KOREAN ACADEMY OF LASER DENTISTRY 물방울레이저를이용한치은착색제거에관한임상적연구 Clinical investigation of Er.Cr.YSGG laser on treatment for gingival hyperpigmentation 최석인 * 1), 김남구 2), 김진수 3), 권태규 4), 김종식 1), 최동주 1) 한림대학교구강악안면외과학교실 1), 라이프치과 2), 치아사랑치과의원 3), 안양연합치과 4) Seok-In Choi* 1), Nam-Ku Kim 2), Jin-Soo Kim 3), Tae-kyu Kim 4), Jong-Sik kim 1), Dong-Ju Choi 1) Department of Oral & maxillofacial surgery, College of medicine, Hallym University 1), Life dental clinic 2), Teeth love dental clinic 3), Anyang yunhap dental clinic 4) Purpose: Er.Cr.YSGG laser are used in a variety of dental applications. Laser therapy is superior to previous methods in aspects of hemostasis, pain, treatment time, bio-stimulating effect, infection prevention. The purpose of this study was to report about clinical case of treatment for gingival hyperpigmentation on Er.Cr.YSGG laser with reviewing literature. Material and methods: Patients was visited in Kangdong Sacred Heart Hospital Oral Maxillofacial surgery Dept. and treatment with Er.Cr.YSGG laser and performed assessment of 6 month clinical follow up and check the whether being complication and repigmentation. Result: When using a Er.Cr.YSGG laser, comparing with general treatment, it was more effective in pain control and hemostasis. Conclusion: The laser treatment for gingival hyperpigmentation was valuable. Key word: Er.Cr.YSGG laser, gingival hyperpigmentation Introduction 1964년레이저가처음으로치과영역에사용됨이보고되었고 1) 그이후부터간편한술식과높은환자만족도로인해치과영역에서의사용범위가넓어졌다. 의료용레이저의종류에는 CO₂레이저, Nd:YAG레이저, Ho:YAG레이저, Er:YAG레이저, 아르곤레이저, 구리증기레이저, 루비레이저, Er:Cr:YSGG 레이저, HeNe 레이저, InGaAlP레이저, GaAlAs 레이저, GaAs레이저등이있다. 2) 19
대한레이저치의학회 이중 Er:Cr:YSGG 레이저는 Erbium, Chromium, Yttium, Scandium, Gallium, Garnetdml 복합매질을사용하고, 물분자와결합력이강한 2780nm의고유파장을가지고있다. 분사되는물과의에너지결합에서나오는 hydrokinetic energy를이용하여레이저의단점인열발생을최소화할수있다. 또한 Er:Cr:YSGG 레이저는조직에존재하는수분에대한흡수율이높아서주변조직의손상을최소화할수있다. 3-4) 현재치과분야에서레이저는국소마취, 지혈, 치아우식, 근관치료, 치은염, 연조직질환, 상아질지각과민증, 소대절제술, 치관연장술, 측두하악장애, 치주치료, 교정용브라켓접착, 치아미백, 치은착색제거술등의다양한분야에서적용된다. 2) Melanin에의한치은착색은모든인종에서발생할수있으며특히 gummy smile 을보이는환자에있어서심미적으로중요한문제를야기할수있다. 5) 임상적으로치은의색은연분홍에서흑갈색또는검푸른색의다양한양상을보일수있다. 이는세포질내의멜라닌세포, 상피각화의정도와양, 결합조직내의혈관분포, 피하지방조직, 헤모글로빈의양에의해결정된다. 6) 치은과착색의주요원인으로는멜라노세포에의해발생된멜라닌이상피의기저층과기저상층에다량분포하기때문이다. 7) 또한흡연, 내분비이상, 외상, Albright s syndrome, malignant melanoma, Peutz-Jeghers syndrome등을통하여서도치은과착색이관찰된다. 8) 치은착색제거술은레이저치료외에도 phenol 처치법, cryosurgery, 치은상피제거술등이존재한다. 하지만외과적술식은술후통증과늦은치유의단점이있고 9) cryosurgery는특수장비가필요하며숙련된기술을요구한다. 10) 반면에레이저는사용이쉽고술후통증이적으며생체자극효과에의해창상치유속도도빠르다. 또한레이저는선택적광열분해성 (selective photothermolysis) 을갖는다. 11-12) 특정구조물에서특정파장의레이저의흡수율이높아지고, 레이저의광에너지가열에너지로전환되어조직파괴가일어나는것을선택적광열분해성이라한다. 선택적광열분해성으로인해레이저를이용한외과적술식에서주변조직의피해를최소화하고치료효율을증가시킬수있다.. 이에저자들은다양한장점을갖는레이저중 Er:Cr:YSGG 레이저를이용한멜라닌착색제거에대한임상증례를보고하고자한다. Case report 본연구는멜라닌착색제거를위해 Er:Cr:YSGG 레이저처치를받은환자를대상으로하였고 Biolase사의 Waterlase YSGG를 1W, 19% air, 16% water 모드로사용하였다. 술후평가는임상적경과관찰및합병증유무평가를통해시행하였다. 20
KOREAN ACADEMY OF LASER DENTISTRY Case 1 환자는 18세 여성으로 상악 전치부 순측 치은의 pigmentation을 주소로 내원하였고 술 후 6개월에 재발의 소견은 보이지 않았다. (a) (b) Fig. 1. a) Gingival hyperpigmentation on Mx. Ant. labial area b) After 6 months, lesion decreased. Case2 환자는 47세 남성으로 상하악 전치부 순측 치은의 pigmentation을 주소로 내원하였다. 술 후 6개월에 재발의 소견은 보이지 않았다. (a) (b) (c) (d) (e) (f) Fig. 2. a) b) Gingival hyperpigmentation on Mx. & Mn. Ant. labial area. c) laser application. d) After 2 weeks, only half removed state. e) f) After 6 months, lesion decreased. 21
대한레이저치의학회 Case 3 환자는 35 세남성으로상악중절치사이치은의 pigmentation 을주소로내원하였다. 술후 6 개월에재발의소견은보이지않았다. (a) (b) (c) (d) Fig. 3. a) Gingival hyperpigmentation between both Mx. Medial incisor area. b) laser application. c) After laser application. d) After 6 months, lesion decreased. Discussion 치은착색제거술에대한레이저의치료는기존의전통적인방법과비교해훌륭한대안이될수있다. Er.Cr.YSGG laser를사용하여치은에침착된색소제거시마취를하지않아도보통환자들은큰불편감이없다. 1주일후에회복하고 6개월까지재발이일어나지않는다. 13) 간혹 11개월째에 repigmentation이일어났다고보고된사례도있기는하다. 14) 광에너지를열에너지로바꾸어치료에사용하는레이저의특성때문에인접조직의열손상은 22
KOREAN ACADEMY OF LASER DENTISTRY 어쩔수없는레이저의단점이다. 그러나 Er.Cr.YSGG laser의경우레이저조사시물과공기가동시에나올수있기때문에열손상을줄일수있다. Bur를사용해서와동을형성할경우와 Er.Cr.YSGG laser를사용하여와동을형성할경우치수에서의온도변화를비교해보면, 물과바람을뿌리지않고 bur를사용하여와동을형성한경우 14도의온도상승, 물과바람을뿌리며 bur를사용하여와동을형성한경우 4도의온도상승이일어난반면에, Er.Cr.YSGG laser를사용하여와동을형성한경우온도가 2도하강하였다. 15) 주수는온도의하강과더불어레이저의성능을높여주기도한다. Er.Cr.YSGG laser를사용하여와동형성시물을뿌려줄경우에삭제깊이가더깊었고 carbonization과삭제면에 microhole이형성되지않았다. 16) 또한마취를하지않고와동을형성한환자대부분에서만족할만한결과를얻었다. 17) Er.Cr.YSGG laser는근관치료에서사용할수있다. Er.Cr.YSGG laser를사용하여근관내박테리아를살균할경우, 1W의출력에서근관내세균의 77% 가감소했고, 1.5W에서 96% 까지감소한다. 18) 2W의출력으로 60초동안조사할경우 5% NaOCl과유사한효과가관찰된다. 19) Er.Cr.YSGG laser (tissue cutting mode (air; 11%, water; 7%, power; 1.5W) 와 600µm의 tip) 와조대술을사용해서 ranula를제거하기도한다. 20) 지각과민환자에서 Er.Cr.YSGG laser 사용시 Yilmaz등의보고에서는효과가있었으나 21-22) Sgolastra등의논문에서는플라시보군과차이가없다고보고했다. 23) Er.Cr.YSGG laser는치아와동형성뿐만아니라법랑질, 상아질표면처리에도사용할수있다. Er.Cr.YSGG laser를사용해서법랑질과상아질의표면을에칭하고법랑질과상아질의표면거칠기를 SEM으로관찰하였다. 그결과 37% phosphoric acid를 30초간적용한군과비교했을때 smear layer를효과적으로제거하고 enamel이나 dentin에금을형성하지않았다고보고한다. 24) 교정용브라켓접착을위해 Er.Cr.YSGG laser를사용하여법랑질에칭을대신할경우인산에칭과비슷한결과를보고했다. 하지만실험체개개의편차가크므로실제로사용하기에는아직어렵다고보고했다. 25) 이와같이 Er:Cr:YSGG 레이저는다양한치과분야에서사용되고있으며레이저치료는적은통증, 쉬운술식, 짧은치료시간, 지혈작용, 생체자극효과, 감염방지효과면에서이전치료방법들보다뛰어나다. Conclusion 본증례에서는물방울레이저의 (Er.Cr.YSGG laser) 치은착색제거와문헌고찰등을통해 그효과를알아보았다. 기존외과적술식대신레이저를사용할경우술후동통, 부종, 감염 23
대한레이저치의학회 등의합병증이더적게나타났고환자의만족도도더높았다. 레이저는여러가지많은장점을가지고있으므로앞으로도더욱더많은영역에서적용될수있을것이다. 하지만술자들은레이저의치료기전을명확히이해하고각각의증례에맞추어레이저의설정값을조절할수있는능력을갖추어야할것으로사료된다. Reference 1. Stern RH, Sognnaes RF. Laser beam effect on dental hard tissues. J Dent Res 1964;43:873. 2. Jan Tuner, Lars Hode. Laser Therapy. 1 st ed., seoul, 2006, 도서출판정담, pp. 28-49. 3. Eversole LR. Rizoiu IM. Preliminary investigations on the utility of an erbium, chromium YSGG laser. J Calif Dent Assoc 1995;23:41. 4. Hossain M. Nakamura Y. Yamada Y. Effects of Er.Cr.YGSS laser irradiation in human enamel and dentin: ablation and morphological studies. J Clin Laser Med Surg 1999;17:155. 5. Min-Gu Jung, Sung-Sin Kim, Sng-joon Youn. Treatment of gingival hyperpigmentation by Nd:YAG laser : case report. Oral Biology Research 2006;30(3):201-211. 6. Bergamaschi O, Kon S. Melanin repigmentation after gingivectomy. Int J Periodont Rest Dent 1993;13:85-92. 7. Martini FH. Timmons MJ. Tallitsch RB. Human anatomy. 2nd ed., new Jersey, 1995, Benjamin-Cummings Pub Co, pp. 88-93. 8. Esen E, Haytac MC, Karsli ED. Ginginal melanin pigmentation and its treatment with the CO2 laser. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98:522-527. 9. Tamizi M. Taheri M. Treatment of severe physiological gingival pigmentation with free gingival auto graft. Quint Int 1996;27:555-558. 10. Yeh CJ. Cryosurgical treatment of melanin pigmented gingiva. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:660-663. 11. Jeffy S. Randall L. Pigmented guinea pig skin Irradiated with Q-Switched ruby laser pulses. Arch Dermatol 1989;125:43-49. 12. Nakamura Y. Funato A. Wakabayashi H. A study of the removal of the melanin 24
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대한레이저치의학회 24. Mozammal hossain, Yukio nakamura, Yoshishige yamada, Nobuyuki suzuki, Yoshiko murakami, Koukichi matsumoto. Analysis of Surface Roughness of Enamel and Dentin after Er,Cr:YSGG Laser Irradiation. Journal of Clinical Laser Medicine & Surgery 2001;19(6):297-303. 25. Serdar Usumez, Metin Orhan, Aslıhan Usumez. Laser etching of enamel for direct bonding with an Er,Cr:YSGG hydrokinetic laser system. Am J Orthod Dentofacial Orthop 2002;122:649-656. 26