ISSN 1229-5418 Implantology 2016; 20(3): 132~141 상악무치악에서단일상지르코니아를이용한임플란트 - 지지고정성보철물수복증례 박성우, 권주현, 장재승, 김선재 강남세브란스치과병원치과보철과 Implant-Supported Fixed Prostheses in Maxillary Edentulous Patient with Monolithic Zirconia Sungwoo Park, Joo-Hyun Kwon, Jae-Seung Chang, Sunjai Kim Department of Prosthodontics, Gangnam Severance Dental Hospital, Seoul, Korea bstract Generally, implant-supported fixed prostheses are fabricated with metal framework, acrylic resin, and feldspar porcelain. These prostheses are associated with high complication rates. Recently, implant-supported fixed prostheses made of monolithic zirconia was used for maxillary edentulous patient based on inherent good properties of zirconia. This case was fabricated by computer-aided design/ computer-aided manufacturing (CD/CM). Key Words: computer-aided design/computer-aided manufacturing, maxillary edentulous, monolithic zirconia, poly methyl methacrylate Reprint requests: Sunjai Kim Department of Prosthodontics, Gangnam Severance Dental Hospital, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea Tel: 82-2-2019-3568, Fax: 82-2-3463-4052 E-mail: sunjaikim@gmail.com Received for publication: ugust 13, 2016 Revised for publication: ugust 17, 2016 ccepted for publication: ugust 18, 2016 교신저자 : 김선재 (06273) 서울시강남구언주로 211 강남세브란스치과병원치과보철과 Tel: 82-2-2019-3568, Fax: 82-2-3463-4052 E-mail: sunjaikim@gmail.com 원고접수일 : 2016 년 8 월 13 일원고수정일 : 2016 년 8 월 17 일게재확정일 : 2016 년 8 월 18 일 Copyright 2016. The Korean cademy of Oral & Maxillofacial Implantology This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 132 Implantology Vol. 20 No. 3, 2016
I 서론 를얻었기에이를보고하고자한다. 임플란트-지지고정성보철물은금속구조물, 레진치아, 아크릴릭레진으로제작되어왔다. 그러나최근의연구에서는임플란트-지지고정성보철물이상대적으로높은합병증을갖는다고보고되었다 1. 이러한보철물에서는레진치아의마모, 의치치아탈락, 레진과합금의파절, 색소침착등의부가적인문제점들이발생했다. 이를보완하기위해금속지지위에도재로형태를형성하는보철물도사용되었으나도재부분의파절등의문제점이있었다 (Fig. 1) 2. 그래서최근에는단일상지르코니아를지지대및치아형태로형성하고핑크포세린으로심미성을향상시킨보철물형태가제안되어임상에서사용하고있다 1. 지르코니아는독성이없고표면이활택하여박테리아부착이적어생체친화적이며관리하기가편하다는장점이있다. 또한레진이나장석계도재에비해뛰어난물리적성질로파절이적다는장점이있다 3. 이에본증례에서는상악무치악에서단일상지르코니아를이용한임플란트-지지고정성보철물을제작하여만족할만한결과 II 증례보고 1. 진단및치료계획 59 세여자환자가상악임플란트에서고름이나오고 통증이있으며, 고정성보철물로수복하기를원하여본원에내원하였다. 특이할만한전신병력은없었고, 과거외국에서 #13, #23 부위에임플란트치료를받았고 #23 부위에는임플란트주위염의증상이관찰되었다 (Fig. 2). Fig. 2. Panoramic view. Peri-implantitis was found on #23. Sungwoo Park et al. : Implant-Supported Fixed Prostheses in Maxillary Edentulous Patient with Monolithic Zirconia. Implantology 2016 C Fig. 1. Complications of implant-supported fixed dental prostheses. () Continuous wear. () Resin denture tooth fracture. (C) Metal framework fracture. 대한구강악안면임프란트학회지 20 권 3 호, 2016 133
Case Report Fig. 3. () Implant ball attachment. () Overdenture. 부위를없앤납의치시적을통해고정성보철물을원하는환자에게고정성보철물수복으로인한안면지지의부족을미리보여줄수있다고설명한바있다. 환자는납의치시적을통해안면및상순지지의부족을보였다. 이러한기준에따라가철성보철물로수복을결정하였다 (Fig. 6) 4. Fig. 4. Implant first stage surgery (Superline; Dentium, Seoul, Korea). Sungwoo Park et al. : Implant-Supported Fixed Prostheses in Maxillary Edentulous Patient with Monolithic Zirconia. Implantology 2016 내원당시상악임플란트 2개를이용한의치를사용중이었다 (Fig. 3). 임플란트주위염이관찰된 #23 임플란트를제거하고 #17, #16 부위와 #24, #26, #27 부위에임플란트를식립 (Superline; Dentium, Seoul, Korea) 하였다 (Fig. 4). 임플란트식립 4개월후이차수술을시행하였고 (Fig. 5), 구강내검사와환자안모평가결과 (Table 1), 환자는오목한측모형태를보였고골격성 3급교합형태를보였다. 미소선은내려오지않았으며, 상순의길이또한약 18 mm로짧았다. Zitzmann과 Marinello 4 는 flange 2. 바피개의치수복바 (bar) 피개의치를최종보철물로선택하여임플란트에멀티유닛지대주 (Ti-cylinder diameter 5.5; Dentium) 체결후최종인상을채득했다. 수직고경측정및납의치시적을거쳐완성된납의치에서의인공치아를석고인덱스를사용하여최종모델에인기하여바의높이를결정하였다. 가능한공간을활용하여 framework 공간만을남겨둔채최대한의높이로 bar를주조했다. 이후 framework 을제작하였고, 석고인덱스를활용하여치아배열을복제하여완성된최종의치를환자에게장책해주었다 (Fig. 7). 134 Implantology Vol. 20 No. 3, 2016
Table 1. Checklist for implant treatment: extraoral examination (based on an acceptable existing prosthesis or an ideal wax trial denture) Structure Fixed implant prostheses Removable prostheses Upper lip support Esthetic plane ngle class Horizontal tooth display Length of upper lip Unnecessary Convex profile Class I/II 6~10 teeth Long (26~30 mm), average (21~25 mm) Cited from the article of Zitzmann et al. (J Prosthet Dent. 1999; 82: 188-196) 4. Necessary Concave profile Class III 10~14 teeth Short (16~20 mm) Fig. 5. () Implant second stage surgery. () Stitch-out. C Fig. 6. () Esthetic line. () Length of upper lip. (C) Flangeless wax denture try-in. 대한구강악안면임프란트학회지 20 권 3 호, 2016 135
Case Report C D E F Fig. 7. ar overdenture restoration. () ar design made of pattern resin. () Plaster denture teeth index. (C) Milled bar tryin, space evaluation. (D) Overdenture framework. (E) Plaster denture teeth and overdenture framework. (F) ar overdenture. 136 Implantology Vol. 20 No. 3, 2016
C D E F Fig. 8. Temporary implant-supported fixed prosthesis made of acrylic resin (Luxatemp; DMG). () Master cast. () Putty index. (C) crylic resin pouring. (D) crylic resin temporary fixed prosthesis. (E) Pink resin build up. (F) Intraoral try-in. 대한구강악안면임프란트학회지 20 권 3 호, 2016 137
Case Report C D E F Fig. 9. (, ) Digital scanning (MCX5; Sirona). (C) Fixed prosthesis was merged into master cast (exocad; exocad GmbH). (D) PMM disc milling (PMM disc, YMHCHI DENTL Materials). (E) PMM temporary fixed prosthesis. (F) Pink resin build up. 138 Implantology Vol. 20 No. 3, 2016
3. 임플란트-지지고정성보철물지속적인경과관찰시행중, 3개월후환자가틀니가움직이고, 임플란트를여러개식립했는데가능한한고정성으로보철물을제작하고싶다고하였다. Zitzmann 과 Marinello 4 에의하면 (Table 1), 환자는가철성보철물의적응증에해당하므로고정성보철물제작시상순지지및안모를최대한변화없이시행할수있도록치은부위형성이가능한고정성보철물을제작하기로하였다. 환자는기존치아형태및배열에는만족하였으므로기존의치의치아배열을그대로옮기기로결정했다. 기 존의치의치은, 치아형태및배열을복제하기위해실리콘인덱스를사용하였고, 구강내에서악간관계채득후최종모형단계에서아크릴릭레진 (Luxatemp utomix Plus; DMG, Hamburg, Germany) 과인덱스를사용하여임플란트-지지고정성보철물을임시로제작했다. 치은부위에핑크레진을첨가하여심미성을더한후환자구강내에시적하였고, 구강내에서교합조정을시행했다 (Fig. 8). C D Fig. 10. Implant-supported fixed prosthesis was duplicated and milled with zirconia (Zirpremium UT plus; cucera). () fter milling state. () Coloring. (C) Sintering. (D) Pink porcelain build up. 대한구강악안면임프란트학회지 20 권 3 호, 2016 139
Case Report 4. 고정성임시보철물의장착임플란트-지지고정성임시보철물을지속적으로경과관찰하여치은과의접촉부위를레진첨가및 tooth brush instruction 을시행하여음식물침착을줄이기위해노력했다. 수정된형태를최종모델에다시장착하고모델스캐너 (InEOS X5; emsheim, Sirona, Gemany) 로스캔하였고, 임시보철물부위만따로잘라내어 STL 파일로추출했다 (inlab; Sirona). 추출된보철물형태를멀티-유닛실린더가장착된최종모형에합치고실린더에적합시켰다 (exocad; exocad GmbH, Darmstadt, Germany). PMM 디스크 (PMM Disk; YMHCHI DENTL Materials, Changshu, China) 를사용하여임시보철물을복제한형태로 PMM 보철물을제작했다. 구강내에서 pressure index paste (PIP) 를이용한내면조정및교합조정시행후이전보다활택한형태의보철물시적으로인한변화를확인했다 (Fig. 9). 5. 고정성최종보철물의장착 PMM에서내면조정한형태를참고하여내면디자인의변형후지르코니아 (ZirPremium UT plus 25 mm 98Ø; cucera, Pocheon, Korea) 로복제하여제작했다 (Fig. 10). 기존보철물참고하여유사한형태및색 Fig. 11. Implant-supported fixed prosthesis delivery. 140 Implantology Vol. 20 No. 3, 2016
상으로핑크도재축성을시행했다. 구강내에서내면조정시행후실린더와의접착 (Rely X Unicem; 3M Deutschland GmbH, Neuss, Germany) 을하였고장착시 one-screw technique 을시행하여구강내에보철물을체결하였고, 교합조정을시행했다. TI 및보철물관리교육을시행했고, 지속적인경과관찰을통해음식물침착및불편감을해결했다 (Fig. 11). 상지르코니아로제작하기에는밀링기계에한계가있었고밀링축의개수, bur의접근각도, 25 mm 두께의지르코니아디스크를소프트웨어가인식하지못하는등의문제가있었다. IV 결론 III 총괄및고찰 이번증례에서디지털스캔을활용하여가철성보철물과유사한형태의고정성임시보철물및최종보철물로성공적인복제를할수있었다. 또한 PMM 임시보철물을수정하여지르코니아최종보철물의제작에반영할수있었던것은 computer-aided design (CD) 으로수정이가능했기때문이다. 또한보철물의합병증이발생시같은형태의보철물을재제작할수있다. 보철물의외형은복제가가능했지만최종모형내에인기되는내면까지는복제가불가능하다는한계가있었다. 아크릴릭레진임시보철물에서 PMM 임시보철물전환에서는내면복제가불가능했으나보철물디자인이후내면디자인형태의수정이가능하다는것에착안하여 PMM 임시보철물에서지르코니아최종보철물변환시에과도한치은압박부위를조절하는방법으로구강내조절시간을줄일수있었다. PMM 임시보철물의구강내시적과정에서 PIP와 fit checker 등을통해내면에과도한접촉부위를표시하고이를 CD상에서수정하는형태로지르코니아최종보철물의내면을형성했다. 최종보철물제작시어려웠던점으로는환자의악궁전체를수복하는보철물제작과같이큰보철물은단일 고정성보철물에서단일상지르코니아와치은부위에핑크포세린을사용하여, 상순지지가부족한환자에게지지를부여할수있었다. 디지털시스템을통하여보철물을복제할수있었으며, 같은디자인의다른재료를갖는보철물제작이가능했고필요에따라원하는형태의보철물로수정할수도있었다. 이러한단일상지르코니아와핑크포세린을이용하여환자와술자모두만족할만한보철물을장착하였지만앞으로장기적인결과에대한연구가필요하리라생각된다. References 1. Jemt T, Johansson J. Implant treatment in the edentulous maxillae: a 15-year follow-up study on 76 consecutive patients provided with fixed prostheses. Clin Implant Dent Relat Res. 2006; 8: 61-69. 2. ozini T, Petridis H, Garefis K, et al. meta-analysis of prosthodontic complication rates of implant-supported fixed dental prostheses in edentulous patients after an observation period of at least 5 years. Int J Oral Maxillofac Implants. 2011; 26: 304-318. 3. Denry I, Kelly JR. State of the art of zirconia for dental applications. Dent Mater. 2008; 24: 299-307. 4. Zitzmann NU, Marinello CP. Treatment plan for restoring the edentulous maxilla with implant-supported restorations: removable overdenture versus fixed partial denture design. J Prosthet Dent. 1999; 82: 188-196. 대한구강악안면임프란트학회지 20 권 3 호, 2016 141