ISSN Vol. 35 No. 1, 2016 Vol. 35 No. 1 June 2016

ISSN 1229-7038 Vol. 35 No. 1, 2016 Vol. 35 No. 1 June 2016

Journal of Dental Implant Research AIMS AND SCOPE Journal of Dental Implant Research is the official peer-reviewed, quarterly publication of the Korean Academy of Implant Dentistry (KAID). The Journal publishes original research papers, clinical observations, review articles, viewpoints, commentaries, technical note, case reports, and letters to the editor in subjects relating to clinical practice and related basic research on dental implant including other reconstructive procedures for maxillofacial areas. Eventually, the journal aims to contribute to academic advancement of dentistry and improvement of public oral and general health. BACKGROUND Journal of Dental Implant Research was renamed from Journal of The Korean Academy of Implant Dentistry, which was first published in 1976. It was initially published once a year but became a biannual journal from 2005. The KAID is the official member of the Korean Academy of Dental Science. OPEN ACCESS JDIR is not for sale. Full text PDF files are also available at the official website. Journal of Dental Implant Research is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creatviecommons. 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. 대한치과이식임플란트학회지 2016 년 6 월, 제 35 권제 1 호 Journal of Dental Implant Research June 2016 Vol. 35 No. 1 발행인김현철 위원장팽준영 편집간사이덕원 Publisher Editor-in-Chief Managing Editor Hyoun-Chull Kim Jun-Young Paeng Deok-Won Lee 인쇄일 2016 년 6 월 26 일 발행일 2016 년 6 월 30 일 발행처대한치과이식임플란트학회서울특별시종로구대학로 101 ( 연건동 ) 서울대학교치과병원 B168 호전화. (02) 2273-3875 팩스. (02) 2273-3871 인쇄 ( 주 ) 메드랑서울특별시마포구월드컵북로 5 가길 8-17 전화. (02) 325-2093 팩스. (02) 325-2095 Printing date June 26, 2016 Publication date June 30, 2016 PUBLISHED BY The Korean Academy of Implant Dentistry #B168, 101, Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel. 82-2-2273-3875 Fax. 82-2-2273-3871 PRINTED BY MEDrang Inc. 8-17 WorldCupbuk-ro 5ga-gil, Mapo-gu, Seoul 04001, Korea Tel. 82-2-325-2093 Fax. 82-2-325-2095 This paper meets the requirements of KS X ISO 9706, ISO 9706-1994 and ANSI/NISO Z.39.48-1992 (Permanence of Paper)

편집위원회 Editorial Boards 편집위원장 (Editor-in-Chief) 팽준영 ( 경북치대 ) Jun-Young Paeng (Kyungpook National Unviersity Hospital) 편집간사 (Managing Editor) 이덕원 ( 강동경희대학교치과병원 ) Deok-Won Lee (Kyunghee University Dental Hospital at Gangdong) 편집위원 (Editorial Board) 권긍록 ( 경희치대 ) 권대근 ( 경북치대 ) 권용대 ( 경희치대 ) 김수관 ( 조선치대 ) 김영균 ( 분당서울대병원 ) 김용호 ( 김용호치과 ) 김은석 ( 위례서울치과 ) 김태영 ( 서울킴스치과 ) 김태인 ( 태원치과 ) 김태일 ( 서울치대 ) 김현철 ( 리빙웰치과병원 ) 문홍석 ( 연세치대 ) 박원서 ( 연세치대 ) 박원희 ( 한양대구리병원 ) 박준범 ( 가톨릭대서울성모병원 ) 신승일 ( 경희치대 ) 신재명 ( 인제대일산백병원 ) 안강민 ( 서울아산병원 ) 양병은 ( 한림대학교성심병원 ) 여인성 ( 서울치대 ) 우승철 ( 마포리빙웰치과 ) 이양진 ( 분당서울대병원 ) 전상호 ( 고려대병원 ) 정승미 ( 원주세브란스기독병원 ) 지숙 ( 고려대병원 ) 지유진 ( 강동경희대학교치과병원 ) 최병갑 ( 연세힐링치과 ) 황경균 ( 한양대병원 ) 홍종락 ( 삼성서울병원 ) Kung-Rock Kwon (Kyunghee University) Tae-Geon Kwon (Kyungpook National Unviersity) Yong-Dae Kwon (Kyunghee University) Su-Gwan Kim (Chosun University) Young-Kyun Kim (Seoul National University Bundang Hospital) Yong-Ho Kim (Private Practice, Seoul) Eun-Suk Kim (Private Practice, Seoul) Tae-Young Kim (Private Practice, Seoul) Tae-In Kim (Private Practice, Seoul) Tae-Il Kim (Seoul National University) Hyun-Cheol Kim (Private Practice, Seoul) Hong-Seok Moon (Yonsei University) Won-Seo Park (Yonsei University) Won-Hee Park (Hanyang University) Jun-Beom Park (Catholic University Seoul ST. Mary's Hospital) Seung-Il Shin (Kyunghee University) Jae-Myung Shin (Inje University Ilsan Paik Hospital) Kang-Min Ahn (Seoul Asan Hospital) Byoung-Eun Yang (Hallym University Hospital) In-Sung Yeo (Seoul National University) Seung-Cheol Woo (Private Practice, Seoul) Yang-Jin Yi (Seoul National University Bundang Hospital) Sang-Ho Jun (Korea University Medical Center) Seung-Mi Jung (Wonju Severance Christian Hospital) Suk Ji (Korea University Medical Center) Yu-Jin Jee (Kyunghee University Dental Hospital at Gangdong) Byeong-Gap Choi (Private Practice, Seoul) Kyung-Gyun Hwang (Hanyang University) Jong-Rak Hong (Samsung Medical Center) ( 가나다순 )

대한치과이식임플란트학회지 Journal of Dental Implant Research 개요 대한치과이식임플란트학회지는 1976 년 5 월 21 일창립된대한치과이식임플란트학회의기관지입니다. 1980 년 6 월, 1 권 1 호를발행한이후 2004 년까지는연 1 회, 2005 년 24 권부터연 2 회 (6 월 30 일, 12 월 31 일 ), 2012 년부터연 4 회 (3 월 31 일, 6 월 30 일, 9 월 30 일, 12 월 31 일 ) 발행되고있습니다. 발행목적과범위 대한치과이식임플란트학회지는치과임플란트와관련된과학적, 임상적지식을공유함으로써치과임플란트의이론과술식을발전시키기위한목적으로발행되고있습니다. 본학회지는치과임플란트와관련된모든주제 ( 치료계획, 진단, 재료, 술식, 교합, 심미및관련학문 ) 를다루고있으며과학적연구논문과종설및임상증례를게재합니다. 발행윤리연구의대상이사람인경우, 헬싱키선언에입각하여환자또는보호자에게연구의목적과연구참여중일어날수있는정신적, 신체적위해에대하여충분히설명하여야하고이에대한서면동의서를받았음을명시하는것을원칙으로합니다. 연구의실험대상이동물인경우, 실험동물의고통과불편을줄이기위하여행한처치를기술하여야하고, 그실험과정이당해연구기관의윤리위원회규정이나동물보호법의동물실험에관한원칙에저촉되지않았음을명시하는것을원칙으로합니다. 편집위원회는필요시서면동의서또는기관의윤리위원회나 IRB 승인서의제출을요구할수있습니다. 날조, 위조, 변조, 표절, 자기기만, 중복투고, 논문분할, 부당한저자표시, 타인에대한강요와같은연구부정행위가있어서는안됩니다. 대한치과이식임플란트학회지는연구부정행위와관련하여과학기술부훈령제236호 연구윤리확보를위한지침 을준수합니다. 모든연구윤리와관련된심사및처리절차는대한의학학술지편집인협의회에서제정한의학논문출판윤리가이드라인 (http:// kamje.or.kr/publishing_ethics.html) 을따릅니다. 발행형태대한치과이식임플란트학회지는비매품이며대한치과이식임플란트학회회원및관련된교육연구기관에무료배포되고있습니다. 주소변경및문의사항은학회사무실 (Tel. 02-2273-3875) 로연락하시기바랍니다. 대한치과이식임플란트학회지는학회홈페이지 (www.kaidimplant.or.kr) 를통해서도무료로다운받으실수있습니다.

대한치과이식임플란트학회지 제 35 권제 1 호 2016 년 6 월 목 차 1 백서임플란트주위염모델에서 808 nm 와 810 nm 파장의 Diode Laser 를이용한박테리아제거효과 김위붕, 이성호, 김륜경, 임호경, 변수환, 임영준, 김성민, 이종호 9 구치부발치후즉시식립임플란트의변연골흡수에대한임상적분석 최기관, 팽준영 17 초기고정없이즉시식립된임플란트 : 증례보고와문헌고찰 김동관, 최정임, 김승우, 박관수 22 치은연하로파절된전치부치아의외과적정출술을이용한수복증례 정기현, 이성원, 정주련, 최종원, 노성수, 김주형, 김태건, 박창주, 황경균 27 치조정접근으로시행한상악동막거상술시발생한상악동막천공의치조정을통한수복 : 증례보고 최정임, 김동관, 김초록, 박관수

Journal of Dental Implant Research Vol. 35 No. 1 June, 2016 CONTENTS 1 Bacteria removal in a SD rat peri-implantitis model using diode laser of 808 nm and 810 nm Wei-Fung Jin, Sung-Ho Lee, Ryun Kyung Kim, Ho-Kyung Lim, Soo-Hwan Byun, Young-Joon Lim, Soung-Min Kim, Jong-Ho Lee 9 A clinical study on implantation of the marginal bone loss after the posterior immediate implants Ki-Kwan Choi, Jun-Young Paeng 17 Immediately placed implant without primary stability: case report and literature review Dongkwan Kim, Junglim Choi, Seung-Woo Kim, Kwan-Soo Park 22 Intra-alveolar transplantation for crown-root fractured anterior maxillary tooth Ki-Hyun Jung, Seong-Won Lee, Joo-Ryun Chung, Jong-Won Choi, Seong-Su Ro, Joo-Hyung Kim, Tae-Geon Kim, Chang-Joo Park, Kyung-Gyun Hwang 27 Repair of perforated sinus membrane through the alveolar crest during sinus elevation by crestal approach: case report Junglim Choi, Dongkwan Kim, Cho-Rok Kim, Kwan-Soo Park

Vol. 35 No. 1, June 2016 Journal of Dental Implant Research 2016, 35(1) 1-8 백서임플란트주위염모델에서 808 nm 와 810 nm 파장의 Diode Laser 를이용한박테리아제거효과 김위붕 1, 이성호 1, 김륜경 2, 임호경 1,3, 변수환 4, 임영준 5, 김성민 1,6, 이종호 1,6, * 1 서울대학교치과병원구강악안면외과, 2 성균관대학교정보통신공학, 3 고려대학교구로병원구강악안면외과, 4 동탄한림대학교병원구강악안면외과, 5 서울대학교치과병원보철과, 6 서울대학교치과대학치의학연구소 Bacteria removal in a SD rat peri-implantitis model using diode laser of 808 nm and 810 nm Wei-Fung Jin 1, Sung-Ho Lee 1, Ryun Kyung Kim 2, Ho-Kyung Lim 1,3, Soo-Hwan Byun 4, Young-Joon Lim 5, Soung-Min Kim 1,6, Jong-Ho Lee 1,6, * 1 Department of Oral and Maxillofacial Surgery, Clinical Trial Center, Seoul National University Dental Hospital, Seoul, 2 College of Information and Communication Engineering, Sungkyunkwan University, Suwon, 3 Department of Oral and Maxillofacial Surgery, Korea University Medical Center, Guro Hospital, Seoul, 4 Department of Oral and Maxillofacial Surgery, Dongtan Sacred Heart Hospital, Hallym University Medical Center, Hwaseong, 5 Department of Prosthodontics, Seoul National University Dental Hospital, 6 Dental Research Institute, School of Dentistry, Seoul National University, Seoul, Korea Purpose: Peri-implantitis is defined by an inflammation that occurs at the soft tissue and the alveolar bone around the site of an implant. The failure of implant placement or the loss of the supporting bone may occur due to peri-implantitis. From a pathological perspective, A. actinomycetemcomitans, Capnocytophaga sp., F. nucleatum, or other infectious agent is seen as the cause of the peri-implantitis. To remove the cause of the disease, many non-invasive methods are being studied. In this study, we demonstrated decontamination of the implant surface and its surroundings through experiments using diode laser products in existing products and diode laser experiments that studied the effect on the decreasing peri-implants. Materials and Methods: 12-week-old male Sprague-Dawley rats weighing 300 g were purchased. The size of 1.2 * 4 mm hole was drilled into the hard plate of the maxillary bone to insert titanium screw implant. Test groups were divided into control, titanium screw implant group, peri-implantitis group, and laser-treated peri-implantitis group. Infection levels around the site of implants were checked with SEM. The degree of microbial reproduction was checked through real-time PCR (qpcr) for each group. Results: The use of 808 nm Diode laser (0.5 w, 15 seconds in continuous mode) to treat the inflammation caused by peri-implantitis in the soft tissue and the alveolar bone resulted in an effective reduction in the number of bacteria without the surface denaturation of the implant due to the laser. In comparison to the existing products, such as Picaso Diode laser (810 nm) and Bison Diode laser (808 nm), both products have shown effectiveness in eliminating bacteria. In particular, 808 nm Diode laser showed equal effectiveness to the 810 nm Diode laser at a lower temperature. Conclusion: Peri-implantitis was treated in the inflammation region of soft tissue and alveolar bone using the 808 nm and 810 nm Diode laser in continuous mode at 0.5 w for 15 seconds. As a result, laser-induced excessive heat generation or denaturation on the implant surfaces did not occur and the number of bacteriadecreased. (JOURNAL OF DENTAL IMPLANT RESEARCH 2016;35(1):1-8) Key Words: 808 nm, 810 nm, Diode laser, Peri-implantitis, SD rat, Bacteria Received Apr 23, 2016, Revised May 15, 2016, Accepted May 20, 2016. cc This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creative commons.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. 교신저자 : 이종호, 03080, 서울시종로구대학로 101, 서울대학교병원구강악안면외과 Correspondence to: Jong-Ho Lee, Department of Oral and Maxillofacial Surgery, Seoul National University Dental Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Tel: +82-2-2072-2630, Fax: +82-2-766-4948, E-mail: leejongh@snu.ac.kr This study was supported by a grant of Ministry for Trade, Industry, and Energy, Republic of Korea (10047615). The first two authors (Wei-Fung Jin, Sung-Ho Lee) contributed equally for this study. JOURNAL OF DENTAL IMPLANT RESEARCH www.kaidimplant.or.kr

2 김위붕등 : 백서임플란트주위염모델에서 808 nm 와 810 nm 파장의 Diode Laser 를이용한박테리아제거효과 서론 치과에서임플란트를이용한보철치료가보급됨에따라임플란트주위질환의발생빈도가높아지게되어 1), 이에대한적절하고효과적인치료방법이계속적으로연구되고있다. 현재의치료방법으로는비외과적치료방법 6) 과외과적치료방법 7) 으로구분되며, 비외과적치료법으로항생제, 소파술 (curettage), 초음파세정술 (ultrasonic scaling), 레이저 (laser) 등이이용되고있다 2,8). 그러나비외과적인다양한치료법의다양한시도에도불구하고임플란트주위염에대해적용이편리하고명확한결과를보이는치료법은아직없는실정이다 3). Diode Laser 치료방법은치주염치료에서많이이용되었으며, 임상적데이터와치료결과에긍정적영향을가지고있다 9). 그러나 Diode laser를임플란트주위염에적용하여치료효과를살펴본실험데이터는미미한상태이며, titanium 금속에 Diode laser를조사하였을때열발생이나표면변화그리고세균조절의정도등에대한연구는미흡하다. 본연구는 in vitro, in vivo 연구를통하여임플란트주위염에새로개발된 Diode laser (808 nm) 를이용하여치료가얼마만큼효과적이고안전한지를평가하고자하였으며, 기존출시된 Picasso Diode laser (810 nm) 와같이비교효능조사를시행하였다. 대상및방법 1. Diode laser 시스템연속발진 (continuous wave) 동작과펄스파 (pulse wave) 동작의레이저출력이모두가능한 808 nm 파장의다이오드레이저를사용하였다 (Bison Medical Co., Seoul, Korea). 펄스파동작의 레이저를치료에이용할경우에는펄스폭 (pulse width) 과펄스반복율 (pulse repetition ratio) 을원하는사양대로조정할수있으며, 이에따라출력되는레이저의출력파워는달라진다. 레이저시스템은연속발진 (continuous wave) 동작과펄스파 (pulse wave) 동작의레이저출력이모두가능한 808 nm 파장의다이오드레이저를사용하였다 (Bison Medical Co., Seoul, Korea).(Fig. 1) 레이저의출력은 200 m의코어를가지는광섬유를이용하여치료를위한핸드피스 (hand-piece) 로구성되었으며, 펄스파동작의레이저를치료에이용할경우에는펄스폭 (pulse width) 과펄스반복율 (pulse repetition ratio) 을원하는사양대로조정하였다. 장비의출력파워는기존상품으로출시되어있는 810 nm의 diode laser인 Picasso Lite 장비 (Dentsply international, Sarasota, FL, USA) 와비교하여특성을알아보았다. 레이저의출력파워는 laser powermeter (Gentec-EO Inc, Quebec, Canada) 를이용하여레이저핸드피스끝부분의출력파워를측정하였으며약 5 mm 거리에서측정하였다. 2. 임플란트준비및임플란트조사시표면의변화임플란트는두가지형태를준비하였다. 기존의상품으로나와있는임플란트 (3.8 8.0 mm, Dentium Co, Suwon, Korea) 와백서에식립할수있는 1.2 4 mm SLA-coated Titanium Screw 를주문준비하였다. Diode laser를조사했을때 SLA-coated Titanium screw (SLA-TS) 의표면에미치는영향을알아보기위해 SLA-TS에 808 nm (Bison), 810 nm (Picaso) 의 Diode laser를조사하고표면의물리적변화를주사현미경 (SEM) 으로관찰하였다 10). 아무런처리를하지않은 SLA-TS와조사강도 1.5, 2.0, 2.5 watt, Pulse mode로 15초간 diode laser를조사한 SLA-TS 를주사현미경 ( 배율 100배와 50000배 ) 으로관찰하였다 11,12). Fig. 1. Bison Medical 에서개발한 808 nm Diode Laser 장비. 3. In vitro 열발생측정소뼈에 6.0 mm 깊이, 3.5 mm 직경이되도록 drilling을하고 3.8 8.0 mm SLA-TS를식립하되상부 2 mm는소뼈에서노출되도록하였다. SLA-TS를식립하고, 주위에온도측정센서를장착할홀을 0.5 mm 직경깊이 1 mm로레이저조사점의 medial, distal, superior, inferior에총 4개뚫었다. 각 SLA-TS에온도측정장비 (Omron, ZR-RX40, JAPAN) 의센서를삽입하여온도를측정하였다 ( 열전식온도기록계에실시간그래프로표시온도범위는최저 20 o C에서최고 60 o C로설정 ).(Fig. 2) 치경부 2 mm는임플란트주위염으로간주하고 810 m Picasso Diode laser와 808 nm Bison Diode laser를 0.5, 1.0, 1.5, 2.0, 2.5 W로 non-initiated tip으로 Continuous mode와 Pulse mode로식립된임플란트표면에 surround 방식으로각각 15초간조사하고조사할때각센서의열발생수치를기록하여비교분석을진행하였다. Journal of Dental Implant Research 2016, 35(1) 1-8

Jin WF, et al: Bacteria removal in a SD rat peri-implantitis model using diode laser of 808 nm and 810 nm 3 Fig. 2. In vitro 열발생측정. (A) 소뼈에 SLA-TS 식립모식도와레이저조사위치에대한 schematic graph. 오른쪽부터시계방향으로 Mesial, Distal, Buccal, Lingual 로가정하여 mesial 부위에 Diode laser 를조사한다 (B) 소뼈에 SLA-TS 를식립한뒤온도측정센서를장치한모습. Fig. 3. Peri-implantitis-induced in rat. (A) Peri-implantitis 유발에적합한재료를위해 wire 와 floss silk 를사용함 (n=3, P<0.0001). (B) 아무런처치를하지않은 SLA-TS (C) SLA-TS 에플로스실크를감은모습 (D) 백서경구개에 (B), (C) 를식립한모습 (E) 경구개에식립한 SLA-TS 에서임플란트주위염이유발된모습 (F) 식립된 SLA-TS 를추출한모습. (G) 임플란트주위염유발기간에대한 schematic graph. 4. 백서임플란트주위염형성 Sprague-Dawley 종 (300 350 g) 수컷백서를구입 (Orient Bio, Gapyeong, Korea) 하여일정한온도 (21 o C±1 o C), 습도 (55%), 12시간간격의명암주기 ( 명 : 07:30 20:00, 암 : 20:00 07:30) 를유지하는 SPF (Specific-Pathogen-Free) 실험동물실에서동물을사육하였다. 일반사료 (Purina Rodent Chow, Purina Co,. Seoul, Republic of Korea) 와정수된물을자유급식하였으며, 1주일간검역기간을가졌다. 적응기간을거친백서의복강에 pentobarbital (Hanlim Pharm. Co., LTD, Gyeonggi, Korea) 과 chloral hydrate (Sigma-Aldrich. Co., ON, Canada) 혼합액 3 ml (100 mg/kg) 을주사하여신속히깊게마취시킨후의좌우상악골구개부에 1.2 4 mm짜리 SLA-TS 를좌우각각식립하였다 4). 좌측 SLA-TS에면소재의플로스실크 (floss silk) 또는 26 G 강선을 SLA-TS head에결찰하여플라크를형성하여임플란트주위염형성을시도하였다. 정상타액, SLA-TS만심은곳, 강선또는 Journal of Dental Implant Research 2016, 35(1) 1-8

4 김위붕등 : 백서임플란트주위염모델에서 808 nm 와 810 nm 파장의 Diode Laser 를이용한박테리아제거효과 플로스실크를결찰한 SLA-TS 주위열구액 (Gingival crevicular fluid, GCF) 을근관치료용페이퍼포인트 (Absorbent Paper Point, META BIOMED CO., Itd. Cheongju, Korea) 를이용하여채취한뒤, 중합효소연쇄반응 (CytoGen CO., Ltd, Seoul, Korea) 을실시하여 5) 2, 4, 7, 10, 14일간관찰하였고, 프로스실크가 4일이면효과적으로임플란트주위염을일으키는것으로파악하였다.(Fig. 3) 5. 백서임플란트주위염모델에서 Diode laser 치료효과백서에식립한 titanium screw 주위를 Diode laser 0.5 w, 15초간 continuous mode로조사후 SLA-TS 주위열구액 (Gingival crevicular fluid, GCF) 을근관치료용페이퍼포인트 (Absorbent Paper Point, META BIOMED CO., Itd. Cheongju, Korea) 를이용하여채취한뒤 13), 중합효소연쇄반응 (CytoGen CO., Ltd, Seoul, Korea) 을실시하였다 14). 그리고백서에식립한 SLA-TS를제거하여 4% PFA용액에 24시간보관한뒤주사현미경으로 screw head의박테리아를관찰하고균수계측을실시하였다 5). 결과 1. Diode laser의출력특성본연구를위하여준비된 Diode laser 장비의출력파워를측정 Fig. 4. Diode Laser 의출력파워측정. (A) Bison Diode laser: 808 nm, 7 W (max.). (B) Picasso Lite Diode laser: 810 nm, 2.5 W (max.) Bison Diode laser 는최대출력 7 W 의장비세팅에서 6.34 W 의출력파워를보이며 90% 이상의효율을보였으나, Picasso Lite diode laser 는최대출력 2.5 W 에서 1.98 W 로서 80% 정도의효율을보였다. Fig. 5. 주사현미경으로관찰한 SLA surface Titanium screw. (A) Diode laser 는 15 초간 1.5, 2.0, 2.5 watt 로조사하였으며, 흰색화살표위치에조사하였다. SEM 을이용하여 100 배율과 5000 배율로대조군과관찰한결과 diode laser 에의한표면변화는관찰되지않았다. (B) SLA-TS 에 Picasso Diode laser 와 Bison Diode laser 를조사한결과 SLA-TS 의표면변화는관찰되지않았다. Journal of Dental Implant Research 2016, 35(1) 1-8

Jin WF, et al: Bacteria removal in a SD rat peri-implantitis model using diode laser of 808 nm and 810 nm 5 하여임플란트주위염에이용할때실제조사되는레이저파워와레이저시스템의효율성을알아보았다. 레이저는 continuous mode 동작에서측정하였는데 Fig. 4A는새로개발된 808 nm 다이오드레이저의출력파워이며 Fig. 4B는기존의 Picasso Lite의다이오드레이저의출력파워이다. Bison Diode laser는최대 7 W 출력파워를 setting하였을때 6.34 W의출력파워를나타냄으로써 90.6% 의효율을가졌다. 그리고 Picasso Diode laser의최대출력인 2.5 W 파워에서는 2.35 W 출력파워로써 94% 의높은효율을보였으며, 1.5 W 파워에서 93% 이상출력효율의 1.4 W의출력파워를가졌다. 이는다이오드레이저와광섬유의 coupling 효율이높고레이저빛의손실 (loss) 이크지않음을보여주었다. 그러나 Picasso Diode laser는최대 2.5 W 출력파워에서 1.98 W 레이저출력으로서약 80% 정도의효율을보였다. 2. 임플란트표면의변화 Diode laser를조사했을때 SLA-coated Titanium screw의표면에어떠한영향을미치는지알아보기위해 808 nm Diode laser를 15초간 1.5, 2.0, 2.5 watt 세기로조사한뒤 SEM으로관찰한결과, 대조군과실험군사이에뚜렷한변화는관찰되지않았다. (Fig. 5A) Picasso와 Bison Diode laser 간의 SLA-TS 표면변화에대해확인해보고자 15초간 1.5 watt의세기로조사한결과두그룹모두 SLA-TS 표면에변화를관찰할수없었다.(Fig. 5B) 3. In vitro 열발생측정 Diode laser가 SLA-TS에조사되었을때구강내에미치는온도의영향을확인해보기위하여소뼈에 SLA-TS를식립한다음 mesial에서 Diode laser를조사하여온도변화를관찰하였다.(fig. 6) Picasso와 Bison Diode laser를이용하여 Continuous mode로 0.5, 1.0 watt로 15초간 mesial에조사한뒤온도변화를측정한결과 Picaso Diode laser는조사시 25.3 o C에서시작하여 15초간 29 o C까지상승하여평균 3.7 o C 상승하였으며, Bison Diode laser는조사시점에 22.7 o C에서시작하여 25.8 o C로상승하여평균 3.1 o C 상승하여두장비간에온도상승폭은 3.1 o C 3.7 o C 이며, Bison Diode laser가 Picaso Diode laser 보다낮은온도를유지하는것으로측정되었다.(Fig. 6A, B) 각각의장비를이용하여 Pulse mode에서 0.5, 1.0 watt 세기로 15초간 mesial에조사한결과, Picaso Diode laser는 25.2 o C에서 27.5 o C로약 2.3 o C 상승하였으며 Bison Diode laser는 22.8 o C에서 24.5 o C로약 2.3 o C 상승하여온도상승의폭은비슷하지만 (+2.3 o C), 808 nm Bison Diode laser가 810 nm Picasso Diode laser 보다낮은온도를유지하는것으로측정되었다.(Fig. 6C, D) 4. 백서임플란트주위염모델에서 Diode laser 치료효과 4일과 7일간에식립한 SLA-TS그룹과임플란트주위염유발후 Fig. 6. 소뼈에서열발생측정. (A) 소뼈에 SLA-TS 를식립한뒤오른쪽부터시계방향으로 Mesial, Distal, Buccal, Lingual 로가정하여 mesial 부위에 Diode laser 를조사한다. (B) (A) 에서의 schematic 과동일하게소뼈에 SLA-TS 를식립한뒤온도측정센서를부착한모습. (C, D) Picaso Laser 와 Bison Laser 각각 Continuous mode, 0.5 watt 와 1.0 watt 로 mesial 부위에 15 초간조사한온도편차 (P<0.001). (E, F) (C), (D) 와동일한조건에서 Pulse mode 로조사한온도편차 (P<0.001). Journal of Dental Implant Research 2016, 35(1) 1-8

6 김위붕등 : 백서임플란트주위염모델에서 808 nm 와 810 nm 파장의 Diode Laser 를이용한박테리아제거효과 Fig. 7. 임플란트주위염유발기간. (A) 임플란트주위염유발기간에대한 schematic graph. (B, C) SLA-TS 를백서경구개에식립한뒤, 4 일과 7 일째에 Diode laser 의조사전ㆍ후를비교함 (n=6, P<0.001). Fig. 8. 박테리아중합효소연쇄반응. (A) Fig. 3 (A) 의결과에따라 floss silk를이용하여 peri-implantitis를유발시킨뒤 Diode Laser를조사하여박테리아중합효소연쇄반응을통계로나타낸그래프 (n=6, Unit=1*10 6 *Normal vs All group (P<0.001), **Screw vs Peri, Laser-B and Laser-A (P<0.001), ***Peri- vs Laser-B and Laser-A (P<0.001), # Lasre-B vs Laser-A (P<0.001)). (B) (C) 의결과를바탕으로 Piscaso와 Bison laser간의박테리아제거효과를확인하여 q-pcr을시행한그래프 (n=6, Unit=1*10 7, *Picasso-B vs Bison-A (P<0.001), **Picasso-A vs Bison-A (P<0.001), ***Bison-B vs Bison-A (P<0.001)). Diode laser 처치를한그룹간에박테리아를검출하여 q-pcr을관찰한결과, 4일째에서 Diode laser 처치에의한박테리아감소를확인하였다.(Fig. 8A, B) 5. 박테리아중합효소연쇄반응 SLA-TS에 floss silk를감아임플란트주위염을일으킨다음 diode laser처치효과를파악하기위하여 Normal, SLA-TS 식립군, 임플란트유발군, 레이저처치전후를비교한결과임플란트유발후레이저처치한군에서박테리아가낮게나타나는것을관찰하였다.(Fig. 8A) Picasso Diode laser와 Bison Diode laser간에비교실험을한결과 Bison Diode laser를이용하여임플란트유발후레이저처치한군에서박테리아가낮게나타나는것을관찰하였다.(fig. 8B) 백서경구개에식립한 SLA-TS 를 SEM으로관찰한결과박테리아가유발되는것을관찰하였고,(Fig. 9B, F) 임플란트주위염유 발군의 SLA-TS를관찰한결과 SLA-TS 식립군에비해박테리아가증가하는것을관찰하였다.(Fig. 9C, G) 임플란트주위염유발후 Picasso Diode laser와 Bison Diode laser를 0.5 w, 30 s간조사한결과박테리아가줄어드는것을관찰하였다.(fig. 9D, H) 각각의그룹에서발생된박테리아균수를계측한결과 810 nm Picasso Diode laser와 808 nm Bison Diode laser를이용하여레이저처치한군에서박테리아가효과적으로줄어드는것을관찰할수있었다.(fig. 9I) 고찰 Diode laser 치료가임플란트표면에미치는영향에대해알아보고자 1.5, 2.0, 2.5 watt로임플란트표면에직접조사한뒤 SEM 으로관찰한결과 808, 810 nm 두파장모두표면변화를일으키지않는것으로나타났다. 또한 SLA-TS가백서에식립된상태에서레 Journal of Dental Implant Research 2016, 35(1) 1-8

Jin WF, et al: Bacteria removal in a SD rat peri-implantitis model using diode laser of 808 nm and 810 nm 7 Fig. 9. 박테리아균수계측. (A, E) Control, (B, F) SLA-TS, (C, G) Peri-implantitis, (D, H) Laser treat 그룹. 백서에식립한 SLA-TS head 를 SEM 으로관찰하였다. (I) SEM 으로관찰한 SLA-TS head 의박테리아균수를계측한결과 Diode Laser 를조사하였을때, 박테리아의수량이 SLA-TS 군과 Peri-implantitis 군에비해적어지는것을관찰하였다 (n=6, * vs Control (P<0.001), ** vs SLA-TS (P<0.001), *** vs Peri- implantitis (P< 0.001)). 이저조사를받을때 continuous mode에서는백서구강내온도 29 o C에서시작하여 15 s까지온도가증가하였는데, 0.5 watt는큰온도변화의폭이없는것으로나타났다. Pulse mode 모두 15 s 까지는온도가상승하지만 20 s 이후부터는안정적으로떨어지는것을관찰하였다.(Fig. 3) SLA-TS가뼈에식립된뒤 Diode laser 를조사하였을때, 뼈에미치는온도의영향을 mesial, distal, buccal, lingual 부위에서측정한결과 distal, buccal, lingual에서는온도변화영향을미치지않았으나, mesial에서는온도가상승하는것을관찰할수있었다. 백서경구개에 SLA-TS를식립했을때백서에서손실이발생되지않고유지되는기간으로측정된 4일과 7일간에 (Fig. 7) Diode laser를조사하여 q-pcr을통해박테리아의감소효과를관찰하였다.(fig. 5) 임플란트주위염을유발시킬수있는다양한방법중에 SLA-TS에 wire와 floss silk를감아서이물질에의한오염및감염에대한유발을시도하였다. 중합효소연쇄반응으로관찰한결과아무런처치를하지않고식립한 SAL-TS 에비해 floss silk를감은실험군에서높은수의박테리아를관찰 할수있었다. 이를바탕으로임플란트주위염유발군은 SLA-TS에 floss silk를감아서진행했으며, Diode laser를이용하여후처치한결과 SLA-TS 식립군보다도낮은수의박테리아를관찰할수있었다. 또한 808, 810 nm Diode laser가동일한효과를얻는지확인해본결과임플란트주위염유발후레이저처치에서두장비모두박테리아의수가줄어드는것을확인하였으며, 808 nm Diode laserrk 보다더효율적으로줄어드는것을관찰하였다. 백서경구개에식립한각실험군의 SLA-TS 의머리부분을 SEM으로관찰한결과일반적인식립군의경우박테리아가관찰되었으며, 임플란트주위염을유발한그룹에서는일반적인식립군에비해더많은수의박테리아가관찰되었다. 반면임플란트주위염유발후레이저처치를한그룹에서는적은수의박테리아가관찰되었다. 이를균수계측해본결과임플란트주위염유발군에서일반식립군에비해많은수의박테리아가관찰되었으며, Diode laser를처치한뒤에는박테리아의수가현저히줄어드는것을관찰하였다. 이연구를통해서 Diode laser 장비가임플란트주위염에서발 Journal of Dental Implant Research 2016, 35(1) 1-8

8 김위붕등 : 백서임플란트주위염모델에서 808 nm 와 810 nm 파장의 Diode Laser 를이용한박테리아제거효과 생되는박테리아제거에효과적인것을알수있었다. 그동안임플란 트주위염치료에사용되는 Diode laser 의파장대는 810 nm 파장 을이용해오고있었다 15). 그러나이번실험에서적용한 808 nm Diode laser 는 7 W 출력의 200 m 의광섬유로레이저빛을출력 시켜기존에임플란트주위염치료에효율을보였던 Picasso Diode laser 와비교했을때, 식립된임플란트에조사되는 mesial 부위에서보다낮은온도를유지하면서도박테리아제거에는동일또는그이상의효율성을보이는것으로관찰되었다. 이것으로보아백서에서유발시킨임플란트주위염에 808 nm Bison Diode laser가 810 nm Picasso Diode laser와최소한동일한효과를보일것으로사료되었다. 결 론 임플란트주위염에서 808 nm, 810 nm 파장의 Diode laser를이용하여연조직과치조골의염증부위를치료한결과 (0.5 w, 15초간 continuous mode), 레이저에의한과도한열발생이나임플란트표면변성은발생되지않았고, 효과적으로세균수를감소시키는것을확인하였다. 이상의결과로 Diode laser가임플란트주위염치료가효과적이고안전하게될수있을것으로판단되었다. REFERENCES 1. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. Journal of clinical periodontology 2008;358 Suppl):286-91. 2. Mailoa J, Lin GH, Chan HL, MacEachern M, Wang HL. Clinical outcomes of using lasers for peri-implantitis surface detoxification: a systematic review and meta-analysis. Journal of periodontology 2014;85(9):1194-202. 3. Park SH, Lee JK. Nonsurgical interventions for treating peri-implantitis and prognosis. Journal of Korean dental association 2014;52(7):396-401. 4. Abtahi J, Agholme F, Sandberg O, Aspenberg P. Effect of local vs. systemic bisphosphonate delivery on dental implant fixation in a model of osteonecrosis of the jaw. Journal of dental research 2013;92(3):279-83. 5. Takasaki AA, Aoki A, Mizutani K, Kikuchi S, Oda S, Ishikawa I. Er:YAG laser therapy for peri-implant infection: a histological study. Lasers in medical science 2007;22(3):143-57. 6. Schwanrz F, Sculean A, Rothamel D, Schwenzer K, Georg T, Becker J. Clinical evaluation of an Er:YAG laser for nonsurgical treatment of peri-implantitis: a pilot study. Clinical oral implants research 2005;16(1):44-52. 7. Azzeh MM. Er,Cr:YSGG laser-assisted surgical treatment of peri-implantits with 1-year reentry and 18-month follow-up. Journal of periodontology 2008;79(10):2000-5. 8. Figuero E, Graziani F, Sanz I, Herrera D, Sanz M. Management of peri-implant mucositis and peri-implantitis. Periodontology 2000 2014;66(1);255-73. 9. Slot DE, Jorritsma KH, Cobb CM, Van der Weijden FA. The effect of the thermal diode laser (wavelength 808-980nm) in non-surgical periodontal therapy: a systematic review and meta-analysis. Journal of clinical periodontology 2014; 41(7):681-92. 10. Castro GL, Gallas M, Nunez IR, Borrajo JL, Alvarez JC, Varela LG. Scanning electron microscopic analysis of diode laser-treated titanium implant surfaces. Photomedicine and laser surgery 2007;25(2):124-8. 11. Yamamoto A, Tanabe T. Treatment of peri-implantitis around TiUnite-surface implnatis using Er:YAG laser microexplosions. The International journal of periodontics & restorative dentistry 2013;33(1):21-30. 12. Freire MO, Sedghizadeh PP, Schaudinn C, Corur A, Downey JS, Choi JH, Chen W, Kook JK, Chen C, Goodman SD, Zadeh HH. Development of an animal model for Aggregatibacter actinomycetemcomitans biofilm-mediated oral osteolytic infection: a preliminary study. Journal of periodontology 2011;82(5): 778-89. 13. Ebadian AR, Kadkhodazadeh M, Zarnegarnia P, Dahlen G. Bacterial analysis of peri-implantitis and chronic periodontitis in Iranian subjects. Acta medica Iranica 2012;50(7):486-92. 14. Guo M, Wang Z, Fan X, Bian Y, Wang T, Zhu L, Lan J. Kgp, rgpa, and rgpb DNA vaccines induce antibody responses in experimental peri-implantitis. Journal of periodontology 2014; 85(11):1575-81. 15. Roncati M, Lucchese A, Carinici F. Non-surgical treatment of peri-implantitis with the adjunctive use of an 810-nm diode laser. Journal of Indian Society of periodontology 2013;17(6): 812-5. Journal of Dental Implant Research 2016, 35(1) 1-8

Vol. 35 No. 1, June 2016 Journal of Dental Implant Research 2016, 35(1) 9-16 구치부발치후즉시식립임플란트의변연골흡수에대한임상적분석 최기관, 팽준영 경북대학교치의학전문대학원구강악안면외과 A clinical study on implantation of the marginal bone loss after the posterior immediate implants Ki-Kwan Choi, Jun-Young Paeng Department of Oral and Maxillofacial Surgery, Kyungpook National University School of Dentistry, Daegu, Korea Purpose: The objective of this study was to evaluate the clinical results of marginal bone loss of the maxillary and manbibular posterial immediate implants and analyse the possible influence of different conditions. Materials and Methods: A total of 89 patients (67 men and 21 women) received 107 short implants between 2013 and 2015. The potential influence of different variables (cause of extraction, implant diameter, length, location, surgical procedure, width of extraction socket, general disease, additional bone grafting procedure) were studied based on the medical records and oral radiographs. Results: Out of 107 immediate implants, none was lost after mean observation time of 12 months and the cumulative survival rate was 100%. Mean marginal bone loss was 0.09 mm on 3 month, 0.05 mm on 6 month and 0.03 mm on 24 months. Implant type and extraction cause and other factors had an impact on marginal bone loss (P<0.05). Conclusions: Immediate implants is considered as an effective and safe treatment option on most situations, even in atrophic jaws and with general disease. (JOURNAL OF DENTAL IMPLANT RESEARCH 2016;35(1):9-16) Key Words: Immediate implant, Marginal bone loss 서론 Branemark 1) 에의해시작된치과임플란트는오늘날상실된치아를수복하는방법으로서가장많이선택되는시술이되었다. 또한현재까지도임플란트는다양한방법으로발전해오고있다. 다양한재료들이개발되었고, 다양한시술방법들이시도되어많은성공적인개념들이소개되고있다. 초기부터통상적으로사용되어온임플란트식립방법은식립시기를기준으로보았을때발치와의치유가완료되고연조직의재생이이루어진다음시행하는것으로여겨져왔었다. Branemark 등 2) 은발치한부위의임플란트식립을위해서는최소 8개월에서 12개월 의치유기간을주어야한다고하였다. 그러나최근에는발치후즉시식립하는임플란트에대한결과가기존의방법에비해나쁘지않고여러가지장점들을가진다는것이보고되면서 3-5), 많은임상가들에의해서시도되고있는실정이다. 무엇보다발치후즉시식립하는임플란트는발치후발치와의치유과정에서일어나는원치않는골흡수를줄여줄수있다는점과기존조직및인접해있는치아들과의관계에서바람직한위치에임플란트를식립할수있다는점, 또한치아상실에서부터임플란트식립, 그리고보철물제작까지걸리는시간을줄여줄수있다는점을장점으로들수있다. 임플란트전단계에있어서의시간을단축시키면서도기존의방식과큰차이가없다고인정되는발치후즉시식립방법은임상가들과환자양쪽을 Received May 2, 2016, Revised May 13, 2016, Accepted May 23, 2016. cc This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creative commons.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. 교신저자 : 팽준영, 41940, 대구시중구달구벌대로 2175, 경북대학교치과병원구강악안면외과 Correspondence to: Jun-Young Paeng, Department of Oral and Maxillofacial Surgery, Kyungpook National University School of Dentistry, 2175, Dalgubeoldae-ro, Jung-gu, Daegu 41940, Korea. Tel: +82-53-600-7561, Fax: +82-53-426-5365, E-mail: jypaeng@knu.ac.kr JOURNAL OF DENTAL IMPLANT RESEARCH www.kaidimplant.or.kr

10 최기관, 팽준영 : 구치부발치후즉시식립임플란트의변연골흡수에대한임상적분석 만족시켜줄수있는시술이라고생각된다. 본연구는발치후즉시식립임플란트에서, 임플란트가성공적으로식립되고보철과정까지완료된뒤 3개월이상의기간이지난뒤의변연골의위치를측정분석함으로써, 환자의연령과전신질환의유무, 발치의원인에따른차이점이나, 발치당시의발치창의크기, 임플란트매식체와지대주의조건, 그리고식립위치및골이식유무등의다양한환경적요소가변연골에어떤영향을주었는지를후향적으로연구하고자하였다. 연구대상및방법 1. 연구대상 2013년부터 2015년사이에임플란트시술을받은환자중발치후즉시임플란트를식립한경우를대상으로하였다. 남자는 58명, 여자는 21명이며연령층은다양하게나타났다. 식립후보철물을올린직후의방사선사진과보철물제작후 3개월에서 1년이상경과되고방사선사진이확보된환자들만을대상으로 107개의임플란트를조사하였다. 2. 연구방법환자들의진료기록부를토대로성별, 나이, 발치당시의전신적인병력및투약여부, 발치의직접적인원인, 식립된임플란트의직경과길이, 식립부위, 골이식유무등을조사하였다. 1) 임플란트의종류모든환자들에있어서동일한종류의임플란트로 Osstem사의 CA System (Osstem, Seoul, Korea) 을식립하였다. 임플란트의직경은제일작은것이 3.5 mm이었고, 가장큰경우는 5.0 mm이었다. 임플란트의길이는다양하게식립하였다. 하치조신경관과의거리를충분히확보하기힘든하악제 2대구치부위에서는짧은임플란트로 7 mm까지식립하였다. 또한잔존골의양이충분한경우에도지나치게긴임플란트는지양하고 13 mm까지만식립하였다. 2) 수술방법수술방법은통상적인 1차, 2차수술과정을거치는 2회법으로시행하였다 ( 또한상악구치부의경우상악동까지의잔존골의길이에 Fig. 1. Radiograph before extraction. Fig. 3. Radiograph after implantation. (A) (B) (C) Fig. 2. (A) Extraction of tooth. (B) Curretage of granulation tissue. (C) Implantation of fixture and suture. Journal of Dental Implant Research 2016, 35(1) 9-16

Choi KK, Paeng JY: A clinical study on implantation of the marginal bone loss after the posterior immediate implants 11 따라서치조정접근상악동거상술, Lateral approach 상악동수술등으로구분해서시행하였다.). 1회법은시술부위에치과용리도케인을사용, 국소마취를시행하고구강내외및수술부위를베타딘을사용, 깨끗이소독하고소공포로수술부위를격리한후, 발치를조심스럽게시행한다음치조골내의육아조직을철저히소파술로제거하고더불어주변의염증조직도제거한이후크로로헥시딘으로소독을시행하였다. 그후, Osstem Sugical Kit를사용하여사전에계획한위치와깊이에드릴링 (800 1000 rpm) 을한다음 Osstem사의 CA-System Implant (Osstem, Seoul, Korea) 를식립한후 (10 rpm/35 N), Healing abutment를바로연결하였다. 이후에는 2차수술을필요로하지않았고, 정기적인관찰후 ISQ를측정하여, 일정이상의골결합 ( ISQ 70) 을얻었다고확인되었을때상부구조물로 Transfer Abutment를연결하여보철물을제작하였다 (Torque=30 N). 2회법은 1회법과같은방식으로발치한후, 임플란트를식립하고그다음 Healing abutment를즉시연결하는대신임플란트지대주 (Fixture) 에 Cover screw를연결하여연조직으로덮어두고, 후일에 2차수술을시행하여 Healing abutment를연결하였다. 상악동거상술을시행하여식립하거나, 골결손부위가커서대량의골이 식을시행한경우 ( 차폐막을사용 ) 에주로시행하였다. 골이식을시행한경우에골이식재로는오스템사의이종골 A-Oss (Osstem Implant Co., Busan, Korea) 를주로사용하였고, 환자의혈액을채취, 원심분리한 PRP를보조적으로사용하였다. 차폐막은골결손부의크기나연조직의상태를고려해서사용하였다. 3) 분석을위한분류들식립부위 ( 식립부위는파노라마상에서판독을정확하게하기힘든전치부를제외한소구치부, 대구치부를대상으로하였다 ), 성별및나이분포, 발치원인, 전신질환유무, 임플란트의직경과길이, 발치창넓이, 골이식여부및차폐막사용여부에따라서분류하고각각의결과들을분석하였다. 3. 측정방법 1) 변연골흡수량 (marginal bone loss, MBL) 분석임플란트보철의기능부하 (functional loading) 를가하기전과그이후의기간별 (3개월, 6개월, 1년이상 ) 로방사선사진을비교해서사진상에서임플란트의 Platform 기준으로골흡수량을측정하였다. (A) (B) Fig. 4. (A) Bone substitute used in the study. (B) PRP with bone. (A) (B) Fig. 5. (A) 1 year after loading. (B) Radiograph 1 year after loading. Journal of Dental Implant Research 2016, 35(1) 9-16

12 최기관, 팽준영 : 구치부발치후즉시식립임플란트의변연골흡수에대한임상적분석 MBL=OBL RBL MBL: marginal bone loss OBL: original bone level ( 보철물제작시의 bone level) RBL: resorbed bone level ( 평가시의 bone level) 임플란트중실패는없었으며누적생존율은 100% 이었다 (Table 1). 연구에포함된 107개의임플란트를대상으로시행한기능부하전과기간별방사선사진을비교판독한결과로써전체임플란트의변연골흡수량은 3개월관찰경우에서 0.09 mm, 6개월에서 0.05 mm, 1년에서 0.03 mm이었다. 4. 통계방법통계적분석방법은공개소프트웨어인 R (version 3.2.4, The R Foundation for Statistical Computing, Vienna, Austria) 을사용하였다. 각군의데이터는 Shapiro-Wilk test를사용하여정규성검정을시행하였으며, 정규분포를따르지않아, Kruskal-Wallis test를이용하여비교분석하였다. 유의한차이가있는경우다중비교 (multiple comparison) 를통하여사후검정분석 (post hoc test) 을시행하였다. 결과 2013년 1월부터 2015년 12월까지의기간동안치료받은임플란트환자중에서선별해연구대상에포함된임플란트는 107개였다. 평균관찰기간은보철물을제작한후약 12개월정도이었다. 식립된 1. 환자의연령에따른변연골흡수량의변화총 107개의발치후즉시식립임플란트를대상으로보철물제작후의기간별변연골의흡수량 (MBL; maginal bone loss) 을분석해보았다. 30대가 1개의임플란트, 40대가 29개, 50대가 66개로가장많았고, 60대 7개, 70대 4개이었다. 이각각의임플란트들의 MBL은연령의차이에있어서는별차이가없었고통계적유의성은보이지않았다 (Table 1). 2. 임플란트의직경및길이에따른변연골흡수량의차이임플란트의직경에따른분포를보면 4.5 mm가전체 41% 로가장많았고, 그다음으로 4.0 mm가 27%, 5.0 mm가 25%, 3.5 mm가 6% 이었다. 임플란트의직경에따른기간별변연골의흡수량은 3개월까지가많이나타났고, 6개월이후부터는감소하는추세를보였다. 각기간 Table 1. MBL according to the type of implants Age Number of implants (n) Failed (n) MBL average 3 M 6 M 1 Y 30 39 1 0 0.06±0.000 0.050±0.000 0.020±0.000 40 49 29 0 0.107±0.047 0.063±0.023 0.037±0.019 50 59 66 0 0.099±0.047 0.053±0.025 0.032±0.016 60 69 7 0 0.124±0.122 0.054±0.016 0.031±0.018 70 4 0 0.063±0.005 0.035±0.006 0.018±0013 MBL: marginal bone loss. Kruskal-Wallis: P>0.05. Table 2. MBL according to diameters and lengths of included implants Number of implants (n) 3 M* 6 M* 1 Y* Diameter 3.5 7 0.091±0.020 0.056±0.017 0.033±0.018 4.0 29 0.087±0.043 0.052±0.023 0.027±0.016 4.5 44 0.108±0.066 0.055±0.027 0.034±0.017 5.0 27 0.108±0.045 0.058±0.022 0.034±0.017 Length 7.0 3 0.170±0.085 0.093±0.049 0.057±0.025 8.5 12 0.114±0.057 0.061±0.031 0.033±0.021 10.0 39 0.094±0.033 0.051±0.017 0.030±0.014 11.5 48 0.103±0.064 0.055±0.025 0.033±0.017 13.0 5 0.074±0.023 0.046±0.013 0.024±0.005 *Krusakal-Wallis test P>0.05. Journal of Dental Implant Research 2016, 35(1) 9-16

Choi KK, Paeng JY: A clinical study on implantation of the marginal bone loss after the posterior immediate implants 13 별로직경에따른구분에서약간씩의흡수량의차이는보였지만유의한차이를나타내지는않았다 (P>0.05) (Table 2). 임플란트의길이에따른분포는 11.5 mm가전체 44% 로가장많고, 10 mm가 36%, 8.5 mm가 11%, 13 mm가 6%, 7.0 mm가 3% 로나타났다. 임플란트의길이에따른로딩후기간별변연골흡수량에서는유의한차이를나타내지는않았다 (P>0.05) (Table 2). 3. 식립부위에따른변연골흡수량의변화식립된임플란트는상악소구치 23개로 21.4%, 상악대구치는 23개로 21.5%, 하악소구치가 13개로 12.1%, 하악대구치는 37개로 34.6% 이었다. 식립부위에따른변연골흡수량의변화는유의한차이를나타내진않았다 (P>0.05) (Table 3). 4. 시술방법및골이식술에따른변연골흡수량의변화임플란트식립방법으로서 1회법으로시술한임플란트는총 98 개, 2회법은 9개이었으며 100% 생존률을보였다. 변연골흡수량의차이에서는유의한차이를나타내진않았다 (P>.05) (Table 4). 수술중골이식을시행한경우는 55개, 골이식없이시술한경우는 52개이었다. 이경우도각각의변연골흡수의변화는유의한차이를나타내진않았다 (P>0.05) (Table 4). 5. 환자의전신병력에따른변연골흡수량의변화발치후즉시식립임플란트의연구에포함된환자중에서전신병력을가진환자에서의임플란트의수는 DM (Diabetes mellitus) 이 10개, 고혈압이 4개, 그외의다른병력에해당되는것이 21개이 Table 3. MBL according to the location of included implants Location Number of implants (n) MBL 3 M 6 M 1 Y Mx. premolar 34 0.100±0.049 0.052±0.022 0.029±0.017 Mx. molar 23 0.085±0.029 0.063±0.025 0.040±0.016 Mn. premolar 13 0.116±0.048 0.051±0.019 0.032±0.011 Mn. molar 37 0.100±0.067 0.055±0.027 0.031±0.018 Mx.: maxilla, Mn.: mandible. Kruskal-Wallis: P>0.05. Table 4. MBL according to the surgical procedures and additional bone grafting technique Number of implants (n) MBL 3 M 6 M 1 Y Surgical procedures 1-stage 98 0.100±0.055 0.055±0.024 0.032±0.017 2-stage 9 0.112±0.041 0.059±0.024 0.034±0.017 Bone grafting Yes 55 0.104±0.049 0.057±0.026 0.033±0.018 No 52 0.099±0.059 0.053±0.022 0.031±0.016 Kruskal-Wallis: P>0.05. Table 5. MBL according to the general history of patients General history Number of implants (n) MBL 3 M 6 M 1 Y No history 72 0.105±0.058 0.058±0.026 0.034±0.018 DM 10 0.118±0.055 0.048±0.018 0.034±0.012 Hypertension 4 0.065±0.024 0.035±0.013 0.013±0.010 Others 21 0.087±0.034 0.051±0.018 0.030±0.012 DM: diabetes mellitus. Others: heart disease, myoma uteri, hyperthyroidism, hypothyroidism. Kruskal-Wallis: P>0.05. Journal of Dental Implant Research 2016, 35(1) 9-16

14 최기관, 팽준영 : 구치부발치후즉시식립임플란트의변연골흡수에대한임상적분석 Table 6. MBL according to the socket width Socket width Number of Implants (n) MBL 3 M 6 M 1 Y <5 mm 39 0.097±0.062 0.053±0.020 0.029±0.015 5 8 mm 26 0.091±0.036 0.049±0.018 0.030±0.014 8 mm 40 0.112±0.053 0.061±0.030 0.036±0.020 Kruskal-Wallis: P>0.05. Table 7. MBL according to the causes for extraction Extraction Number of Implants (n) MBL 3 M* 6 M 1 Y Caries 27 0.081±0.039 0.047±0.019 0.030±0.016 Fx 2 0.065±0.007 0.035±0.007 0.020±0.000 Perio 78 0.109±0.057 0.058±0.025 0.033±0.017 *Kruskal-Wallis P<0.05 (perio and caries showed statistically significant differences in post hoc test). 었고, 전신병력이없는경우가 72개였다. 고혈압을가진환자의경우에서 3개월에서의측정결과로흡수율이조금낮게나왔으나통계상의유의한차이를나타내진않았다 (P>0.05) (Table 5). 6. 발치창넓이에따른변연골흡수량의변화발치창의넓이는 5 mm 미만이 39개로 36%, 5 8 mm가 24%, 8 mm 이상이 37% 로나타났다. 발치창의크기에따른분류에서변연골의흡수량은유의한차이를나타내진않았다 (P>.05) (Table 6). 7. 발치원인에따른변연골흡수량의변화발치를하게된원인에따른분류에서는치아우식으로인한발치가 27개로 25%, 파절로인한발치가 2개로 2%, 치주질환으로인한발치가 78개로가장많았고 73% 로나타났다. 발치원인에따른분류에서변연골의흡수량은치주질환으로발치한경우에변연골의흡수가많은것으로나타났다 (P<0.05) (Table 7). 고찰 발치후즉시식립임플란트의양호한결과를위해서는수술전의정확한진단과치료계획이중요하며, 발치와염증소파술시행후발치창의골의양과질에대한이해와평가가반드시필요하다. 또한환자의전신적인병력이나, 발치후의골흡수양상을고려하여수술을시행해야한다. 발치후즉시식립임플란트에대한많은후향적추적연구가이루어져서발표되고있다 6-8). 본연구에서는발치후즉시식립임플란트의증례들에서보철을마무리한시점을기준으로 1년이상추적한 107개의임플란트들을대상으로임플란트의변연골에영향을미칠수있는요소들을분석 하였다. 발치후즉시식립임플란트는전체치료기간을줄여주는장점이있어서환자들에게많은호응을얻는술식으로서발치후일어날수있는연조직의상실을막을수있고, 발치와의자연치유과정을통해임플란트와골의유착을기대할수있으며, 치아식립시에이상적인위치에식립할수있는장점들도있다. 다만구치부의경우임플란트의직경에비해발치와의직경이큰경우가많기때문에임플란트상방연조직의일차적치유가쉽지않거나, 발치창의구조적특수성때문에초기고정력을얻기가어려울때가있다는점은단점으로지적되어왔다. 본연구에서는잔존치은의양이나치조골의결손의상태에따라서 1회법과 2회법수술을구분해서시행하였고, 하악에서하치조신경까지의잔존골의길이가부족한경우 7 mm의짧은임플란트를식립하기도하였다. 국내자료중에서 8.5 mm 이하의짧은임플란트를식립한경우에도생존율이나변연골흡수량의변화가긴임플란트와비교해서나쁘지않은결과로보고되고있다 9). 최근에는임상적인결과들과더불어여러논문들을통해서도치주질환등으로인해잔존골이부족한경우에도골이식, 또는골유도재생술과더불어발치후즉시식립한임플란트에있어서결과가통상의방법과큰차이가나타나지않는다고보고되고있다 10). 본연구에서도많은경우에서치조골이식술이동반되었고, 그것이미치는변연골흡수에대한영향을살폈다. 본연구에서시행된발치후즉시식립임플란트는많은경우발치당시의조건이치주염등으로인한상당량의골소실을보이는증례들이어서임플란트식립과더불어골이식을동시해시행하는경우가많았다. 골이식을시행한경우의대부분흡수성또는비흡수성차폐막을같이사용하였다. Toffler 등 11) 은상악동수술에서골이식을동반한경우에도골이식없이임플란트를식립한경우와유사한 Journal of Dental Implant Research 2016, 35(1) 9-16

Choi KK, Paeng JY: A clinical study on implantation of the marginal bone loss after the posterior immediate implants 15 결과가나왔다고하였다. 본연구에서도골이식이변연골흡수에미치는영향은유의하지않은것으로나왔다. Nevins와 Langer 12) 는치주질환으로인해발치해야할환자의경우에서도발치후즉시식립시에 95% 가넘는수술성공률을보였다고보고하였다. 본연구에서도치주질환으로발치후즉시식립한임플란트에서도모두성공적인결과를나타냈지만, 치아우식증등의다른이유로발치한증례보다임상적으로많은양은아니지만통계적으로유의한변연골의흡수가더많이나타났다. 일반적으로임플란트시술후일정기간이경과하는동안변연골에서골소실은어느정도관찰된다. 임플란트수술후의변연골소실이일어나게되는원인으로, Oh 등 13) 은수술시의외상, 임플란트형태등을들었으며, 그중교합과부하가주된원인중하나라고보고하였다. 다른여러연구들에서도과부하는골소실의원인으로보고되고있다 14). 차정섭등 15) 의연구에의하면, 발치후즉시식립과즉시하중을가한경우에서발치원인의차이곧치주질환과우식증에대한각집단간의생존율이나주위변연골의흡수량의차이는유의하지않고, 또한상하악간, 임플란트의길이나식립부위가다른경우에서도변연골변화량의유의한차이는나타나지않는다고보고하였다. 연령별로식립된임플란트를살펴본결과도골소실비율은환자의연령에따라서도별차이가없음을확인하였다. 또한발치창이넓은경우 (8 mm 이상 ) 나좁은경우 (5 mm 이하 ) 에서도결과의차이는보이지않았다. 전신병력의경우당뇨가있는환자의경우골형성, 골유착능력이 30% 이상낮아진다고보고되기도하였다 16). 그러나본연구에서는당뇨환자의경우어느정도당뇨의조절이되는환자들에한해서수술을시행하였고, 고혈압환자에서와마찬가지로그결과는전신질환이없는환자의경우와유의한차이를보이지않았다. 그러므로전신질환이있다하더라도조절되는환자의경우라면철저한소독과섬세한수술방법, 충분한사전-사후투약을동반하면발치후즉시임플란트를식립하는데임상적인차이를보이지않을것으로예상된다. 전신질환중골다공증은임플란트수술에상당한위험요소로인식되고있다. 비록 Friberg 등 17) 이골다공증환자에서도임플란트수술의높은성공률을보고한바가있긴하지만, 여러논문들에서골다공증은임플란트수술후많은합병증을나타내는것으로보고되었다 18). 또한많은골다공증환자가복용하고있는 Bisphosphonate과관련된골괴사증 (BRONJ, Bisphosphonate Related Osteonecrosis of the Jaw) 의위험성은많은증례들이보고되었다 19,20). 흡연은임플란트의성공과밀접한관련이있는것으로알려져있다. Schwart-Arad 등 21) 에의하면흡연이임플란트의초기골유착을방해하고초기실패와골소실의주요원인이된다고하고다른논문들에서도비슷한결과가보고되었는데 22) 본연구에서는흡연력에대한정확한병력을측정할수없어흡연을하는경우와그렇지못한경우와의비교를시행하지못하였다. 임플란트의직경과길이에대해서는많은연구가있었다. 하악제2대구치부위는많은경우하치조신경관으로인해충분한길이의임플란트를식립하기힘들다 23). 특히즉시식립임플란트의경우초기고정을얻기위해발치창과하치조신경사이에충분한골이필요하지만, 증례에따라서는이길이를확보하기어려운경우도있어 8.5 mm 이하의짧은길이의임플란트를식립하기도하였다. Schnitman PA 등 24) 에의하면임플란트의직경과길이가중요하지만그보다는골의밀도와임플란트의초기결합과안정성이더중요한요소라고보고하였다. 본연구에서도직경과길이에따른골소실의변화량은차이를보이지않았다. 본연구의한계점으로는 1년간의추적데이터를바탕으로한것으로장기간의추적결과를분석하지는못하였다. 하지만대부분의임플란트의변연골소실은식립후 1년이내에나타나는것으로알려져있어즉시식립임플란트주변변연골의변화에관련된임상적의미를어느정도분석한것으로생각된다. 결 론 본연구에서는발치후즉시식립하고보철물장착후 1년이상추적관찰을시행한 107개의임플란트를대상으로변연골의변화에영향을미치는요소들을분석하여다음과같은결론을얻었다. 1. 변연골의소실은환자의전신질환의유무, 발치당시의발치와의조건, 임플란트매식체또는지대주의조건, 그리고보철물제작시기및골이식유무등의요소에따라차른차이를보이지않았다. 2. 발치의원인에따라치주질환이원인이되어발치한경우에치아우식등의다른원인으로발치한증례보다통계적으로유의하게많은양의변연골소실을보였으나, 임상적으로임플란트의성공이나생존에영향을미치는정도는아니었다. 3. 다양한조건에서식립된즉시식립임플란트는양호한결과를보여예지성있는임상적치료로판단된다. REFERENCES 1. Bråanemark PI, Zarb G & Albrektsson T. Tissue integrated prosthesis. Osseo-integration in clinical dentistry. Quintessence Publishing Co, Inc. Chicago, 1985. 2. Branemark PI. Osseointegration and its experimental background. J Prosthetic Dent 1983;50:399-410. 3. Balshi TJ, Wolfinger GJ. Immediate loading of Branemark implants in edentulous mandibles : a preliminary report. Implant Dent 1997;6:83-8. 4. Cooper LF, Rahman A, Moriarty J, Chaffee N, Sacco D. Immediate mandibular rehabilitation with endosseous implants: simultaneous extraction, implant placement and loading. Int J Oral Maxillofac Implants 2000;17:517-25. 5. Degidi M, Piattelli A. Comparative analysis study of 702 dental implants subjected to Immediate functional loading and im- Journal of Dental Implant Research 2016, 35(1) 9-16

16 최기관, 팽준영 : 구치부발치후즉시식립임플란트의변연골흡수에대한임상적분석 mediate nonfunctional loading to traditional healing periods with a follow up of up to 24 months. Int J Oral Maxillofac Implants 2005;20:99-107. 6. Wagenberg BD, Ginsburg TR. Immediate implant placement on removal of the natural tooth: retrospective analysis of 1081 implants. Compendium of Continuing Educ Dent 2001;22: 399-404. 7. Penarrocha M, Uribe R, Balaguer J. Implant in imediatos a laexodoncia. Situacion actual. Med Oral 2004;9:232-42. 8. McNutt MD, Chou CH. Current trends in immediate osseous dental implant case selection criteria. J Dent Edu 2003; 67(8):850-9. 9. 송민중. Retrospective study on survival and marginal bone loss of short implants: clinical results after 2-4 years. 단국대석사논문 2015;19 10. 김재현. 발치후즉시식립임프란트에서골이식이일차및이차안정도에미치는영향에관한연구. 고려대석사논문 2013;21 11. Toffler M. Osteotome-mediated sinus floor elevation: a clinical report. Int J Oral Maxillofac Implants. 2004 Mar-Apr;19: 266-73. 12. Nevins M, Langer B. The successful use of osseointegrated implants for the treatment of the recalcitrant periodontal patient. J Periodontol 1995;66:150-7. 13. Oh TJ, Yoon J, Misch CE, Wang HL. The causes of early implant bone loss: myth or science? J Periodontol 2002 Mar;73: 322-33. 14. Quirynen M, Naert I. Fixture design and overloading influence marginal bone loss and future success in the BranemarkR system. Clin Oral Imp lres 1992;3:104-11. 15. Cha JS, Min KK, Jeon SH, Kwon JJ. A retrospective study of the peri-implant bone changes in immediate installation implants with different causes for loss of teeth. JOURNAL OF THE KOREAN ACADEMY OF IMPLANT DENTISTRY 2010;29(2):1-12 16. Shin SH, Kim JR, Park BS. Bone formation around titanium implants in the tibiae of streptozotocin induced diabetic rats. J Kor Assoc Maxillofacial Plastic and Reconstructive Surgeons 2000;22(5):522-41. 17. Friberg B, Ekestubbe A, Mellstrom D, Sennerby L. Brånemark implants and osteoporosis. A clinical exploratory study. Clin Implant Dent Relat Res 2001;3:50-6. 18. Blomqvist JE, Alberius P, Isaksson S, Linde A, Hansson BG. Factors in implant integration failure after bone grafting: an osteometric and endocrinologic matched analysis. Int J Oral Maxillofac Surg 1996; 25:63-8. 19. Badros A, Weikel D, Salama A, Goloubeva O, Schneider A, Rapoport A, et al. Osteonecrosis of the jaw in multiple myeloma patients: clinical features and risk factors. J Clin Oncol 2006;24:945-52. 20. Marx RE, Cillo JE, Jr, Ulloa JJ. Oral bisphosphonate-induced osteonecrosis: risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral Maxillofac Surg 2007;65:2397-410. 21. Schwartz-Arad D, Samet N, Samet N, Mamlider A. Smoking and complications of endosseous dental implants. J Periodontol. 2002 Feb;73(2):153-7. 22. Lee LL, Lee JS, Waldman SD, Casper RF, Grynpas MD Polycyclic aromatic hydrocarbons present in cigarette smoke cause bone loss in an ovariectomized rat model. Bone 2002; 30(6):917-23. 23. 이항빈, 백정원, 김창성, 최성호, 이근우, 조규성. 하악제 1,2 대구치를대체하는단일임프란트간의성공률비교. 대한치주과학회지 2004;34:101-12. 24. Schnitman PA, Wohrle PS, Rubenstein JE, Dasilva JD, Wang. Ten year results for Brånemark implants immediately loaded with fixed prosthesis at implant placement. Int J Oral Maxillofac Impl 1997;12:495-503. Journal of Dental Implant Research 2016, 35(1) 9-16

Vol. 35 No. 1, June 2016 Journal of Dental Implant Research 2016, 35(1) 17-21 초기고정없이즉시식립된임플란트 : 증례보고와문헌고찰 김동관, 최정임, 김승우, 박관수 인제대학교의과대학상계백병원구강악안면외과학교실 Immediately placed implant without primary stability: case report and literature review Dongkwan Kim, Junglim Choi, Seung-Woo Kim, Kwan-Soo Park Department of Oral and Maxillofacial Surgery, Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea Recently, many clinicians prefer recently to place implant immediately after extraction and patients are satisfied with overall results because of short period of treatment and brief operating process. For the success of immediate implant placement, the initial stability is known as one of the most important factors. We experienced the two cases that osseointegration of immediate implant placement was successful in spite of not having initial stability. The immediate placement was planned on hopeless premolar tooth. Although they could not have initial stability, the fixtures were inserted into their sockets without conventional drilling procedure. After several weeks, both abutments were tightened at 30 Ncm and implant prostheses had maintained stable during follow-up period of 20 months and 6 months, respectively. To be properly considered the anatomy of operative site is the essential prerequisite for a successful outcome of immediate implantation, even if it could not be gained the primary stability. Further study should be needed to get predictable results. (JOURNAL OF DENTAL IMPLANT RESEARCH 2016;35(1):17-21) Key Words: Dental implant, Immediate implant, Primary stability, Insertion torque 서론 이전세대의임플란트연구는발치전의건전한자연치아상태를재현해서본래의기능을갖춘인공치아를얼마나잘만들수있는지가주안점이되어왔다. 최근들어, 많은임상가들의관점이환자중심으로전환되면서, 환자의치아상실기간을최소화시킬수있는임플란트술식에대한연구가진행되고있다. 특별히, 발치후즉시임플란트식립은치료기간을단축시킬수있으며, 적절한골이식술을함께시행할때에는과도한치조골흡수를예방하는효과가있다. 임플란트수술에있어초기고정은필수적인것으로여겨져왔고모든임상가는수술시초기고정을얻기위해노력한다. 발치후즉시식립의경우에도초기고정은성공을위한중요한요소로여겨져왔지만발치와의잔존골이양적이나질적으로불량하고해부학적제한으로인해적절한초기고정을얻지못할가능성이존재한다. 본증례에서는, 발치후즉시식립중에초기고정측정이되지 않았지만임플란트식립을그대로시행하였고, 적절한골유착이이루어졌다. 이에저자등은, 즉시식립시에초기고정을얻지못한경우의증례를보고함과함께이에관한문헌을고찰하여보고자한다. 증례보고 1. 증례 1 26세여자환자로, 상악좌측제2소구치우식으로인한치관파절로발치후수복이필요한상태였다.(Fig. 1) 술전방사선소견상상악동거상술등을동반한임플란트수술이필요하리라판단하였으나환자는침습적수술을원하지않아상악동거상술없는발치후즉시식립을계획하였다. 잔존치근을죄소한의외상으로발거한후발치와를조심스럽게탐침하여주변에임플란트와접촉할치조골의존재를확인하고방사 Received Apr 26, 2016, Revised May 13, 2016, Accepted May 26, 2016. cc This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creative commons.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. 교신저자 : 박관수, 01757, 서울시노원구동일로 1342, 인제대학교의과대학상계백병원구강악안면외과학교실 Correspondence to: Kwan-Soo Park, Department of Oral and Maxillofacial Surgery, Sanggye Paik Hospital, College of Medicine, Inje University, 1342, Dongil-ro, Nowon-gu, Seoul 01757, Korea. Tel: +82-2-950-1161, Fax: +82-2-950-1167, E-mail: oms_kspark@paik.ac.kr JOURNAL OF DENTAL IMPLANT RESEARCH www.kaidimplant.or.kr

18 김동관등 : 초기고정없이즉시식립된임플란트 : 증례보고와문헌고찰 Fig. 1. The initial radiograph of the case 1. Fig. 4. Intraoral photograph taken after Implant placement & GBR of the case 1. Fig. 2. Intraoral photograph taken after extraction of the case 1. Fig. 5. Radiograph taken after Implant OP of the case 1. Fig. 3. Radiograph taken after extraction of the case 1. 선촬영을통해해부학적위험성을판단하였다.(Fig. 2, 3) 원심측으로치근중앙부근까지함기화된상악동벽을고려하여, 드릴사용없이 4.0 11.5 mm의임플란트를바로식립하였다 (TS3, Osstem, Seoul, Korea). 초기고정을얻을수없어식립토크는측정할수없었으며힐링스크류를살짝연결할정도로고정력이없었다. 임플란트몸체와발치와사이의틈에는골이식을시행하였으며콜라겐플러그를삽입하였다. 모든과정은절개없이시행되었으나술후치은의위치안정을위해봉합사로치은을고정하였다.(Fig. 4, 5) Fig. 6. CBCT view of 7 Months after final restoration delivery of the case 1. 술후 3개월에지대주는 30 Ncm 으로연결되었고보철물을장착하였으며보철완료후 20개월의경과관찰결과특이소견을보이지않았다.(Fig. 6, 7) 2. 증례 2 34 세여자환자로, 상악좌측제 2 소구치우식으로인한치관파절 Journal of Dental Implant Research 2016, 35(1) 17-21

Kim D, et al: Immediately placed implant without primary stability: case report and literature review 19 Fig. 7. Radiograph of 20 Months after final restoration delivery of the case 1. Fig. 10. Intraoral photograph taken after Implant placement & GBR of the case 2. Fig. 8. The initial radiograph of the case 2. Fig. 11. Radiograph taken after Implant OP of the case 2. Fig. 9. Intraoral photograph taken after extraction of the case 2. 로, 발치후즉시식립을계획하였다.(Fig. 8) 외상을최소화하여발치하였으며,(Fig. 9) 앞선증례와유사하게, 모든과정은무절개로진행되었고드릴링과정없이 4.5 8.5 mm의임플란트 (TS3, Osstem, Seoul, Korea) 를발치와에직접식립하였고식립토크는측정할수없었다. 임플란트몸체와치조골사이틈에는골이식후콜라겐플러그를삽입하였으며, 봉합은시행하지않았다.(Fig. 10, 11) Fig. 12. Intraoral Photograph taken after final restoration delivery of the case 2. 임플란트식립 10 주후에보철치료를진행하였으며, 지대주는 30 Ncm 으로체결되었다.(Fig. 12) 보철 6 개월후 F/U 결과, 양호한 임플란트보철물을유지중이다.(Fig. 13) -Journal of Dental Implant Research 2016, 35(1) 17-21

20 김동관등 : 초기고정없이즉시식립된임플란트 : 증례보고와문헌고찰 Fig. 13. Radiograph of 6 Months after final restoration delivery of the case 2. 고 찰 최근까지발치후즉시식립임플란트식립에대해서많은연구가 진행되어왔다. 발치시행과임플란트식립이동시에가능할것인가 에대한연구는이미 1980 년대말부터진행이되어왔다. 1988 년 Barziley 1) 부터 Lazzarra (1989 년 ) 2), Knox (1991 년 ) 3), Lundgren (1992 년 ) 4), Barziley (1994 년 ) 5) 등의연구들에서발치창에즉각적 인임플란트식립이온전한골유착으로진행됨을밝혀왔다. 1998 년 Tehemar 6) 연구에서는발치후즉시식립시동반되는다양한이점 을강조하였다. 발치후발치창의치유를기다리는시간의단축, 수 술적절차의간소화, 전체적인치료시간단축과비용의감소, 최적의 기능적, 심미적결과를위한수직적, 수평적잔존치조골의보존, 임 플란트식립과정의열발생의감소등을언급하였다. 2000 년대에 들어서면서, 많은연구들에서발치후즉시식립임플란트의예후를 평가하였다. Schropp 등 7) 의연구에서, 발치후치유완료된곳에 식립한임플란트와발치후즉시식립한임플란트의성공률은유사한것으로보고되었다. 2004년에발표된 consensus statement 8) 에서는발치후임플란트의식립시기에따라 4가지로분류하고각각의치유양상과장단점에대해소개하였다. 이 consensus 에따르면, 즉시식립 (type1) 과지연식립 (type4) 의임플란트성공률은유사한것으로보고되었다. 특별히, 당시까지의연구를종합하고있는 consensus에서본증례보고와연관하여주목해야할부분이있다. 2004년당시의 Consensus 권고사항에는, 발치후임플란트즉시식립시초기고정을얻을수없을때에는임플란트식립을하지말것을권하고있었다. 많은앞선문헌에따르면, 초기고정은성공적인임플란트골유착의기본이되는척도로알려져왔다 9-11). 또한, 관련된이전의연구결과에서임플란트식립시부적절한초기고정을가지는경우에높은임플란트실패율을보고하였다 12). 초기고정의평가는주로임플란트식립시에측정되는토크와 RFA (Resonance Frequency Analysis) 를이용한 ISQ (implant stability quotient) 두가지로이루어진다. 많은연구들에서초기고정을위한최소의식립토크, 최적의식립토크수치에대한연구를진행해왔다. Ottoni 등 13) 의연구에서는임플란트골유착을위해최소 32 Ncm의식립토크가필요함를제안하였다. 또한, 20 Ncm 이하의식립토크를보인임플란트에서 90% 의실패율을보였고, 평균적인식립토크는 38 Ncm을기록하였다. 또한, Neugebauer 등 14) 의연구에서는즉시하중을위한최적의식립토크로 35 Ncm을제안하였다. ISQ 값을기준으로, 성공적인초기고정을이루었다고평가될수있는수치는일반적으로 60 80으로연구보고되었다 15-17). 물론이범위이하의 ISQ가측정되었을때, 반드시임플란트의안정성이부족하다고결론을낸문헌적합의는없다. 그러나, 몇몇연구에서는, 임플란트식립시적어도 55 이상의 ISQ값을만족해야만임상적안정성을갖으며, 성공적인골유착으로간주할수있다고언급하였다 16,17). 물론, 식립토크와 ISQ에대한앞선연구들은대부분발치와의치유가완료된지연식립을대상으로하였다. 실제로, 아직즉시식립과관련된초기고정에대한연구는부족한상황이다. 이는모든발치와의형태와환경이상이함으로, 연구결과의유의미성을도출하기에어렵기때문일것이다. 하지만, 역설적으로대부분의발치후즉시식립에관한연구에서초기고정에관한평가치를기록하는것은대다수의연구자들이초기고정을골유착성공을위한중요한요소로인식하고있음을반증한다. 즉시식립술식에서는임플란트표면과잔존골의직접적인접촉이지연식립에비교하기어려울정도로부족하기때문에, 초기고정값은최우선적으로갖춰야할조건으로예상할수있다. 지금까지대부분의발치후즉시식립술식에서는치근단에추가적으로 2 mm 이상의드릴링을시행하여치근단 1/3 영역에서임플란트가골접촉을이뤄만족스러운초기고정값을가능하도록하였다. 하지만, 초기고정이없을시임플란트골유착이불가능한것인지에대한의문은여전히남아있다. Massimiliano 등 18) 의동물실험연구에서는, 의도적으로드릴링을과확대하여초기고정을허용하지않은후임플란트를매식하였다. 4개월후대조군과의조직학적평가에따르면, 초기고정유무에상관없이통계학적으로유의성을발견할수없었다. 결과적으로초기고정이없을때에도충분한임플란트골유착을이룰수있음을조직학적으로확인할수있었다. 국내의유사한 Jung 등 19) 의동물실험에서도, 유사한결과를보고하였다. 물론, 발치직후발치창은실험으로재현이불가한독특한치유과정을갖고있기때문에, 위의동물실험과동등한조건은아니다. 하지만, 즉시식립시불량한초기고정만을이유로섣불리즉시식립술식의실패를단정할필요는없을것이다. 적절한형태의소구치발치와가선별된다면, 초기고정이없을시에도발치후즉시식립에유리한조건을가질것을예상할수있다. 대구치에비해소구치치근은임플란트몸체모양과유사하기때문에, 초기고정이없더라도미세동요가적을가능성이높다. 또한, 보철 Journal of Dental Implant Research 2016, 35(1) 17-21

Kim D, et al: Immediately placed implant without primary stability: case report and literature review 21 적관점에서볼때, 소구치부위는위험부담이크지않다. 반면에, 상악전치의경우발치와를따라그대로식립하였을경우, 순측치조 골의흡수에의해불량한심미적결과로이어질수있다. 초기고정없는발치후즉시식립을시도할때추가적으로고려하 여야할해부학적제한은, 발치와의근단부에임플란트를감싸고있 는잔존치조골의형태이다. 소구치부위의치조골형태는치조정부 에서는두께를유지하다가도치근단부위에서는움푹꺼진모양의와 (fossa) 를형성할때가종종있어드릴을이용한식립부위형성없이발치와를따라식립할경우치근단부치조골천공을만들어예후에나쁜영향을주기쉽다. 현재까지의연구결과를토대로임상적예지성을고려할때에는즉시식립시에초기고정이없을경우지연식립으로계획을변경하는것이표준적인방법이라할것이다. 하지만, 일부연구결과및본증례에서보는바와같이발치와에드릴로임플란트의식립부위를형성하지않고초기고정이없이직접식립을시행할경우에도보철적수복을위한적절한골유착이얻어질가능성이있으며일상적인치료프로토콜로자리잡기위해서는추가적인연구가필요하리라사료된다. REFERENCES 1. Barziley I, Graser GN, Caton J, Shenkle G. (1988) Immediate implantation of pure titanium treated implants to extraction sockets. Journal of Dental Research 67: 142, abstract234. 2. Lazarra R.J. (1989) Immediate implant placement into extraction sites: Surgical and restorative advantages. International Journal of Periodontology and Restorative Dentistry 9:332-42. 3. Knox R, Candill R, Meffert R. (1991) Histologic evaluation of dental endosseous implants placed in surgically created extraction defects. International Journal of Periodontology and Restorative Dentistry 11:365-76. 4. Lundgren D, Rylander H, Andersson M, Johansson C, Albrektsson T. (1992) Healing-in of root analogue titanium implants placed into extraction sockets. An experimental study in the beagle dog. Clinical Oral Implants Research 3:136-43. 5. Barziley I. (1993) Immediate implants; their current status. International Journal of Prosthodontics 6:169-75. 6. Tehemar S. (1998) Assessment of heat generation in immediate implant procedure. Journal of Oral and Maxillofacial Surgery 56: suppl 4:36. 7. Schropp L, Kostopoulos L, Bone healing following immediate versus delayed placement of titanium implants into extraction sockets: A prospective clinical study. Int J Oral Maxillofac Implants 2003;18:189-99 8. Hämmerle CH, Chen ST, Wilson TG Jr. Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Implants 2004;19(Suppl):26-8. 9. Dos Santos MV, Elias CN, Cavalcanti Lima JH. The effects of superficial roughness and design on the primary stability of dental implants. Clin Implant Dent Relat Res. 2011;13:215-23. 10. Friberg B, Jemt T, Lekholm U. Early failures in 4,641 consecutively placed Branemark dental implants: a study from stage 1 surgery to the connection of completed prostheses. Int J Oral Maxillofac Implants. 1991;6:142-6. 11. Cameron HU, Pilliar RM, Mac Nab I. The effect of movement on the bonding of porous metal to bone. J Biomed Mater Res. 1973;7:301-11. 12. Misch CE. Implant design considerations for the posterior regions of the mouth. Contemp Implant Dent. 1999;8:376-86. 13. Ottoni JM, Oliveira ZF, Mansini R, Cabral AM. Correlation between placement torque and survival of single-tooth implants. Int J Oral Maxillofac Implants. 2005 SepeOct;20(5): 769e776. 14. Neugebauer J, Traini T, Thams U, Piattelli A, Zoller JE. Periimplant bone organization under immediate loading state. Circularly polarized light analyses: a Minipig study. J Periodontol 2006;77(2):152e160. 15. Huwiler MA, Pjetursson BE, Bosshardt DD, Salvi GE, Lang NP. Resonance frequency analysis in relation to jawbone characteristics and during early healing of implant installation. Clin Oral Implants Res. 2007;18:275-80. 16. Sim CPC, Lang NP. Factors influencing resonance frequency analysis assessed by Osstell mentor during implant tissue integration: I. Instrument positioning, bone structure, implant length. Clin Oral Implants Res. 2010;21:598-604. 17. Han J, Lulic M, Lang NP. Factors influencing resonance frequency analysis assessed by Osstell mentor during implant tissue integration: II Implant surface modifications and implant diameter. Clin Oral Implants Res.2010;21:605-11. 18. Rea M, Lang NP, Ricci S, Mintrone F, González González G, Botticelli D. (2014) Healing of implants installed in over- or under-prepared sites an experimental study in dogs. Clinical Oral Implants Research, doi: 10.1111/clr.12390 19. Jung U-W, Kim S, Kim Y-H, Cha J-K, Lee I-S, Choi S-H. Osseointegration of dental implants installed without mechanical engagement: a histometric analysis in dogs. Clin. Oral Impl. Res. 23, 2012, 1297-301. -Journal of Dental Implant Research 2016, 35(1) 17-21

Vol. 35 No. 1, June 2016 Journal of Dental Implant Research 2016, 35(1) 22-26 치은연하로파절된전치부치아의외과적정출술을이용한수복증례 정기현 1, 이성원 1, 정주련 1, 최종원 1, 노성수 1, 김주형 2, 김태건 3, 박창주 1, 황경균 1 한양대학교의과대학치과학교실구강악안면외과 1, 교정과 2, 보존과 3 Intra-alveolar transplantation for crown-root fractured anterior maxillary tooth Ki-Hyun Jung 1, Seong-Won Lee 1, Joo-Ryun Chung 1, Jong-Won Choi 1, Seong-Su Ro 1, Joo-Hyung Kim 2, Tae-Geon Kim 3, Chang-Joo Park 1, Kyung-Gyun Hwang 1 Departments of 1 Dentistry/Oral and Maxillofacial Surgery, 2 Dentistry/Orthodontics, 3 Dentistry/Conservative Dentistry, College of Medicine, Hanyang University, Seoul, Korea This case report presents successful tooth intra-alveolar transplantation with crown-root fracture on maxillary central and lateral incisor. After endodontic treatment, the maxillary central and lateral incisor were extracted and three millimeters of the apex of the root was cut off extraorally. Then retrofilling was done with mineral trioxide aggregate (MTA). The teeth were rotated 180 degrees and fixed with resin-wire splint in a more coronal position so that enough tooth structure was exposed above the crest of alveolar bone. After 8 weeks, resin-wire splint was removed and definitive restoration was placed 4 weeks later. A long-term follow up examination revealed that the transplanted tooth was satisfactory in mastication and in clinical X-ray result. (JOURNAL OF DENTAL IMPLANT RESEARCH 2016;35(1): 22-26) Key Words: Intra-alveolar transplantation, Surgical extrusion, Crown-root fracture 서론 치아에대한외상성손상은상악전치부특히상악중절치에서호발하고, 유치열에서 30%, 영구치열에서 22% 정도의빈도로나타나는것으로보고된다 1,2). 치아손상의유형은치관파절, 치근파절또는치관-치근파절로분류된다. 치관-치근파절은치아파절이치관과치근에이르러발생하여법랑질, 상아질및백악질까지이환된경우로정의되며, 치수노출포함여부에따라단순파절과복잡파절로분류된다. 치관-치근파절은예후가불량하며영구치열에서약 5% 의발생빈도를보인다 3). 전치부의치관-치근파절은직접적외상에의한수평적충격의결과로발생하며정면에서힘이가해졌을경우파절선이설측에서치은연하로연장되어나타나는것으로보고된다 1). 치관-치근파절된치아의치료목표는치은절제술 (Gingivectomy) 이나교정적정출술 (Orthodontic extrusion, forced eruption), 또는외과적정출술 (Intra-alveolar transplantation, surgical uprighting and surgical extrusion) 등을이용하여파절된치아의생물학적폭경을재건한후심미적, 기능적인보철로수복하는것이다. 외과적정출술은치료과정과치유원리가자가치아이식 (Conventional transplantation) 과동일하고특히의도적재식술 (Intentional replantation) 의과정과방법이동일하다. 그러나치주질환에이환되거나수직치근파절이있는치아, 치조골이약한경우에는적용하기어렵지만, 치료기간이비교적짧고성공률이높으며, 발치후발치와와치조골의상태및치근을직접적으로관찰할수있다는장점이있다. 본증례에서는치관-치근파절된치아를외과적정출술을이용하여생물학적폭경을확보한후임시수복을하였으며, 추후 3개월간의예후관찰후올세라믹크라운으로최종수복하여치료기간을단축시켰고비교적만족할만한결과를얻었기에보고하는바이다. Received May 3, 2016, Revised May 20, 2016, Accepted Jun 2, 2016. cc This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creative commons.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. 교신저자 : 황경균, 04763, 서울시성동구행당동 17, 한양대학교의과대학치과학교실구강악안면외과 Correspondence to: Kyung-Gyun Hwang, Department of Dentistry/Oral and Maxillofacial Surgery, College of Medicine, Hanyang University, 17, Haengdang-dong, Seongdong-gu, Seoul 04763, Korea. Tel: +82-2-2290-8646, Fax: +82-2-2290-8673, E-mail: hkg@hanyang.ac.kr JOURNAL OF DENTAL IMPLANT RESEARCH www.kaidimplant.or.kr

Jung KH, et al: Intra-alveolar transplantation for crown-root fractured anterior maxillary tooth 23 증례보고 상기환자는 15세여자환자로운동중넘어져서본원에내원하였다. 초진시구외부위의외상은없었고, #21, 22 치아의치수가노출된치관파절을보였다. 임상검사및방사선검사에서 #21, 22 치아의순측파절선은치은연상에있었으나, 구개측파절선은약 5 6 mm 치은연하에있었다. 환자가성장기의청소년으로보호자가치아보존에대한치료를원해서외과적정출술을시도하기로하여내원당일국소마취하에파절된치관조각을제거하고치수개방및발수하였다.(Fig. 1) 2주에걸쳐통상적인근관치료를시행하였고 Fig. 1. Intra-oral photogragh and Initial radiogragh. (A) #21, 22 Crown-root fracture, (B) Initial periapical x-ray view, (C) Fractured tooth fragments, (D) Access opening and pulp extirpation. Fig. 2. Procedure of intra-alveolar transplantation. (A) Root canal filling with gutta-percha, (B) Tooth extraction with extraction forcep, (C) Retrograde filling with Mineral trioxide aggregate (MTA), (D) Tooth repositioning in extraction socket labio-palatal reversely. Journal of Dental Implant Research 2016, 35(1) 22-26

24 정기현등 : 치은연하로파절된전치부치아의외과적정출술을이용한수복증례 근관치료 2주후 #21, 22치아의외과적정출술을시행하였다.(Fig. 2) 이때교합면의삭제및치근절제를약 3 mm 정도시행하고, Mineral trioxide aggregate (MTA) 로역충전을시행한후, 파절선을치은연상에위치시키고정출량을최소화하기위해치아를 180 도회전시켜순측과구개측을반대방향으로발치와에식립하였다. #21 치아의경우순측과구개측을반대로식립하였을때순측의파절선이치은연상에위치하도록하기위해충분히삽입하지않고교합평면방향으로약 2 mm 정출시켜레진와이어스플린트 (Resinwire splint) 로고정하였다.(Fig. 3) 레진와이어스플린트장착기간동안초기고정의중요성에대하여환자교육을철저히실시하고정기적인검사를함으로써초기적합도를얻을수있었다. 이식 8주후레진와이어스플린트를제거하였을때 #21, 22치아는동요도가없었고, 방사선사진상치근단부의골형성이양호하게이루어지고있음을확인할수있었다.(Fig. 4) 이식 10주후임시크라운으로임시수복을하였고,(Fig. 5) 12주후에올세라믹크라운을이용하여 보철수복을완료하였다. 이식 6개월후치아는임상적으로전혀불편감이없었으며, 방사선사진상골형태가주변정상치와유사한양상으로치유됨을볼수있었고, 치조백선이정상적으로나타나고치근유착이나치근흡수는관찰할수없었다.(Fig. 6) 고찰 심미적인부위인전치부에서치관-치근파절이일어난경우발치후임플란트치료가좋은방법일수있으나발치하지않고자연치를이용한보철수복이가능하다면그것이바람직한치료법이될수있다. 치아파절선이치은연하로연장된치관-치근파절의경우파절된치아를발치할지유지할지결정해야하는데유지하기로한경우치료는치은절제술 (Gingivectomy) 이나교정적정출술 (Orthodontic extrusion, forced eruption), 또는외과적정출술 (Intra-alveolar transplantation, surgical uprighting and Fig. 3. Fixation with resin-wire splint. Fig. 4. Intra-oral photo and X-ray view of #21, 22 after 8 weeks intra-alveolar transplantation. Fig. 5. Intra-oral photo and X-ray view of #21, 22 after 10 weeks intra-alveolar transplantation. Journal of Dental Implant Research 2016, 35(1) 22-26

Jung KH, et al: Intra-alveolar transplantation for crown-root fractured anterior maxillary tooth 25 Fig. 6. Intra-oral photo and X-ray view of #21, 22 after 6 months intra-alveolar transplantation. surgical extrusion) 을이용할수있다 1). 치은절제술의경우치은선에손상을주므로심미적으로눈에띄지않는부위에파절된경우에시행할수있고치은판막을이용하여파절선을노출시킬수도있다 4-6). 교정적정출술은부착소실없이수직적골결손을감소시킬수있어치은건강에유리하다는장점이있는반면, 치료기간이길며내원시마다장치를조종해주어야하는단점이있다 7-9). 반면외과적정출술은치료기간이짧으며발치창, 치조골및치근을직접확인할수있고파절선을순측으로위치시킴으로써정출량을감소시킬수있다는장점이있지만, 치조골이약한경우발치가어렵고술후치근유착및치근흡수가능성이존재한다는단점이있다 10,11). 따라서발치만용이하게이루어질수있다면외과적정출술을우선적으로고려해볼수있다. 자가치아이식술 (Autotransplantation of tooth) 은본인의치아를발치와 (Extraction site) 또는수술적으로준비된와 (Surgically prepared socket) 에옮겨심는술식으로정의된다 12). 자가치아이식술은치아를완전히다른위치로옮겨심는술식인전통적인자기치아이식술 (Conventional transplantation), 치아를원래의위치에서조금옮겨심는술식인외과적정출술 (Intra-alveolar transplantation, surgical uprighting and surgical extrusion), 의사가의도를가지고치아를안전하게발치하여구강외에서치료한후다시재자리에심는술식인의도적재식술 (Intentional replantation) 으로분류된다 13). 외과적정출술은의도적재식술과그원리나과정이거의비슷하나, 외과적정출술은치아를교합면방향으로끌어올리는치료로의도적재식술에비해생물학적폭경확보와추후보철적수복을위한고려할사항이추가로있다. 외과적정출술시해부학적치근의길이는술후안정적인치관-치근비율을확보하는것이중요하므로발치한치아는최대한깊이식립하여정출량을최소화하는것이바람직하다. 그러나전치부의경우순측과인접면의치은변의높이차가크므로건전치질을확보하기위해서정출만으로는정출량이너무많아져치근이너무짧아지는단점이있다. 따라서전치부의경우치아를 180도회전시켜서순-구개측을반대로식립하면파절선이노출되는경우가많아정출량을최소화할수있다 14). 본증례에서도 #21, 22 치아는구개측에서파절선이치 은연하 5 6 mm 위치하여통상적인정출술로는정출량이상당하여고정을얻기힘들었다. 따라서 180도회전시켜순-구개측을반대로식립하여정출량을줄이되, 추후보철적수복을위하여건전한치질이치조정 4 mm 상방까지위치하도록하였다. #22 치아의경우순-구개측을반대로식립하는것만으로충분하였으나 #21 치아의경우순-구개측을반대로식립한후추가적으로교합면방향으로 2 mm 정출이필요하였다. 성공적인자가치아이식치료를위해가장중요한요소는이식치에부착된치주인대의생활력이다 15). 치주인대는삼투압과 ph에민감하기때문에구강외에노출되었을때생활력이감소하는것으로보고되고있다 16). 이전의연구에서치주인대가구강외에노출되는 18분이후생활력이급격히감소하는점을고려하여본증례에서는구강외시간을 6분이내로하였다 17). 이식된치아가적절하게고정되지않으면치료실패로이어질수있다. 이는이식된치아에부착되어있는치주인대는치조골로부터만혈액공급을받기때문에치아가안정적으로고정되었을경우신생혈관이생성되어혈액공급을원활하게받을수있다. 고정이불안정한경우신생활관생성이실패되어치주인대의괴사가일어나며이로인해치주질환이발생하여치료실패로이어진다 18). 이식한치아를고정하는방법에는첫째거즈를물고있게하는방법, 둘째레진와이어스플린트로고정하는방법이있다. 거즈를물고있는경우는단순하고빠르게할수있는장점이있지만물고있는동안치아가움직일수있어치아고정이매우좋은경우에만사용하는것이좋다. 레진와이어스플린트로고정하는경우원래위치로고정하는방법과치아위치를변경하여고정하는방법이있다. 전자의경우진정한의미의의도적재식술로보철을하지않거나전치부의경우이용할수있다. 후자는 3차원적으로최적의위치를설정하여고정하는방식으로생물학적폭경확보에유리하므로추후보철치료에큰도움이된다. 이때고정은 1 2개월유지하고 2 3개월후보철수복이가능하다. 보철수복은 1 2개월간임시보철물을사용한후최종보철물로수복한다. 또다른성공요소는이식한치아를고정한후교합조정을하여아예교합이되지않도록하는것이다. 이는초기고정기간동안치아의안정에도움이된다 12,19). Journal of Dental Implant Research 2016, 35(1) 22-26

26 정기현등 : 치은연하로파절된전치부치아의외과적정출술을이용한수복증례 자가치아이식의성공기준은임상적으로불편감이없고정상적인 동요도를보이며치주낭의깊이가정상이어야한다. 또한방사선적 으로정상치주강의넓이와치조백선을보이면서치근흡수를보이지않아야한다 20). 이러한경우저작이가능하므로보철수복을하여도무방하다. 하지만치주낭의깊이는정상이나동요도가있는경우는아직치조골재생이부족한경우로고정을더유지하는것이좋다 13). 본증례의경우후자의방법을이용하여약 8주간이식한치아를고정후치아평가를시행하였으며약 2주간임시보철물을유지하였고이식 12주후올세라믹크라운을이용하여최종보철수복하였다. 결 론 파절선이치은연하에위치한치관-치근파절된치아를외과적정출술을이용하여생물학적폭경을확보한후 3개월간의예후관찰후올세라믹크라운으로최종수복하였고임상적, 방사선적으로성공적인결과를보였다. REFERENCES 1. Andreasen J, Andreasen FM. Root fracture. Essentials of Traumatic Injuries to the Teeth: A Step-by-Step Treatment Guide, Second Edition, Dental traumtology 1994:63-75. 2. Andreasen J, Ravn J. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Maxillofac Surg 1972;1:235-9. 3. Ellis RG, Davey KW. The classification and treatment of injuries to the teeth of children: a reference manual for the dental student and the general practitioner. 1970. 4. Linaburg RG, Marshall FJ. The diagnosis and treatment of vertical root fractures: report of case. J Am Dent Assoc 1973; 86:679-83. 5. Clyde J. Transverse-oblique fractures of the crown with extension below the epithelial attachment. Br Dent J 1965;119: 402. 6. Langdon J. Treatment of oblique fractures of incisors involving the epithelial attachment. A case report. Br Dent J 1968; 125:72. 7. Lee EM, Kim TW, Kim HJ, Kim YJ, Nam SH. Surgical extrusion of the crown-root fractured incisors: case report. JKAPD 2008;35:305-12. 8. Delivanis P, Delivanis H, Kuftinec MM. Endodontic-orthodontic management of fractured anterior teeth. JADA 1978;97: 483-5. 9. Simon JH, Kelly WH, Gordon DG, Ericksen GW. Extrusion of endodontically treated teeth. JADA 1978;97:17-23. 10. Tegsjö U, Valerius-Olsson H, Frykholm A, Olgart K. Clinical evaluation of intra-alveolar transplantation of teeth with cervical root fractures. Swed Dent J Suppl 1986;11:235-50. 11. Kahnberg KE. Surgical extrusion of root fractured teeth a follow up study of two surgical methods. Dental Traumatology 1988;4:85-9. 12. Tsukiboshi M. Andreasen JO. Classification and Clinical indication. In:Kathryn Funk. Autotransplantation of teeth. Quintessence Pub Co, 2001:58-129 13. Tsukiboshi M. Autotransplantation of teeth: requirements for predictable success. Dental Traumatology 2002;18:157-80. 14. Tsukiboshi M, Yamauchi N. Crown-root fracture. In: Bryn Grisham. Treatment planning for traumatized teeth. Second edition. Hanover Park: Quintessence, 2000:59. 15. Andreasen J. Periodontal healing after replantation and autotransplantation of incisors in monkeys. Int J Oral Maxillofac Surg 1981;10:54-61. 16. Lindskog S, Blomlöf L. Influence of osmolality and composition of some storage media on human periodontal ligament cells. Acta Odontol Scand 1982;40:435-42. 17. Thomas S, Turner S, Sandy J. Autotransplantation of teeth: is there a role? Journal of Orthodontics 1998;25:275-82. 18. Reich PP. Autogenous transplantation of maxillary and mandibular molars. J Oral Maxillofac Surg 2008;66:2314-7. 19. Rouhani A, Javidi B, Habibi M, Jafarzadeh H. Intentional replantation: a procedure as a last resort. J Contemp Dent Pract 2011;12:486-92. 20. Schwartz O, Bergmann P, Klausen B. Autotransplantation of human teeth: a life-table analysis of prognostic factors. Int J Oral Maxillofac Surg 1985;14:245-58. Journal of Dental Implant Research 2016, 35(1) 22-26

Vol. 35 No. 1, June 2016 Journal of Dental Implant Research 2016, 35(1) 27-31 치조정접근으로시행한상악동막거상술시발생한상악동막천공의치조정을통한수복 : 증례보고 최정임, 김동관, 김초록, 박관수 인제대학교의과대학상계백병원구강악안면외과학교실 Repair of perforated sinus membrane through the alveolar crest during sinus elevation by crestal approach: case report Junglim Choi, Dongkwan Kim, Cho-Rok Kim, Kwan-Soo Park Department of Oral and Maxillofacial Surgery, Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea Sinus membrane perforation is the most common intraoperative complication of sinus elevation. Anatomic drawback of sinus is one of the risk factor to perforate its membrane. Prevalence of perforation during sinus lift accessed by alveolar crest is less than that of by lateral window. To repair the laceration of Schneiderain membrane, the resorbable collagen membrane is mostly covered the perforated area, through lateral approach. However, in this report, the perforated sinus membrane is repaired with resorbable collagen membrane through the socket. On six months after loading, new bone under sinus floor would be found. Of course, it needs to study further, but it could attempt to repair the sinus membrane perforation via transalveolar approach without formation of bony window. (JOURNAL OF DENTAL IMPLANT RESEARCH 2016;35(1):27-31) Key Words: Schneiderian membrane, Sinus membrane perforation, Membrane repair, Crestal approach, Resorbable collagen membrane 서론 골의양이부족한상악대구치부의임플란트식립은상악동이라는해부학적단점을극복하기위해상악동거상술이요구된다. 이는 1975년 Tatum과 1980년 Boyne에의해처음소개된이후로, 많은연구들및여러수술법들의발전으로현재보편적으로시행되는예지성있는수술법이다 1). 측방접근법으로시행되는상악동거상술을통해 10 mm에서 12 mm 정도를, 치조정접근법으로는 3.5 mm에서 5.0 mm 정도의골을얻을수있어 2), 부족한골높이및부피를가지는상악대구치부에충분한양의골을제공해주고있다. 상악동거상술에있어서, 점막파열은가장빈번하게나타나는합병증이다. 이는약 10% 에서 60% 정도의다양한빈도로보고되고있다 3,5). 상악동의해부학적다양성은이러한상악동천공에큰영향을끼친다. 즉, 불규칙한상악동저, 얇은상악동막, 과거상악동수술경험이나낮은잔존치조골등은상악동점막파열의큰위험요 소로작용한다 1,3,6,7). 이러한천공이발생할때, 작은크기의천공의경우는수복하지않은채임플란트수술을진행하거나, 수술을연기하기도하고, 경우에따라서는측방접근법으로새로이상악동에접근하여천공된부위에흡수성 collagen 막을이용하여수복한다 1,3,4). 덜침습적으로수술하기위하여치조정접근법으로거상술을시행하다발생한천공을수복하기위해다시판막을열어측방에골창을형성하여침습적수술이되는것에대해환자와술자는부담을느낄수있다. 치조정접근의경우, 천공의여부를술중에인지하기란쉽지않아, 예방이최선이지만천공이발생한경우가능하면비침습적인방법으로수복할수있다면좋을것이다. 이논문에서상악대구치즉시식립시천공되었던상악동점막을측방접근이아닌치조정접근을통하여흡수성막으로천공부위를막고, 골이식을시행한후임플란트를식립하여천공수복에성공하였던증례를보고하고자한다. Received Apr 23, 2016, Revised May 3, 2016, Accepted May 30, 2016. cc This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creative commons.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. 교신저자 : 박관수, 01757, 서울시노원구동일로 1342, 인제대학교의과대학상계백병원구강악안면외과학교실 Correspondence to: Kwan-Soo Park, Department of Oral and Maxillofacial Surgery, Sanggye Paik Hospital, College of Medicine, Inje University, 1342, Dongil-ro, Nowon-gu, Seoul 01757, Korea. Tel: +82-2-950-1161, Fax: +82-2-950-1167, E-mail: oms_kspark@paik.ac.kr JOURNAL OF DENTAL IMPLANT RESEARCH www.kaidimplant.or.kr

28 최정임등 : 치조정접근으로시행한상악동막거상술시발생한상악동막천공의치조정을통한수복 : 증례보고 증례보고 59세여환이상악우측구치부의통증으로본원에내원하였다. 특이한전신질환은없었으며, 내원당시상악우측제1소구치부터제1대구치까지 3본브릿지로수복되어있었다.(Fig. 1) 수복된구치부의이차우식이존재하였으며, 발치및임플란트수술을계획하였다. 임플란트는제1소구치와제1대구치에식립하기로하였다. 상악제1대구치부의골이 5 mm 이상존재하여, 치조정접근법으로의상악동거상술을시행하고, 최소한의손상으로발치및임플란트식립을하기위해무절개로즉시식립하기로하였다. 수술전, 클로로헥시딘으로구강내소독하였으며, 모든수술은무균하에이루어졌다. 상악우측부의전달마취를시행하였고, 기존보철물을제거하고, 절개없이상악우측제1 소구치, 제2소구치및제1대구치를발거하였다.(Fig. 2) 치조정접근을위한전용의도구로 drilling을시행하였으나, drilling 도중, 제1대구치하방에상악동천공이발생하였다.(Fig. 3) 천공은육안으로식별이가능하여즉시이를인지할수있었고, 이는약 5 mm 이하로판단되었다. 이를수복하기위해, 흡수성막 (Cytoplast TM RTM collagen membrane, Osteogenics biomedical, Inc., USA) 을잘라접은후, 치조정을통하여조심스럽게천공부주변에삽입하였다. 삽입후에접힌막이펴지도록하여천공부를수복하고이를육안으로 확인하였다.(Fig. 4) 이후통상적으로골이식재를삽입하여상악동막거상을완료하고 5.0 10.0 mm 임플란트를식립하였고초기고정은 20 Ncm 이상으로잘얻어졌다.(Fig. 5) 임플란트 fixture 와 Fig. 3. Arrow: Perforation of sinus membrane during sinus elevation via crestal approach. Fig. 4. Arrow: After using absorbable membrane (Cytoplast TM RTM collagen membrane, Osteogenics biomedical, Inc., USA) to repair membrane perforation. Fig. 1. The 3-unit gold crown bridge showed a secondary caries on Rt. Mx. Molar. Fig. 2. After removal of the teeth. Fig. 5. Placement of implant fixture (TS III, Osstem, Korea). Journal of Dental Implant Research 2016, 35(1) 27-31

Choi J, et al: Repair of perforated sinus membrane through the alveolar crest during sinus elevation by crestal approach: case report 29 치조골사이의공간은골이식재로채워넣었으며, Collagen plug (Rapiderm TM, Dalim Tissen Korea) 를잘라골이식재가흩어지지않도록골이식재위로치조골사이공간을채워준후, vicryl 로봉합하였다.(Fig. 6) 상악우측제1소구치부위는특이사항없이임플란트를식립하였다.(Fig. 7) 골유착은잘이루어졌고술후 3개월에는최종보철물을장착하였다.(Fig. 8) 부하후 6개월까지추적관 찰결과임플란트 fixuture의첨부에골형성을보였으며, 기능적, 심미적으로성공적인결과를보였다.(Fig. 9, 10) 고찰 상악동거상술은상악대구치부의부족한골의양을늘리기위해, 잔존치조골의양에따라, 측방이나치조정으로접근하여시행하게된다. 이러한수술에서상악동천공은빈번하게발생하는합병증중의하나이다. 상악동막을거상하기위하여시행되는골창형성이나골창을안으로밀어올리는과정, 치조정접근시골절술을시행하는과정에서천공이많이발생한다. 골이식재를넣기위해점막을골에서분리해막을올리는행위또한천공이빈번하게발생하는과정이다. 특히, 상악동의전방부나하방부막을거상할때가장많이발생하여이에주의를기울여야한다 1). 상악동천공은약 10% 에서 60% 의비율로발생한다고보고되고있다 3,5). 접근법에따른천공의비율을직접적으로비교연구한것들이많이발표되고있지는않지만, 몇몇저자들은측방으로접근한것보다, 치조정접근시, 더적은비율로천공이발생한다고주장하 Fig. 6. Insertion bone material and collagen plug (Rapiderm TM, Dalim Tissen Korea) between alveolar socket and fixture. Fig. 9. Periapical radiography on six months after loading. Circle: New bone formation. Fig. 7. Postoperative radiograph. Fig. 8. Final prosthesis delivery on three months after operation. Fig. 10. Intraoral photo: Six months after loading. Journal of Dental Implant Research 2016, 35(1) 27-31