심미적인치관과치은을만들기때문에환자의만족도와치료의완성도를떨어뜨린다. 또전치유도에적합하지못한기울어진치축이나교합형태는교합력을적절히분산하지못하기 때문에기능적인문제외에도스크류의풀림, 치관의반복적인파절, 임플란트찢김과같은불량한결과를초래하기도한다. 또한지나치게깊게식립된식립체는깊은치주낭을형성하여임플란트주위염을지속적으로유발하기도하고, 반대로낮게식립된식립체는식립체나지대주의노출, 검게음영이드리운치은과같은심각한심미적문제를일으키기도한다. 따라서전치부임플란트치료시에는인접치아와의간격, 협설측잔존골의두께뿐아니라, 식립각도, 식립깊이, 대합치과의교합양상, 주변치아들과교합의조화등모든요소를고려하여식립되어야할것이다 3-5. 하지만술자가수술중에이런모든것을살피며식립한다는것은현실적으로어려움이있어전치부수술을위해서는식립체의위치를유도해줄수있는 surgical stent 가필수다. 기존방식의스텐트는인접치와의간격이나이상적인보철의위치를알려줄수는있지만, 치조골의협설폭경과높이에대한고려가없기때문에수술중수정이불가피했다. 삼차원의 CBCT data를이용하는 computer guided surgical stent system은치조골의분석이가능할뿐아니라, 수술계획컴퓨터프로그램상에서가상의보철도제작해볼수있기때문에임플란트치료에필요한모든면을다각도로분석하여정밀한치료계획을세울수있게해준다. Computer guided surgical stent 를사용하면수술중수정이거의필요없고따라서미리제작해놓은지대주와임시치관을식립후바로연결하여전치부의심미, 기능을회복하여줄수도있다. 또 flapless로수술을할수도있고, 수술시간을줄여술중감염가능성과출혈, 통증, 술후부종을줄여준다 6. 이전연구들에따르면 computer guided surgical stent 를이용해수술하면 0.5~1.5 mm의수평적평균오차를보인다 7,8. 이러한오차는최종보철의사전제작은불가능한수치이지만, 레진으로된임시치관을사전제작해 78 Implantology Vol. 20 No. 2, 2016
놓고식립당일에임시치관의내면을소량삭제하거나재이장하여장착하는방식으로충분히조정이가능한정도의수치다. Computer guided surgical stent 를이용한수술에서는스텐트와치아의적합성이떨어지면유격이생겨수술중장치가움직일수있다. 또스텐트에있는 metal sleeve 와 drill 사이의유격에의해서도수평적오차나식립각도오차가생기기도한다. 기술이개선되어감에따라수술의오차도줄어들어가는추세이지만, stent 의정확도외에도술자에의한오차라는변수가있기때문에정확한수술을위해서는술자의숙련도역시중요하다. 최근에는다양한 computer guided surgical stent system 이있기때문에술자에게맞는시스템을선택하는것역시중요하다. 본케이스에서는 computer guided surgical stent 를이용해임플란트식립체를이상적인수평, 수직적위치에자리하고치조골이식을통해치조골형태를개선하였으며, 임시치관을 4개월간유지하며심미적인치은의외연과치간유두형성을유도하였다. 이러한넓은면적의수술은반흔조직, 치은착색을형성하는경우가있기때문에반흔조직제거, 치은변연성형, 치은미백치료를통해전치부치료의완성도를보다높일수있었다. IV 결론 교정을통하여중절치가위치할간격을확보한뒤발치시기를조정하여치조골이식을동반한식립이이루어졌고 computer guided surgical stent 를사용하여이상적인임플란트의위치를얻을수있었다. 이상적인임플란트의위치덕분에심미적이고기능적인보철치료가가능 하였고, 추후주기적인검사에서골소실이나보철물손상없이전치부가잘유지되는것을관찰하였다. 완성도있는전치부치료를위해서는수술전정확한진단과계획이필요하고, 계획한대로식립하는것이중요하다. Computer guided surgical stent 는이것을가능하게해주는유용한수술보조장치다. References 1. Belser UC, Schmid B, Higginbottom F, et al. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants. 2004; 19 Suppl: 30-42. 2. Chen ST, Buser D. Esthetic outcomes following immediate and early implant placement in the anterior maxilla--a systematic review. Int J Oral Maxillofac Implants. 2014; 29 Suppl: 186-215. 3. Arnoux JP, Weisgold AS, Lu J. Single-tooth anterior implant: a word of caution. Part II. J Esthet Dent. 1997; 9: 285-294. 4. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2004; 19 Suppl: 43-61. 5. Ross SB, Pette GA, Parker WB, et al. Gingival margin changes in maxillary anterior sites after single immediate implant placement and provisionalization: a 5-year retrospective study of 47 patients. Int J Oral Maxillofac Implants. 2014; 29: 127-34. 6. Hultin M, Svensson KG, Trulsson M. Clinical advantages of computerguided implant placement: a systematic review. Clin Oral Implants Res. 2012; 23 Suppl 6: 124-135. 7. D'haese J, Van De Velde T, Komiyama A, et al. Accuracy and complications using computer-designed stereolithographic surgical guides for oral rehabilitation by means of dental implants: a review of the literature. Clin Implant Dent Relat Res. 2012; 14: 321-335. 8. Schneider D, Marquardt P, Zwahlen M, et al. A systematic review on the accuracy and the clinical outcome of computer-guided template-based implant dentistry. Clin Oral Implants Res. 2009; 20 Suppl 4: 73-86. 대한구강악안면임프란트학회지 20 권 2 호, 2016 79