대한치주과학회지 : Vol. 37, No. 3, 2007 상악전치부에서단일치아발거후즉시임플란트식립 이승훈 *, 김영성, 김원경, 이영규 서울아산병원치주과 I. 연구배경 1999 년 3rd European workshop 에서임플란트의식립방식을발치후식립시기에따라 immediate, delayed, late placement 로구분하였고, immediate placement는발치즉시, delayed placement는발치 6~10 주사이, late placement 는발치 6개월이후에식립하는것으로정의하였다. 심미성이요구되는부위에발치후즉시임플란트를식립하여해당부위를심미적으로회복하고자하는시도가있었으며이에대한여러보고가있다 1-3). 1) Schropp 등은발치후발치와의너비가약 50% 까지감소하며대부분의변화는첫한달이내에일어난다고하였고 4) Johnson 등도발치후첫한달내에발치와의너비는 2.5~7mm, 높이는 3~7mm 까지의감소가일어난다고주장하였다 5,6). 이에대한해결책으로임플란트의즉시식립이제시되었는데, Covani 등은발치후임플란트를즉시식립한군과 1달후임플란트를식립한군에서의치조골변화를관찰하였고, 즉시식립한군에서협설방향의치조 골상실이적었음을보고하였다. 또한발치와에즉시임플란트를식립하는것은외과적술식의횟수를줄이고치조골의체적을유지하며발치시점으로부터임플란트지지보철물수복까지의기간을줄일수있는장점이있으며이로인해심미적, 기능적인이득이있다고주장하였다 7). 하지만 Lindhe 등은임플란트를즉시식립하는것만으로는발치후의경조직의너비와높이를보존하지못하며, 즉시식립을한경우에도협설측골의심각한표면흡수를관찰할수있다고보고하였다 8,9). 따라서심미성이요구되는부위에서즉시임플란트식립시에는치조제에어느정도의흡수가있어도문제가되지않을적절한위치에임플란트를식립하는것이가장중요하다. 또한발치후치조제의골량이부족한경우골증대술을동반한즉시임플란트식립을고려해야한다. 이번증례보고에서는심미성이요구되는부위인상악전치부에서단일치아발거후즉시임플란트식립을이용해만족할만한결과를얻은치험례를보고하는바이다. * 교신저자 : 이영규, 서울시송파구풍납 2 동서울아산병원치과치주과, 138-736 ( 전자우편 : periolee@amc.seoul.kr) 637
II. 임상증례 전신병력이없는세환자에서발치후즉시임플란트를식립하였다. 1. 즉시임플란트식립후치유지대주연결 ( 증례 1) 외상을주소로내원한 37 세남자환자로임상및방사선학적검사상상악좌측중절치에서치관- 치근파절소견을보였으며치은의 biotype 은 thin scalloped type 이었다 (Figure 1, 2). 파절선이치조골하방까지연장되어있었기에해당치아의발거후즉시임플란트를식립하기로계획하였다. 리도카인 ( 휴온스염산리도카인, 휴온스, 대한민국 ) 으로국소마취를시행한후 Periotome 을사용하여 외상없이치아를발거하였다 (Figure 3). 골삭제시에구개측판막의손상이예상되어구개측전층판막을거상하였으며수술에의한외상을최소화하기위하여순측판막은거상하지않았다. 최초드릴링은치근첨에서 3mm 상방구개측치조골에시행하였으며제조사의추천식립법에따라 4mm 직경, 13mm 길이의임플란트 (Astra, Astra Tech, Sweden) 를식립하였다. 즉시식립시임플란트의협설측위치는인접치의설면결절부위와일치하게하였고, 근원심으로는인접치와 2mm 거리를두었다 (Figure 4). 5.5mm short healing abutment(astra, Astra Tech, Sweden) 를연결하고임플란트와순측골판사이의공극에자가골과탈단백우골 (Bio-Oss, Geistlich AG, Wolhusen, Switzerland) 을충전한후 Collatape (Zimmer Dental, Calsbad, CA) 과조직접합제 (Dermabond, Ethicon Inc, Cornelia, Figure 1. Preoperative view of left maxillary central incisor scheduled for extraction. Figure 2. Periapical view. Fracture line was not distinct because the tooth was fractured labio-palatally. Figure 3. Tooth extracted atraumatically by periotome. Figure 4. The implant is in place. Note that palatal full-thickness flap was elevated but labial flap was not elevated for minimizing surgical trauma. 638
Figure 5. Bio-col technique is applied using Bio-Oss, Colla-tape, Dermabond. Figure 6. Pontic is splinted with approximal teeth using Z-100 resin. Figure 7. The provisional restoration is placed at 5 months after implant placement. Figure 8. The final restoration is placed at 7 months after implant placement. GA) 를적용하고 5-0nylon(Blue Nylon, Ailee, Pusan, Korea) 으로봉합하였다 (Figure 5). Sinfony 레진 (3M ESPE, Germany) 을이용하여가공치를제작하고 Z-100 레진 (3M ESPE, USA) 으로인접치에고정하였다 (Figure 6). 수술 5개월후임시수복물을장착하였고 (Figure 7), 7개월후최종수복물을장착하였다. 7개월까지의관찰결과치은퇴축이나염증소견은보이지않았으며임상적으로심미적인결과가유지되었다 (Figure 8). 2. 즉시임플란트식립과동시에임시수복물연결 ( 증례 2) 외상을주소로내원한 32 세남자환자로임상적, 방사선학적검사결과상악측절치의수평치근파절로진단되어발거후즉시임플란트를계획하였다 (Figure 9, 10). 리도카인 ( 휴온스염산리도카인, 휴온스, 대한민국 ) 으로국소마취를시행한후 Periotome 을사용하여 외상없이치아를발거하였다 (Figure 11). 수술에의한외상을최소화하기위하여판막은거상하지않았다. 최초드릴링은치근첨에서 3mm 상방구개측치조골에시행하였으며제조사의추천식립법에따라 4mm 직경, 13mm 길이의임플란트 (Astra, Astra Tech, Sweden) 를식립하였다. 즉시식립시임플란트의협설측위치는인접치의설면결절부위와일치하게하였고, 근원심으로는인접치와 2mm 거리를두었다 (Figure 12). 식립토크는 40N 이었으며초기고정이양호하여즉시임시수복물을제작하여장착하기로결정하였다. 증례 1에서와마찬가지로순측골판과임플란트사이의공극에자가골과탈단백우골 (Bio-Oss, Geistlich AG, Wolhusen, Switzerland) 을충전하고 Collatape (Zimmer Dental, Calsbad, CA) 을적용하였다. 발거한치아의치관을이용하여임시수복물을제작하였다. 제작방법은치관의설측을삭제하고순측면및인접면을남긴후레진으로임시지대주 (Temporary abutment, Astra Tech, Sweden) 에고 639
Figure 9. Preoperative view of left maxillary lateral incisor scheduled for extraction. Figure 10. Radiographic image showing the horizontal root fracture. Figure 11. Root fragment removed by periotome. Figure 12. The implant is in place. Figure 13. Customized provisional restoration using crown portion of extracted tooth. Figure14. Customized provisional restoration is placed in site immediately after implant placement. Figure 15. The final restoration is placed at 6 months after implant placement. Figure 16. 9 months after immediate implant placement. 640
정하였다 (Figure 13). 이렇게제작된임시수복물을즉시임플란트에연결하였다 (Figure 14). 술후 6개월에최종보철물을장착하였고 (Figure 15), 9개월까지의관찰결과치은퇴축이나염증소견을보이지않았으며심미적결과가유지되었다 (Figure 16). 3. 즉시임플란트식립과동시에골증대술시행 ( 증례 3) 상악중절치의동요를주소로내원한 37 세여자환자로임상적, 방사선학적관찰결과좌측상악중절치의치관-치근파절로진단되었다 (Figure 17, 18). 탐침시 6~7mm 의치주낭깊이를보였고누공이관찰되었지만농이배출되지는않는상황이어서발치후즉시임플란트식립과골유도재생술 (GBR) 을동시에시행하기로계획하였다. 리도카인 ( 휴온스염산리도카인, 휴온스, 대한민국 ) 으로국소마취를시행한후전층판막을거상하고치아를발거하였다. 해당부위의 GBR 을위하여 curvilinear beveled incision을시행하였다. 치간유두보존술을시행하려했으나좌측상악측절치의근심측에서치간유두의보존에실패하였다. 판막거상후해당치아의순측골이 3~4mm 상실된것이관찰되었다 (Figure 19). 최초드릴링위치는치근첨에서 3mm 상방구개측치조골에시행하였으며제조사의추천식립법에따라 4mm 직경, 13mm 길이의임플란트 (Astra, Astra Tech, Sweden) 를식립하였다. 즉시식립시임플란트의협설측위치는인접치의설면결절부위와일치하게하고근원심으로는인접치와 2mm 거리를두었다. 또한수직적으로는인접치의치관 -치근경계부 (CEJ) 를연결하는가상선상에서 3mm 하방에임플란트의최상부가위치 Figure 17. Preoperative view of right maxillary central incisor scheduled for extraction. Figure 18. Periapical radiograph showing horizontal fracture line. Figure 19. The recipient site after tooth extraction. Figure 20. GBR procedures were performed following immediate implant placement. 641
Figure 21. Primary closure was achieved. Figure 22. Pontic is splinted with approximal teeth. Figure 23. Provisional restoration was placed. Note the loss of #22 mesial papilla. 되도록하였다. 골유도재생술을위한공간유지의효과를목적으로 4.5mm 높이의 zebra healing abutment(astra Tech, Sweden) 를임플란트에연결하고, 자가골과탈단백우골 (Bio-Oss, Geistlich AG, Wolhusen, Switzerland) 을골결손부위에충전하였다 (Figure 20). 흡수성차폐막 (Bio-Gide, Geistlich AG, Wolhusen, Switzerland) 으로골이식부위를피개한후순측판막을이용하여일차의도봉합을시행하였다 (Figure 21). 임시가공치는레진 (Z-100, 3M ESPE, USA) 을이용하여인접치에고정하였다 (Figure 22). 술후 1개월경부터상악좌측측절치근심측의치간유두가퇴축되기시작하였고 5개월후 direct abutment(astra Tech, Sweden) 를이용하여임시수복을시행할때까지도치은퇴축은해결되지않았다 (Figure 23). 치은퇴축으로인해생긴치간공극의심미적문제를해결하기위하여인접한측절치와견치를재수복하였다. 재수복후절충된심미성을관찰할수있다 (Figure 24). Figure 24. Compromized esthetic result was accomplished by re-restoring approximal teeth. III. 토의 치아발거후즉시임플란트식립은외과적술식의횟수감소, 치조골의체적유지, 그리고발치로부터임플란트지지보철물의수복까지의기간을줄일수있는점등의장점이있다. 또한심미성이요구되는부위에서즉시임플란트식립을시행하였을때에심미적으로만족할만한결과를얻은여러연구가있어즉시임플란트식립은심미적인결과를얻기위한예지성이높은치료법이라할수있다 1-3). 인간과동물을대상으로한연구에의하면, 발치와에즉시식립한임플란트와협측골사이의공극은발치와가건전한경우차단막이나이식재의적용없이도건강한골로치유되어임플란트와정상적인골유착을형성할수있다고하였다 7,10). 자연적으로치유될수있는공극의임계크기는학자마다다르며 Botticelli 등의연구에서거친표면의임플란트를사용한경우임계거리가 1.25~2.25mm 라고보고하였다 14,15). Araujo 등은공극이경조직으로자연치 642
유되나그과정은발치와내부의골형성과외부의골흡수가동시에일어나는방식으로진행된다고하였다 8). Spray 등은임플란트식립후협측골판의흡수가발생하지않도록임플란트외측으로최소존재해야하는골의두께 (Critical buccal bone thickness) 가존재하며그두께는약 1.8mm 라고주장하였다 11). 또한 Testori 등은임계거리보다는협측골판의두께에의해골이식술의여부가결정되어야한다고하였다 12). 즉두께가 1.8mm 이하이면협측골의상실이많이일어나므로이러한경우에는골증대술을동시에시행해주는것이좋다. 증례 1과증례 2의경우발치와가건전하였고임플란트와순측골판사이의공극은 2mm 정도였다. 순측골의두께는증례 1에서는 2mm 정도였으며증례 2에서는판막을거상하지않아확인할수없었다. 즉시임플란트식립시의순측골상실을줄이기위해공극내에탈단백우골 (Bio-Oss, Geistlich AG, Wolhusen, Switzerland) 을채우고 Sclar의 Bio-col technique 23) 을응용하여 Collatape 을적용한후조직접합제 (Dermabond, Ethicon Inc, Cornelia, GA) 로폐쇄를시행하였다. 수개월간의관찰결과눈에띄는순측치조제의흡수는관찰되지않았으며이는순측치조골의두께가 Critical buccal bone thickness 보다두꺼웠기때문으로보인다. Thin scalloped bio-type 의경우치은의퇴축이나타날가능성이있다. 본증례에서는수개월의관찰기간동안치은퇴축이나타나지는않았으나, 임플란트식립시결합조직이식술을동시에시행한다면연조직퇴축등의합병증예방에더욱유리할것이라생각된다. Garber 등은즉시부하를가하기위해서는식립토크가 40Ncm 이상이어야한다고주장했다 13). Schwartz -Arad 등에의하면발치후즉시식립하고즉시비기능적부하를준경우에도통상적인이단계법에의해식립한임플란트와마찬가지로 97.6% 의높은생존률을보였다 14). 증례 2에서는임플란트식립시 40Ncm 의식립토크를얻을수있었기에즉시임시 수복을시행하였다. Botticelli 등은개를이용한실험에서, 협측골이부분적으로상실되었을경우에임플란트식립과동시에흡수성차단막을사용했을때협측골의재생이불완전하게이루어짐을보고하였고이는불완전한공간유지기능때문이라고하였다 15,16). 반면 Lekholm 등은 e-ptfe membrane 을사용한경우협측열개형결손이거의완전하게재생되었음을보고하였다 17). Nemcovsky 등은즉시식립임플란트에서차폐막사용의적응증으로 4mm 이상의열개결손, 임플란트식립후임플란트둘레길이의 1/4 이상이골로쌓여있지않은경우를제시했다 18). 증례 3에서는순측골이 3~4mm 가량수직적으로상실되어있었기에 Nemcovsky 등이제시한차폐막사용의적응증에해당된다고할수있다. 따라서즉시임플란트식립후골결손부를자가골과탈단백우골 (Bio-Oss ) 로충전하고흡수성차폐막 (Bio-Gide ) 으로피개하였다. 여기서는 Botticelli의실험과달리공간유지목적으로탈단백우골과자가골을충전하였으므로흡수성차단막을사용하였더라도어느정도의재생효과를기대할수있을것이라생각된다. 한편 Covani 등은재생술식의시행여부와관계없이발치창에즉시식립된임플란트는 4년간의관찰동안약 97% 의높은누적성공률을보였다고하였다 19). 따라서재생술식을함께시행한증례 3의경우에도장기적으로심미적인결과가유지될수있을것으로예상된다. 전치부임플란트의경우심미적인결과를얻기위해서는치간유두를보존하는것이중요하고이를위해임플란트주위의생물학적폭경을고려하여삼차원적으로적절한위치에식립하여야한다. Buser 등은치간유두를보존하기위해서임플란트식립후협측으로는적어도 2mm 의치조골이잔존해야하며근원심적으로는인접치에서최소 1.5mm 의거리를두어야하고수직적으로는임플란트의최상부가치은연에서 2~3mm 하방에위치하여야한다고하였다 24). 또한결손부치조제의근원심적인거리가 6mm 이상인경우치간유두를보존하는판막설계 643
를하는것이추천된다 25). 증례 3의경우식립위치는적절하였으나판막거상시에상악좌측측절치근심부의치간유두보존에실패하였기때문에치간유두의퇴축이발생한것으로보인다. 본증례들은관찰기간이최대 7개월로단기간이므로향후장기적인관찰이필요하다. IV. 결론 심미성이요구되는부위에서발치후즉시임플란트를식립하는것은적절하고성공적인치료법이라할수있다. 또한대부분의경우에발치후즉시임플란트식립및적절한연조직, 경조직처치를시행함으로써자연스러운임플란트주위조직형태를얻을수있다. V. 참고문헌 1. Gelb DA. Immediate implant surgery: Three years retrospective evaluation of 50 consecutive cases. Int J Oral Maxillofac Implants 1993;8:388-399. 2. Becker BE, Becker W, Ricci A, Geurs N. A prospective clinical trial of endosseous screw shape implant placed at the time of tooth extraction without augmentation. J Periodontol 1998;69:920-926. 3. Schwartz-Arad D, Chaushu G. Placement of implants into fresh extraction sites: 4 to 7 years retrospective evaluation of 95 immediate implants. J Periodontol 1997;68:1110-1116. 4. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single tooth extraction: A clinical and radiographic 12-months prospective study. Int J Periodontics Restorative Dent 2003;4:313-323. 5. Johnson K. A study of the dimensional changes occuring in the maxilla after tooth extraction-part 1.Normal healing. Australian Dental Journal 1963;8:428-433. 6. Johnson K. A study of the dimensional changes occuring in the maxilla after tooth extraction. Australian Dental Journal 1969; 14:241-244. 7. Covani U, Bortolaia A, Sbordone L. Bucco-Lingual crestal bone changes after immediate and delayed implant placement. J Periodontol 2004;75:1605-1612. 8. Araujo MG, Wennstrom JL, Lindhe J. Modeling of the buccal and lingual bone walls of fresh extraction sites following implant installation. Clin Oral Impl Res 2006;17:606-614. 9. Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Tissue modeling following implant placement in fresh extraction sockets. Clin Oral Impl Res 2006;17:615-624. 10. Paolantonio M, Dolci M, Scarano A., et al. Immediate implantation in fresh extraction sockets. A controlled clinical and histologic study in man. J Periodontol 2001;72:1560-1571. 11. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone thickness on facial marginal bone response: Stage 1 placement through stage 2 uncovering. Ann Periodontol 2000;5:119-28. 12. Testori T, Del Fabbro M, Szmukler-Moncler S, Francetti L, Weinstein RL. Immediate occlusal loading of Osseotite implants in the completely edentulous mandible. Int J Oral Maxillofac Implants 2003;18:544-51. 13. Garber DA, Belser UC. Restoration driven implant placement with restoration generated site development. Compend Contin Educ Dent 1995;16(8):796-802. 644
14. Schwartz-Arad D, Laviv A, Levin L. Survival of immediately provisionalized dental implants placed immediately into fresh extraction sockets. J Periodontol 2007;78:219-223. 15. Botticelli D. Berglundh T, Buser D, Lindhe J. The jumping distance revisitied. An experimental study in the dog. Clin Oral Impl Res 2003;14:35-42. 16. Botticelli D, Berglundh T, Lindhe J. Resolution of bone defects of varying dimension and configuration in the marginal portion of the peri-implant bone An experimental study in the dog. J Clin periodontol 2004;31:309-317. 17. Lekholm U, Becker W, Dahlin C, Becker B, Donath K & Morris E. The role of early versus late removal of GTAM membranes on bone formation at oral implants placed into immediate extraction sockets. An experimental study in dogs. Clin Oral impl Res 1993;4:121-129. 18. Nemcovsky CE, Artzi Z & Moses O. Split palatal flap A surgical approach for primary soft tissue healing in ridge augmentation procedures: Techniques and clinical results. Int J Periodontics Restorative Dent 1999;19:175-8. 19. Covani U, Crespi R, Cornelini R, Barone A. Immediate implant supporting single crown restoration: 4-year prospective study. J Periodontol 2004;75:982-988. 20. Araujo MG, Lindhe J. Dimensional Ridge alterations following tooth extraction.an experimental study in the dog. J Clin Periodontol 2005;32:212-218. 21. Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog. J Clin Periodontol 2005;32:645-652. 22. Cardaropoly G, Araujo M, Hayacibara R, Sukekava F & Lindhe J. Healing of extraction sockets and surgically produced-augmented and non-augmented-defects in the alveolae ridge. An experimental study in the dog. J Clin Periodontol 2005; 32:435-440. 23. Anthony G. Sclar. Soft tissue and esthetic considerations in implant therapy, p75- p112, Chicago, IL, Quintessence Publishing. 24. Buser D, Belser U, Wismeijer D. et al. Implant therapy in the esthetic zone single tooth replacement, p25-p37, Chicago, IL Quintessence Publishing. 25. 사또나오시. Implant 주위의 tissue management. p15-p36, 한국퀸테센스출판. 645
- Abstract - Immediate implant placement in areas of aesthetic priority Seung-Hoon Lee *, Young-Sung Kim, Won-Kyung Kim, Young-Kyoo Lee Department of Periodontology, Asan Medical Center Implants placed immediately after tooth extraction have been shown to be a successfully predictable treatment modality. Several clinical papers suggest that placing implants immediately after tooth extraction may provide some advantages: reduction of the number of surgical procedures or patient visits, preservation of the dimensions of alveolar ridge, and shortening of the interval between the removal of the tooth and the insertion of the implant supported restoration. In this case report, three patients received single immediate implant placements to replace a maxillary anterior tooth at the time of extraction. As the three cases were somewhat different, treatment protocols had to be modified as follows: Case 1. Immediate implant placement with healing abutment connection. Case 2. Immediate implant placement with immediate provisionalization. Case 3. Immediate implant placement with Guided Bone Regeneration(GBR). Every implant of these cases was placed in proper position buccolingually, mesiodistally and apicocoronally. The procedures following implantation such as immediate provisionalization and GBR were free of problem. Healing of each case was uneventful. In all cases, treatment outcomes were mostly satisfactory and the results maintained during follow-up periods. However, one case (Case 3) showed some papilla loss due to failure in delicate soft tissue handling during surgery. This papilla loss was compromised by prosthetic means. In conclusion, immediate implant placement in the fresh extraction socket can be a valid and successful option of treatment in aesthetic area. Moreover, this treatment protocol seems to maintain the preexisting architecture of soft and hard tissues in most cases. 2) Key words : immediate implant, esthetic area 646