대한치과보철학회지 :Vol. 37, No. 3, 1999 콤비네이션임프란트크라운 (Combination Implant Crown) 을이용한단일치아의임프란트보철수복증례 대림성모병원치과부보철과 김래경 * 송언희 최병갑 김현철 안현정 Ⅰ. 서론골유착성임프란트가무치악의고정성보철물에의한수복에성공함 1-3) 에따라부분무치악에적용되고단일치아의결손증례에도도입된이래 4-5) 보다심미적이고기능적인임프란트수복을위하여여러방법들이고안되고개발되어져왔다 5-9). 단일치아결손의임프란트수복시요구되는조건으로는심미성, 회전에대한저항성 (counter-rotation), 생체에대한적합성 (biocompatibility), 단순성 (simplicity), 청소의용이성 (accessibility), 수정의다양성 (variability), 수리의가능성 (retrievability) 등 9-11) 이있다. 단일치아결손의임프란트수복방법은임프란트본체 (body,fixture) 에보철물이직접연결되는형태인 UCLA형 abutment 11-15) 와같이 abutment와 gold cylinder가일체화된비분할 abutment (non-segmented abutment) 를사용하는직접수복법 (direct restoration) 과임프란트본체와보철물사이에중간 abutment (intermediary abutment) 를사용하는간접수복법 (indirect restoration) 으로구분할수있다. 간접수복법의 abutment는다시최종상부구조를고정하는방법에따라시멘트합착형 (cementation type) 의 abutment와나사유지형 abutment (screw retained abutment) 로분류된다 16-18). 한편나사유지방식은짧은 abutment에서도나사에의해서유지력을얻을수있고, 임프란트의상부구조에조임나사의풀림 (screw loosening) 이나파절 등의문제가생겼을경우에도언제나수리및교체가가능한 retrievability 10,18) 가있는반면, abutment와임프란트크라운을연결시시멘트공간에의한오차보상을할수없으므로고도의보철물적합도가요구되고기능시에나사풀림 (screw loosening) 의가능성이있으며 19-22) 심미성과단순성그리고회전방지의면에서시멘트합착방식보다불리한조건에있다 23-24). 나사의풀림은단일임프란트수복물의부적합및나사의파절등으로골유착에좋지않은결과를가져올수있는데 25), Jemt등 (1991) 24) 의보고에의하면장착후처음 1년동안나사유지형임프란트치관의 26% 에서, 하악 (10.5%) 보다는상악 (31%) 에서훨씬높은빈도로관찰되었다. 시멘트합착방식은임프란트상부의크라운구조의단순성및 abutment와임프란트크라운간의오차를시멘트공간으로보상할수있고, 기능시회전력에대한높은저항성을갖는다 26). 그러나임프란트크라운을나사유지형의 abutment 에인산아연시멘트, 글라스아이오노머시멘트또는레진시멘트등과같은영구적시멘트로일단시멘트합착한후에는합착된임프란트크라운을손상시키지않고는상부구조와임프란트본체의분리가불가능하여 retrievability의면에서열세하고, 경화후시멘트가치은연하에남아제거가어려운점등의문제점이있다 10,27). 두가지방법의장점만을이용할목적으로 Jemt는분리되어있는완성된보철물과 single tooth abut- 375
ment를적절한시멘트로접착한후이들을 abutment screw로임프란트와고정한증례를보고하였으나나사의고정을위한큰진입구 (access hole) 를형성하여기능적인교합면의크기가감소되고심미성이저하되는단점이있었다 5). 본원에서는이와유사한 Calcitek Integral Omniloc System과 spline system의 fixed abutment을이용한콤비네이션임프란트크라운 (Combination Implant Crown) 의경우, 보다작은진입구의형성으로기능적이고심미적인시술로단일치아결손의임프란트보철수복을시행함에있어다소의지견을얻었기에이를보고하는바이다. Ⅱ. 임상증례 < 증례 1> 좌, 우구치부의저작시의동통을주소로내원한 59세남성환자로내원당시 #35와#37을지대치로한금관브릿지로수복되어있었고대합치는건강한자연치였다. 보철물의제거후 #37은분지부병변으로인하여치근분리술을시행하였으며치아결손부위인 #36은직경 5.0mm, 길이 10mm의 HAcoated Spline cylinder implant body를식립하였다. 식립 4개월후 2차수술을시행하고 2주후임프란트주변연조직이충분히치유된후 6.5mm flare의인상용포스트를임프란트본체 (body,fixture) 에장착하였다. 실리콘고무인상재 (Extrude, Kerr) 를이용하여최종인상을채득하고, 통법에의해임프란트본 체아나로그를연결한후연성치은모형제 (soft gingival modeling material) 를 abutment와임프란트본체아나로그주변에주입함으로써기공작업시임프란트 abutment의착탈을용이하게하였다. 6.5mm flare, 4mm cuff의 fixed abutment를 hex driver를이용하여임프란트본체아나로그에설치하고상하악모형을교합기에부착하였다. 교두감합위 (intercuspal position) 에서최종수복물을완성하기에충분한공간이존재하는지검사하고필요한양만교합면을삭제한후 abutment의측벽이약해지지않도록 cuff line하방으로는삭제되지않게주의하여변연부형성을하였다. 통법에의해 wax-up과주조를시행하고교합면으로부터조임나사에도달하기위한진입구의형태를수정한후구강내시적하여치간및교합접촉을조정하였다. 구강외에서글라스아이오노머시멘트를이용하여임프란트크라운을 abutment에부착한후 (Fig. 1) 진입구 (access hole) 를통하여조임나사 (fastening screw) 를조여임프란트본체에나사고정하였다. 교합검사후진입구에면구를넣고그위의공간은 composite resin으로밀봉하였다 (Fig. 2). < 증례 2> #46의금관의탈락을주소로내원한 26세여성환자로동일지대치의심한치은연하우식증으로수복이불가능하여발치를시행하였다. 대합치는금관이장착된상태이고발치 3개월후직경 4.0mm, 길이 15mm의 Integral Omniloc Implant body를식 Fig. 1. retrievable crown is shown before cementation to the abutment Fig. 2. occlusal view of final restoration in model 376
Fig. 3. screw access hole only for allowing access to floating screw Fig. 4. access cavity of cemented restoration is closed with resin Fig. 5. occlusal view of restoratioon seated in master cast Fig. 6. buccal view of finished restoration 립하고 2차수술후 4mm cuff의 abutment를선택한후치은연하 0.5mm에변연형성을하였다. 이후통법에의해임프란트크라운을제작하고구강외에서글라스아이오노머시멘트를이용하여임프란트크라운을 abutment에합착하였다. 본증례의경우 hex driver만들어갈수있을정도로진입구의크기를최소화함으로써보다기능적인교합면을형성할수있었다 (Fig. 3, 4). < 증례 3> 44세의남자환자로타의료기관에서 #47의근관 치료를시행한후방치한결과치근부의수직파절을주소로내원하여발치하였다. 대합치는건강한자연치로발치약 4개월후직경 5mm, 길이 10mm의 Spline cylinder implant body를식립하고약 3개월후 2차수술을시행하였다. 주변연조직의치유후에 6.5mm flare, 2mm cuff의 abutment를사용하여통법에의해최종적인임프란트크라운을제작하고 (Fig. 5, 6), 구강외에서 superbond 레진시멘트를사용하여임프란트크라운을 abutment에합착하였다. 본증례에서는 Spline의 fixed abutment를사용하여증례 2에서와같이진입구의크기를최소화할수있었다. 377
Ⅲ. 총괄및고안단일치아결손의임프란트수복시에임프란트크라운을 abutment 에시멘트로합착하고다시이것을나사에의해임프란트본체 (body, fixture) 에연결하는콤비네이션임프란트크라운은시멘트나나사만을단독으로사용하는연결및유지방식에비해많은장점들을가지고있다. 콤비네이션임프란트크라운은분리되어있는완성된보철물과 single tooth abutment를적절한시멘트로접착한후이들을 abutment screw로임프란트와고정하는 Jemt(1986) 5) 의방법과유사하나 McGlumphy등 (1992) 10) 은 Integral Omniloc Implant System을이용하여조임나사를위한진입구를 hex driver가들어가는정도로작게제작하여본방법의다수의장점을보고하였다. Fig. 7과 Fig. 8은각각증례 1과증례 2의임프란트크라운의진입구를하방에서본장면으로증례 1 은진입구를크게형성하여통상의나사유지방식의진입구와유사한크기로교합면의문제점을계속가지고있었으며, 증례 2는 McGlumphy 등의증례와같이작은진입구를형성하여교합면이보다기능적이고심미적인수복을시행할수있었다. 또한경과관찰중임프란트본체에고정된나사의조정으로수복물의 retrievability가가능한장점을가지고있다고생각한다. 콤비네이션임프란트크라운을적용한 Integral Omniloc Implant System은조임나사가 abutment 내부에서자유로이움직일수있는공간이부여된상태로캡슐화 (encapsulating) 되어조임나사를 abutment의외부로제거할수없는제한성이있어단일치아수복에만사용가능하며진입구를 hex Fig. 7. inferior photo of access hole in case 1. Fig. 8. inferior photo of access hole in case 2. Fig. 9. fixed abutment which contain a floating screw in abutment housing Fig. 10. fractured abutment which preparation below cuff line resulted in 378
driver가들어갈수있는최소한의크기로형성할수있었다 (Fig. 3). 캡슐화되어있지않은다른분할형의임프란트시스템은조임나사의제한성이없으므로 multiple unit에도적용할수있으나 abutment간의 path가평행하거나 abutment의수직공간이충분하여 unscrewing을위한상방 space( 교합간거리 ) 가부여되는경우에한정되어사용할수있다고생각한다. 콤비네이션임프란트크라운을제작시시멘트사용의경우 abutment 상부조임나사의머리부위에시멘트가들어가지않도록주의하여시멘트합착을시행해야한다 (Fig. 9). Abutment에임프란트크라운을합착하는방법은구강내외어디에서든지할수있으나합착의정확도를검사할수있고, 여분의시멘트의제거가용이하므로구강외에서합착하는방법이추천된다 10). 임프란트크라운제작을위한 abutment형성과정시주의할사항으로구강내에서임프란트본체 (body,fixture) 와연결되어있는상태에서 abutment를삭제하지않도록하여열의발생및열전도를방지하고, 기능시 abutment의파절방지를위하여축벽 (axial wall) 부위의과다한삭제와 cuff line하방으로의삭제를하지않도록주의해야한다 10). Fig. 10은 cuff line 하방으로 abutment를삭제하여 abutment가파절된증례를나타내고있다. 콤비네이션임프란트크라운은임프란트보철수복완료후필요시언제든지임프란트본체에서 abutment를분리할수있고, 영구적인시멘트로합착한경우에도약 1,000 F 에서처리하여 18) 임프란트크라운과 abutment를제거하여수리 (retrievability) 가가능하고, emergence profile의수정을할수있으며임프란트주위의연조직의평가및치은연하치석의제거가용이하다 10). 수제 ( ) 의 abutment (custom-cast abutment) 나주조가능한플라스틱패턴의 UCLA abutment 같이제작하는방식은임프란트본체와 abutment 간의적합도가저하되어임프란트상부구조의미세운동에의한조임나사의풀림현상이일어나기쉬운 반면 19) 콤비네이션임프란트크라운은밀링처리된 상태그대로의 abutment 에임프란트크라운이시멘트합착되므로적합도의향상을기대할수있다. 또한 abutment와임프란트크라운간에시멘트로합착 시킴으로써나사유지시발생하는 settling현상의발생을방지하고힘의분산에도움을주어나사의풀림현상을줄일수있을것으로사료된다. 통상적인콤비네이션임프란트크라운의제작의금기증은 abutment의수직공간이불충분하여임프란트크라운의유지에필요한 abutment의길이가짧은경우로, 이경우에는 UCLA 형 abutment와같이 abutment와임프란트크라운일체형의나사유지 abutment (non-segmented screw-retained abutment) 로수복하는것이바람직하다 9). Ⅳ. 결론콤비네이션임프란트크라운은단일치아임프란트수복시필요한요구조건인단순성, 심미성및기능시회전에대한저항성, 수리 (retrievability) 가가능하여경제성의장점을가지며 abutment 와임프란트크라운을연결시시멘트공간에의한오차를보상할수있어보철물적합도가우수하다. 즉, 시멘트합착방식 (cement fixed type) 과나사유지방식 (screw retained type) 의장점을겸비하였다. 콤비네이션임프란트크라운은분할형의임프란트시스템으로임프란트수복의경우에는 Integral Omniloc과 Spline이외의다른시스템에서도적용이가능하다. 앞으로콤비네이션임프란트크라운의장기적인예후에대한보고및보다많은임상적연구가이루어져야할것으로사료된다. 참고문헌 1. Adell R, Lekholm U, Rockler B, et al : A 15 year study of osseointegrated implants in the treatement of the edentulous jaw. Int. J. Oral Surgery. 1981:10:387-416. 2. Kent John N., Block M.S., Finger I.M. et al : Biointegrated hydroxyapatite-coated dental implants: 5 year clinical observations. J. Am. Dent. Assoc. 1990:121:138-144. 3. Kirsch A, Mentag PJ : IMZ endosseous two phase implant system: complete oral 379
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ABSTRACT SINGLE TOOTH IMPLANT RESTORATION USING COMBINATION IMPLANT CROWN : A CASE REPORT Rae-Gyoung Kim*, Eon-Hee Song, Byeong-Gap Choi, Hyoun-Chull Kim, Hyun-Jeong Ahn Department of Prosthodontics, Faculty of Dentistry, Daerim Saint Mary s Hospital The purpose of this article is to present the clinical and laboratory procedures for single tooth restoration using Combination Implant Crown. It is cemented on implant abutment and that abutment is screw-retained over implant body. This type of implant restorations has the advantages of cement-retained restoration while being antirotational and retrievable. And, more esthetic and functional result can be achieved by minimizing the size of access hole. The results were as follows : 1. Preparation of abutment below the cuff line should be avoided 2. Axial reduction of implant abutment should not be excessive because it may weaken the abutment 3. More esthetical and functional occlusal surface was achieved with a minimal access hole which is slightly larger than the diameter of hex driver to enable future total retrievability. 4. Combination Implant Crown has the advantages of both the cement-retained and screw-retained type implant restoration. 5. Cementation between implant crown and abutment reduces screw loosening through even force distribution Key words : Access hole, Cement-retained, Combination Implant Crown, Retrievability 382