대한소아치과학회지 35(2) 2008 외과적정출술을이용한치관 - 치근파절된미성숙영구치의치험례 이은미 김태완 김현정 김영진 남순현 경북대학교치과대학소아치과학교실 국문초록 치아의치관-치근파절은치아파절이치관과치근에걸쳐발생되어법랑질, 상아질및백악질까지이환된경우로정의되며, 치수이환여부에따라복잡파절과비복잡파절로분류될수있다. 치관-치근파절의빈도는유치열에서 2%, 영구치열에서 5% 로나타나며, 보통상악전치부에호발한다. 이러한치관-치근파절된치아의수복을위해서는생물학적폭경이유지되어야한다. 이를위하여사용되는방법은골삭제후치은절제술, 교정적견인, 외과적정출후수복하는방법과, 인위적으로발치하여근관치료와수복후재식하는방법등이있다. 이중외과적정출술은치아를발거하여파절부를치은연상으로이동시켜재식하는방법으로서, 이는치관부파절편이임상치근의 1/2 미만인경우에적응증이될수있으며, 발견하지못한다른파절편을직접시진할수있고때로는파절선을순측에위치시켜치료시시야확보및접근이용이하다는등의장점이있다. 본증례에서는외상으로치관-치근파절된미완성치근단의상악중절치를가진환아에서외과적정출술후근관치료와광중합복합레진을이용한치관수복을시행하였으며, 정기적검진시양호한결과가관찰됨을확인할수있었다. 주요어 : 외과적정출술, 치관 - 치근파절, 미완성치근단, 상악중절치 Ⅰ. 서론 소아의외상성손상은소아치과에서흔히접하게되는문제이며, 유치열에서 30%, 영구치열에서 22% 정도의빈도로나타난다 1,2). Andreasen 1-3) 은어린이들이걷기시작하는 2~4세의시기와뛰어놀기시작하는 8~10세의시기에호발하는것으로보고하였으며, 주로상악전치부, 특히상악중절치에호발한다 1,4,5). 치아에대한손상유형을살펴보면, 유치열에서는지지조직의손상즉, 치아의변위나탈구등이많이나타나고, 영구치열에서는치아손상인치관파절, 치근파절또는치관-치근파절등이많이나타나게된다 1,2). 교신저자 : 남순현 대구광역시중구동인동 2 가 101 번지경북대학교병원소아치과학교실 Tel: 053-420-5964 Fax: 053-426-6608 E-mail: lemylove@hanmail.net 이중치관-치근파절은치아파절이치관과치근에걸쳐발생되어법랑질, 상아질및백악질까지이환된경우로정의되며, 치수노출여부에따라단순파절과복잡파절로분류된다 1). 이러한치관-치근파절은예후가불량하며유치열에서 2%, 영구치열에서 5% 의발생빈도를보이고있다 4). 전치부의치관-치근파절은대개직접적외상에의한수평적충격의결과로발생하며, 정면에서힘이가해졌을경우파절선이설측에서치은연하로연장되어나타난다. 파절선이치은연하로연장된경우이환된치아를발치해야할지또는유지해야할지결정해야하는데, 유지하기로결정한경우치료방법으로는골삭제후치은절제술, 교정적견인이나외과적정출술후수복하는방법과, 인위적으로발치하여근관치료와수복후재식하는방법등이있다. 본증례에서는영구중절치가치관-치근파절된환아에있어서외과적정출술후근관치료및치관부수복을시행하여, 정기적검진시임상적, 기능적, 심미적으로양호한결과가관찰되었기에이를보고하는바이다. 305
J Korean Acad Pediatr Dent 35(2) 2008 Ⅱ. 증례보고 < 증례 1> 이름 : 임 O O 나이 / 성별 : 10세, 남 주소 : 일주일전넘어지면서이가부러짐. 치과적병력 : 1년전자전거타고넘어져서상악좌측중절치가파절되어개인치과의원에서부러진치아의파절편을부착하였으나, 일주일전넘어지면서파절편이다시탈락하여경북대병원소아치과로의뢰됨 의학적병력 : 특이소견없음 임상소견및방사선소견 : 임상소견상상악좌측중절치에서치관-치근파절이관찰되 며, 타진반응에민감하고근심파절편에서 3도의동요도가관찰되었다 (Fig. 1). 인접치아의타진반응과동요도는정상이었다. 방사선사진상에서치조골연하방까지연장된수직파절선을관찰할수있었다 (Fig. 2). 치료및경과 : 치료는상기치아의외과적정출술후, 치근단형성술을시행하고치관부를광중합복합레진을사용하여수복하기로계획하였다. 먼저근심파절편을제거한후, 치아를발치겸자로부드럽게발치하여 90도회전시켜근심파절선을순측치은연상으로위치시키고 resin-wire splinting을시행하였다 (Fig. 3). 구개측에서대합치와조기접촉되는부분은선택적으로삭제하였다. 발수후 ZOE로치관부임시충전을시행하고 (Fig. 4), 2주뒤에 splint를제거하였으며 1달뒤 vitapex로근관을충전하였 Fig. 1. Initial photograph. : #21 crown-root fracture. Fig. 2. Initial radiograph. : subgingival fracture line. Fig. 3. Resin-wire splinting after surgical extrusion. Fig. 4. Pulp extirpation and ZOE filling. 306
대한소아치과학회지 35(2) 2008 Fig. 5. After 1 month : vitapex filling. Fig. 6. After 12 months : vitapex change. Fig. 7. After 18 months : gutta-percha filling. Fig. 8. Radiograph after 24 months. Fig. 9. Photograph after 24 months. 다 (Fig. 5). 이후약 18개월에걸쳐 vitapex를교체하였으며 (Fig. 6), 술후 18개월째 gutta-percha로근관을영구충전하고, 광중합복합레진으로치관부를수복하였다 (Fig. 7). 술후 24개월째정기적검진시특이한임상적증상이없었으며, x- ray상치주인대강과치조골의치유를확인할수있었고 (Fig. 8), 심미적으로도만족할만하다 (Fig. 9). < 증례 2> 이름 : 장O O 나이 / 성별 : 14세 / 여 주소 : 계단에서넘어져치아가부러짐 치과적병력 : 내원한시간전계단에서넘어져서상악좌 측중절치가파절되어개인치과의원에내원하였다가경북대병원소아치과로의뢰됨 의학적병력 : 특이사항없음 임상소견및방사선소견 : 임상소견상수평적치관-치근파절이상악좌측중절치에서관찰되었으며 (Fig. 10), 치관부파절편에서 3도의동요도가나타났다. 방사선사진상에서치은연상의파절선이관찰되었으나 (Fig. 11), 치관부파절편의제거로설측에서파절선이치은연하로연장되어있음을확인할수있었다 (Fig. 12). 치료및경과 : 치관부파절편을제거한후, 발치겸자로조심스럽게치아를발거하여 180도회전시켜설측파절선을순측치은연상으로오도록위치시킴으로써정출량이감소되는것을확인한후, 307
J Korean Acad Pediatr Dent 35(2) 2008 Fig. 10. Initial photograph. Fig. 11. Initial radiograph. Fig. 12. Fragment removal. Fig. 13. Resin-wire splinting after surgical extrusion. Fig. 14. After 3 weeks: vitapex filling. Fig. 15. After 12 months: vitapex change. 308
대한소아치과학회지 35(2) 2008 Fig. 16. After 15 months: gutta-percha filling. Fig. 17. After 15 months: temporary crown setting. resin-wire splinting을시행하였다 (Fig. 13). 고정술후인접치에비하여정출된부분은대합치와조기접촉되는부분의선택적삭제를실시하였다. 발수를시행하고, 2주후에 splint를제거하였으며, 술후 3주째에 vitapex로근관을충전하였다 (Fig. 14). 이후광중합복합레진으로치관부를수복하고, 1년에걸쳐 vitapex를교체하여치근단형성술을시행하였다 (Fig. 15). 술후 15개월째에 gutta-percha를사용한영구근관충전을시행하였으며 (Fig. 16), 이때광중합복합레진의파절이관찰되어레진을이용한 temporary crown을제작하여부착하였다 (Fig. 17). 15개월간관찰한결과특이한임상적증상이나방사선소견은없었으며, 환자는심미적으로도만족하였다. Ⅲ. 총괄및고찰파절된치아의경우, 파절선의위치에따라다른치료법이필요할수있다 6,7). 치관파절이있을경우산부식을이용한광중합복합레진수복을시행할수있으며, 치근의중간또는치근부 1/3의파절이있을경우근관치료후자발적으로치유되도록유도할수있다. 그러나, 복잡치관-치근파절의경우또는치경부 1/3의치근파절의경우, 특히파절선이치은연하로연장된경우에는치관부수복의측면에서많은문제점이있을수있다 6). 치은연하로치관-치근파절된치아의치료방법으로는교정적정출술과외과적정출술, 그리고치은절제술등의시술로생리학적폭경을유지시킨후근관치료와수복을시행하여주는방법이있다 8,27). 교정적정출술은치아를정출시키는보다생리적인방법이며, 치은건강에유리하다는장점이있으나, 치료기간이길고자주내원하여야하며내원시마다장치를조정해주어야한다는단점이있다 8-13). 치은절제술은심미적으로눈에띄지않는부위의파절인경우에시행할수있으며, 치은판막을형성하여파절 부위를노출시켜수복하는방법도있는데이러한경우출혈로인해시술부위의건조곤란이일어날가능성이있다 14-18). 외과적정출술은간단하고빠르게행할수있는술식으로서, 발견하지못한파절선을직접시진하여확인할수있으며파절선을순측에위치시킴으로써치조골의해부학적구조상정출량을감소시킬수있고시야확보및접근이용이하다는장점이있으나, 치근유착이나치근흡수등의합병증이발생할가능성이존재한다 19-20). Kahnberg 등 20-22) 은임상적으로외과적정출술이치근을안전하게유지시키는데유용한술식이라고보고하였으며, Caliskan 23) 은외과적정출술이함입된영구치에서교정적정출술을대신하여사용할수있는좋은방법이라고보고하였다. Andreasen 24) 에의하면, 외과적정출술은치아의정출성탈구와비교할수있으며, 비교적치근흡수의발생률이낮고예후가좋은편이라고보고하였다. Kahnberg 21) 는발치와의치유와새로운치주인대의형성을유도하기위해서는백악모세포의생활력이중요하다고하였으며, Söder 등 25) 은치근면세포가건조될때치아유착이나치근흡수가나타난다고하였다. 이에본증례에서는, 외과적정출술을시행하는동안치아는항상치조와내에서수분이있는상태로유지하도록하였으며, 조심스럽게발치하여치주인대의손상을최소화하여건전하게유지되도록하였다. Vitapex는 Ca(OH)2 30.3%, Iodoform 40.4%, silicone oil 22.4%, 기타 6.9% 로구성되어있다 26,27). 이중 Ca(OH)2 는높은 ph 12.5로인하여치근관감염에서발견되는대부분의세균에항균효과를가지고있으며 28,29), Andreasen 등 30) 과 Tronstad 31) 는치근외흡수의진행을멈추기위해유용하게사용되는제재라고보고하였고, 치근단형성술을위해사용되기도한다. 본증례에서도치근의외흡수를막기위해 Ca(OH)2 제재인 vitapex를사용하였으며, 치근단형성술을위해장기적인 vitapex 충전을시행하였다. Andreasen과 Kristerson 32) 은 309
J Korean Acad Pediatr Dent 35(2) 2008 치주인대의손상으로인한유착과흡수를막기위해수상 1주일후치근관충전재로 Ca(OH)2를사용할것을추천하였다. 본증례에서는치관-치근파절된미성숙영구치에서외과적정출술후 vitapex를이용하여근관치료와치근단형성술을시행하였으며, 18개월에서 24개월의장기적인검진시에도동요도나타진반응, 통증등의임상적증상과방사선검사상치근흡수등의병적소견이나타나지않아양호한결과를관찰할수있었다. 그러나, 추후치아유착이나치근흡수등의합병증이나타날수있으므로계속해서정기적인검진이필요할것으로사료되며, 이러한합병증을줄이기위해서는재식시치주인대의손상을최소화하기위해치아를조심스럽게발거하고구강외노출시간을되도록짧게하는것이필수적이다. Ⅳ. 요약 1. 외상으로치관-치근파절된미성숙영구치에서외과적정출술후근관치료와치관수복을시행한결과, 임상적, 방사선학적검사상장기간의양호한결과를보였다. 2. 수개월간의관찰에서치조와는인접치조골과유사한방사선불투과성및치조백선을회복하였고, 별다른자각증상없이동요도는정상이며타진에반응을보이지않았다. 또한치근의유착또는흡수를보이지않고악골내에보존할수있었으며, 심미적으로만족할수있었다. 3. 추후재식에따른치아유착, 치근흡수, 치근단변화등의합병증이발생할수있으며, 계속적인주기적관찰이필요하리라사료된다. 참고문헌 1. Andreasen JO, Andreasen FM : Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd edition. Munksgaard?Copenhagen. 151-180, 1994. 2. Andreasen JO, Ravn JJ : Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg, 1:235-239, 1972. 3. Ravn JJ : Dental injuries in Copenhagen schoolchildren, school years 1967-1972. Community Dent Oral Epidemiol, 2:231-245, 1974. 4. Ellis RG, Davey KW : The classification and treatment of injuries to the teeth of children. 5th edition. Chicago. Year Book Publishers Inc, 1970. 5. Andreasen JO : Etiology and pathogenesis of traumatic dental injuries. A clinical study of 1298 cases. Scand J Dent Res, 78:329-42, 1970. 6. Andreasen JO, Andreasen FM : Textbook and Color Atlas of Traumatic Injuries to the Teeth. Munksgaard Copenhagen. 151-195, 1981. 7. Caliskan MK, Türkün M, Gomel M : Surgical extrusion of crown-root-fractured teeth: a clinical review. Int Endod J, 32:146-151, 1999. 8. Andreasen JO, Andreasen FM : Textbook and Color Atlas of Traumatic Injuries to the Teeth. 3rd edition. Munksgaard Copenhagen. 257-277, 1994. 9. Bessermann M : Ny behandlingsmetode af kronerodfrakturer. Tandkegebladet, 82:441-444, 1978. 10. Wolfson EM, Seiden L : Combined endodontic-orthodontic treatment of subgingivally fractured teeth. J Canad Dent Assoc, 11:621-624, 1975. 11. Ingber JS : Forced eruption Part II. A method of treating nonrestorable teeth - periodontal and restorative considerations. J Periodontol, 47:203-216, 1976. 12. Delivanis P, Delivanis H, Kuftinec MM : Endodontic-orthodontic management of fractured anterior teeth. J Am Dent Assoc, 97:483-485, 1978. 13. Simon JHS, Kelly WH, Gordon DG, et al. : Extrusion of endodontically treated teeth. J Am Dent Assoc, 97:17-23, 1978. 14. Linaburg RG, Marshall FJ : The diagnosis and treatment of vertical root fractures report of case. J Am Dent Assoc, 86:679-683, 1973. 15. Clyde JS : Transverse-oblique fractures of the crown with extension below the epithelial attachment. Br Dent J, 119:402-406, 1965. 16. Langdon JD : Treatment of oblique fractures of incisors involving the epithelial attachment: a case report. Br Dent J, 125:72-74, 1968. 17. Feldman G, Solomon C, Notaro PJ : Endodontic management of traumatized teeth. Oral Surg Oral Med Oral Pathol, 21:100-112, 1966. 18. Feldman G, Solomon C, Notaro P, et al. : Endodontic management of the subgingival fracture. Dent Radio Photogr, 45:3-9, 1972. 19. Tegsjö U, Valerius-Olsson H, Frykholm H, et al. : Clinical evaluation of intra-alveolar transplantation of teeth with cervical root fractures. Swed Dent J, 11:235-250, 1987. 20. Kahnberg KE : Surgical extrusion of root-fractured teeth - a follow-up study of two surgical methods. Endod Dent Traumatol, 4:85-89, 1988. 21. Kahnberg KE : Intraalveolar transplantation of teeth with crown-root fractures. J Oral Maxillofac 310
대한소아치과학회지 35(2) 2008 Surg, 43:38-42, 1985. 22. Kahnberg KE : Surgical extrusion of root-fractured teeth a follow-up study of two surgical methods. Endod Dent Traumatol, 4:85-89, 1988. 23. Caliskan MK : Surgical extrusion of a completely intruded permanent incisor. J Endod, 24:381-384, 1998. 24. Andreasen JO : Luxation of permanent teeth due to trauma. A clinical and radiographical follow-up study of 189 injured teeth. Scand J Dent Res, 78:273-286, 1970. 25. Söder PÖ, Ottoskog P, Andreasen JO, et al. : The effect of drying on the viability of periodontal membrane. Scand J Dent Res, 84:164-168, 1977. 26. 손주효, 최형준, 손흥규 : 의도적재식술을이용한치관-치근파절의치험례. 대한소아치과학회지, 27:256-261, 2000. 27. Han GY, Park SH, Yoon TC : Antimicrobial activity of Ca(OH)2 Containing pastes with Enterococcus faecails in vitro. J Endod, 27:328-332, 2001. 28. 류정아, 최형준, 이제호등 : 의도적재식술을이용한치관-치근파절된미성숙영구치의치험례. 대한소아치과학회지, 31:267-272, 2004. 29. Sjögren U, Figdor D, Spa ngberg L, et al. : Antimicrobial effect of calcium hydroxide as a shortterm intracanal dressing. Int Endod J, 24:119-125, 1991. 30. Andreasen JO, Tronstad L, Hasselgren G, et al. : ph changes in dental tissues after root canal filling with calcium hydroxide. J Endod, 7:17-21, 1981. 31. Tronstad L : Root resorption etiology, terminology and clinical manifestations. Endod Dent Traumatol, 4:241-252, 1988. 32. Andreasen JO, Kristerson L : The effect of extraalveolar root filling with calcium hydroxide on periodontal healing after replantation of permanent incisors in monkeys. J Endod, 7:349-354, 1981. 311
J Korean Acad Pediatr Dent 35(2) 2008 Abstract SURGICAL EXTRUSION OF THE CROWN-ROOT FRACTURED INCISORS: CASE REPORTS Eun-Mi Lee, Tae-Wan Kim, Hyun-Jung Kim, Young-Jin Kim, Sun-Hyun Nam Department of Pediatric Dentistry, School of Dentistry, Kyungpook National University Crown-root fractures occur throughout both crown and root, and are defined as fractures involving enamel, dentin and cementum. The fractures may be grouped according to pulpal involvement into complicated and uncomplicated one. Crown-root fractures often occur on maxillary anterior teeth and comprise 5% of injuries affecting the permanent dentition and 2% in the primary dentition. To restore crown-root fractured tooth, biologic width must be maintained. For maintaining biologic width, such methods as gingivectomy following osteoplasty or orthodontic extrusion or surgical extrusion are available. Surgical extrusion is a method that extracts the tooth and replants the fractured tooth supragingivally. It is indicated when the length of the crown fragment is less than half the length of the clinical root. In these cases, root canal treatment and crown restoration using light-cured composite resin were performed after surgical extrusion. In following periodic examinations, favorable outcome was observed. Key words : Surgical extrusion, Crown-root fractures, Immature root, Maxillary central incisor 312