구순구개열환자의상악전방분절대한구순구개열학회지골신장술식을이용한 14(1):19~28, 교정치험례 2011 구순구개열환자의상악전방분절골신장술식을이용한교정치험례 유성훈, 최혜영, 유형석, 백형선, 차정열 * 연세대학교치과대학교정학교실, 두개안면기형연구소 ABSTRACT Maxillary Anterior Segmental Distraction with Rigid External Device: Case Report Seong-Hun Yoo, Hye-Young Choi, Hyung-Seog Yu, Hyoung-Seon Baik, Jung-Yul Cha* Department of Orthodontics, Institute of Craniofacial Deformities, Yonsei University, College of Dentistry, Seoul, KOREA Maxillary anterior segmental distraction osteogenesis (DO) has been the alternative treatment option for patients with midfacial retrusion. The patient showed unilateral cleft lip and palate, and premaxillary distraction with rigid external device (RED) was planned to solve midface deficiency and to create alveolar space. Significant advancement of A point was observed, but relapse of A point was detected during consolidation period. The vertical position of the ANS was found to have moved downward. Axis of upper incisor decreased after DO. Maxillary anterior segmental DO is effective for treatment of patient with cleft lip and palate. The alveolar space is regained successfully, and the facial profile is improved without velopharyngeal problems. Key words : Intraoral appliance, Maxillary anterior segmental distraction osteogenesis, RED Introduction 구순구개열환자의치료에서중안모의열성장개선은중요한치료목표가될수있다. 이러한환자들에게심미적, 기능적측면의개선을위하여상악분절골수술을포함하는전통적인수술치료방법이적용되어왔다. 그러나수술범위가넓어지면서골편의이동방향에따라다양한재발경향이발생하는것으로보고되었다 1,2). Le Fort osteotomy 술식의대안으로상악골전방신장술이소개되었다. 그러나이술식의결과과도하게상악골이전방신장되면인두간폐쇄부전 (velopharyngeal incompetemcy) 과과비성성 (hypernasality) 을유발할수있다고보고되었다 3-5). 또한최근보고에따르면, 10 mm 이상의상악골전진술을시행한환자에서발음상의문제를경험할가능성이커진다고보고되었다 3,4). 대부분의구순구개열환자들은상악전치부와소구치부위에선천적치아결손을동반한극심 - 19 -
유성훈, 최혜영, 유형석, 백형선, 차정열 한총생을보인다. 그러므로치아의배열과상악열성장을동시에해결하기위해서는새로운치조골의형성도필수적이다. 구순구개열환자에서상악골전방분절골신장술 (Maxillary anterior segment distraction osteogenesis) 은치조공간의형성과반대교합의해소에적절한술식이며중안면열성장환자의치료대안으로대두되고있다 2,6). 최근에상악골전방분절골신장술에다양한종류의신장기를이용하는방법들이보고되었다. Bengi 등과 Dolanmaz 등은 RPE 스크류와함께사용할것을제안하였다. 하지만치아지지장치는전치부에가해지는힘을증가시켜원하지않는치성효과가발생될수있을것으로여겨진다 5,7,8). 이러한이유로 Karakasis 와 Hadjipetrou는두개의원통형 신장기를동반하는골지지장치를이용한신장술을소개하였다 1). 이러한방법은 Rigid external device (RED) 에비하여상대적으로작은두개부위의손상과심미적으로더우수한치료결과를보인다 9,10). 그러나원통형신장기는신장방향유도가어렵다는기술적인이유로널리사용되지는않는다. 반면 Iida 등은골지지유형의신장기를이용한새로운시스템을소개하였다 5). Iida 는효율적인골지지신장기의작용을위하여미니스크류를사용하였다. 그러나신장기의종류에따른골격적효과나재발양상에대한연구는많지않다. 이번증례는구순구개열환자의치료에 RED 장치를이용하여상악골전방분절골신장술 (Maxillary anterior segmental DO) 을시행후골격적, 치성효과와재발양상을보고하고자하였다. Figure 1. Pretreatment intraoral views and radiographs. - 20 -
구순구개열환자의상악전방분절골신장술식을이용한교정치험례 Diagnosis and Treatment planning 15세남자환자는편측성구순구개열을보였다. 환자는상악좌측측절치와제2소구치의결손, 상악우측치열궁의붕괴로인한 high canine 을동반한 7mm 의극심한총생이있었다. 상, 하악은모두열성장을보였으며상악전치는직립되었고하악전치는약간돌출되었다 (SNA, 68.0 ; SNB, 68.8 ; U1 to SN, 93.6 ; IMPA, 97.5 ). 환자는편측성구순구개열을동반한골격성 III급부정교합으로진단되었다 (Figure 1). 환자의안모와교합을개선하기위해서상악골전방분절골신장술을계획하였다. 견치와결손치의공간을확보하기위하여골절단선은양측소 구치와견치사이에위치시켰으며 RED 를이용하여전방분절골을신장하기로하였다. 골절단의방향과외과용플레이트의위치는측모두부방사선사진을이용한 STO 를통하여결정하였으며, 신장력의방향은교합면과평행하게적용하였다 (Figure 2). Surgical procedure High Le Fort I osteotomy 와함께견치와소구치사이에 vertical osteotomy 가시행되었다. 골절단후에미니플레이트 (Martin Medizin. Technik, Tuttlingen, Germany) 에 miniscrew를이용하여전방분절을고정하였다. 그리고 RED 시스템 (Mar- Figure 2. Intraoral views and radiographs after Distraction osteogenesis. - 21 -
유성훈, 최혜영, 유형석, 백형선, 차정열 tin Medizin Technik, Tuttlingen, Germany) 의여섯개의두부고정용스크류를이용하여두개관과연결되었다 11). 분절골의전방이동을위해강선을미니플레이트와연결하여비강아래부위를관통하여견인장치와연결하였다. Distraction protocol 골절단후 7일동안의휴지기이후에골신장을시작하였다. 하루에 1mm 를신장하였으며오전과오후에 0.5 mm 씩나누어신장하였다. 골신장이후경화기기간은 1개월간시행하였으며, 신장된공간은가철성유지장치와고정식장치를이용하여유지하였다 (Figure 2-5). Results 신장기간동안 ANB 값은증가되었지만유지기간동안감소되었다. 골신장후 A point 는전방으로 14.1 mm 이동되었다 (Table 1). RED 장치 사용결과 ANS 의수직적인위치는하방으로이동되었다. 그리고술후유지기간동안하방이동이더진행되었다 (Figure 3). 골신장후에상악전치부각도 (U1 to SN) 는 21.7 도정도감소되었다. 치조골신장공간은 4.7 mm 가생성되었다. 치료치조골의신장으로인하여상악견치의배열을위한공간의형성이충분하게형성되었으며 CT촬영을통하여신장된결손부위에임플란트식립을위한적절한골질과골양을확인하였다 (Figure 7). Discussion A point 의위치는신장기간동안전방으로 14.1 mm 이동되었다. 이결과는이전의상악골신장술의결과와유사한양이었다. Hashimoto 등은 RED 장치를이용한상악골신장술을시행한결과신장기간동안 ANS 가전방으로 7.5 mm 이동되었다고보고하였다 12). 이번증례에서는골신장시상악골의전방분절은시계방향의회전을보였고, 그결과 A point 가상악전치보다더욱전방으로이동하게되었다. Figure 3. Intraoral views during treatment (9M after distraction osteogenesis). - 22 -
구순구개열환자의상악전방분절골신장술식을이용한교정치험례 Figure 4. Intraoral views and radiographs after treatment. Table 1. Cephalometric data of before and after treatment Measurement Normal PreDO After DO 1Yr F/U SNA (degree) 81.6 68 80.2 78.3 SNB (degree) 79.1 68.8 68.1 70.9 ANB (degree) 2.5-0.8 12.1 7.4 Wits (mm) -2-0.5 10.8 3.6 N-A (mm) -1-17.6-3.5-5.8 N-ANS (mm) 60 56.6 65.9 63.9 SN-GoMe (degree) 36 39.7 42.7 39.3 A/P ratio 65 63.3 61 64 U1 to SN (degree) 106 93.6 71.9 90.2 Space (mm) 4.7 7.5 IMPA (degree) 97 97.5 98.6 99.7 E-Upper lip (mm) 1.2 0.4 8.8 3.8 E-Lower lip (mm) 4 5.73 9 6.2-23 -
유성훈, 최혜영, 유형석, 백형선, 차정열 Pre-DO Post-DO 1Y-Follow up Post-treatment Figure 5. Comparison of extraoral views. 이번증례에서신장기간동안전방부분절골의수직적인이동이관찰되었다. 신장기간동안, 상악전방분절골은시계방향의회전양상을보였다. 이것은신장방식에따른신장방향과분절골의무게중심이연관되어있다. 상악의무게중심은상악제1대구치의상방 14.7 mm 로보고되었다 13). 최근연구에서는상악전방부의무게중심이상악무게중심보다전방에위치하며, ANS 하방의견치사이에존재한다고보고하였다 14). 따라서 RED 를이용한경우, 상악전방분절골의시계방향회전을방지하기위해서는치조골신장기가 RED와결합될필요가있다. 상악전치부경사도 (U1 to SN) 는골신장기간동안 21.7 도가감소되었다. RED 장치의사용시, 상악전치가구개쪽으로경사가되며, 이를해결하기위해서신장후에고정식교정장치를이용하여전치부토오크조절을시행하여야한다. 그러므로상악골전방분절의회전조절은치료기간의단축을위해서필수적이며상악전방분절의저항중심을고려한골신장기가고안될필요가있다. 상악전방분절골신장술 (Maxillary anterior segment DO) 은상악골신장술에비하여신장후에입천장인두기능부전 (velopharyngeal incompetence) 가발생될수있지만반대교합해결을위하여치조공간의확보가필요한환자에게더욱적합하다. 또한 pre-do post-do 1Y-F/U Figure 6. Superimposition of pre-do, post-do and 1Y-F/U. 상악전방분절골신장술은상악골신장시에발생될수있는개방교합이흔히발생하지않는다. 최근의연구에서신생골의생성과함께충분한양의치조골공간형성이보고되었으며, 생성된치조골질은임플란트를식립하기에적합하였다 15). Nosaka 등은개를이용한동물실험에서신장된치조골의골질과골의양은방사선학과조직학적으로우수한결과를나타내었다고보고하였다 14). 이번연구에서는 3D CT 상에서도신장부위의치조골의골질과양이우수한것을확인할수있었다 (Figure 7). 상악전방분절골신장술은여러장점이있지만치료과정중에발생될수있는전방분절의회 - 24 -
구순구개열환자의상악전방분절골신장술식을이용한교정치험례 A B C D E F Figure 7. Investigation of alveolar bone using panoramic X-ray scanning and three-dimensional computed tomography. A, Pre-DO; B, post-do; C, 1Y-F/U; D, axial view of pre-do; E, axial view of post-do; F, lateral view of post-do. 전을고려해야한다. 골신장시원하지않는회전을방지하기위해서는구내장치와 RED 장치를함께사용하여부작용을최소화할수있다. 하지만 RED 장치는비심미적이며불편하기때문에임상적으로충분한경화기간을유지하기어렵다. 필요하다면 Face mask 와치조골신장기를이용하여장기적인골경화가가능하다. 골신장기간동안에성공적으로치조공간을확보할수있지만골경화기기간동안에유의할만한공간손실이관찰되었다. 따라서골신장이후에는아크릴릭레진의공간유지장치가필요하며, 성공적인치료결과의유지를위하여서는장기간의유지가필요하다 (Figure 3). Conclusions 이번증례를통하여상악전방분절골신장술은구순구개열환자의치조골공간확보, 신생골의형성, 인두개부전의문제없는측모개선에효과 적이라는것을알수있다. 상악전방분절골신장술을통하여도많은양의신장이가능하고재발이적다는장점이있지만신장후에는안정성측면에서견고한유지장치와충분한유지기간이추천된다. References 1. Karakasis D, Hadjipetrou L. Advancement of the anterior maxilla by distraction (case report). J Cranio Maxill Surg 2004; 32:150-154. 2. Tong ACK, Yan BSW, Chan TCK. Use of interdental distraction osteogenesis for orthodontic tooth alignment and correction of maxillary hypoplasia: a case report. Brit J Oral Max Surg 2003;41:185-187. 3. Ko EW, Figueroa AA, Guyette TW, Polley JW, Law WR. Velopharyngeal changes - 25 -
유성훈, 최혜영, 유형석, 백형선, 차정열 after maxillary advancement in cleft patients with distraction osteogenesis using a rigid external distraction device: A 1-year cephalometric follow-up. J Craniofac Surg 1999;10:312-320. 4. Harada K, Ishii Y, Ishii M, Imaizumi H, Mibu M, Omura K. Effect of maxillary distraction osteogenesis on velopharyngeal function: A pilot study. Oral Surg Oral Med O 2002;93:538-543. 5. Iida S, Yagi T, Yamashiro T, Okura M, Takada K, Kogo M. Maxillary anterior segmental distraction osteogenesis with the Dynaform system for severe maxillary retrusion in cleft lip and palate. Plast Reconstr Surg 2007;120:508-516. 6. Liou EJW, Chen PKT, Huang CS, Chen YR. Interdental distraction osteogenesis and rapid orthodontic tooth movement: A novel approach to approximate a wide alveolar cleft or bony defect. Plast Reconstr Surg 2000;105:1262-1272. 7. Dolanmaz D, Karaman AI, Ozyesil AG. Maxillary anterior segmental advancement by using distraction osteogenesis: a case report. Angle Orthod 2003;73:201-205. 8. Bengi AO, Gurton AO, Okcu KM, Aydintug YS. Premaxillary distraction osteogenesis with an individual tooth-borne appliance. Angle Orthodontist 2004;74:420-431. 9. Le BT, Eyre JM, Wehby MC, Wheatley MJ. Intracranial migration of halo fixation pins: A complication of using an extraoral distraction device. Cleft Palate-Cran J 2001;38:401-404. 10. Rieger J, Jackson IT, Topf JS, Audet B. Traumatic cranial injury sustained from a fall on the rigid external distraction device. J Craniofac Surg 2001;12:237-241. 11. Minami K, Mori Y, Tae-Geon K, Shimizu H, Ohtani M, Yura Y. Maxillary distraction osteogenesis in cleft lip and palate patients with skeletal anchorage. Cleft Palate-Cran J 2007;44:137-141. 12. Hashimoto K, Otsuka R, Minato A, Sato- Wakabayashi M, Takada J, Inoue-Arai MS, et al. Short-term changes in temporomandibular joint function in subjects with cleft lip and palate treated with maxillary distraction osteogenesis. Orthod Craniofac Res 2008;11:74-81. 13. Ahn JG, Figueroa AA, Braun S, Polley JW. Biomechanical considerations in distraction of the osteotomized dentomaxillary complex. Am J Orthod Dentofacial Orthop 1999;116:264-270. 14. Melsen B, Fotis V, Burstone CJ. Vertical force considerations in differential space closure. Journal of clinical orthodontics : JCO 1990;24:678-683. 15.Van Sickels JE, Abadi B, Attisha R. Anterior segmental distraction for a Class III maxillary prosthetic defect in a cleft palate patient. The Journal of oral implantology. 2011;37:457-461. 16. Nosaka Y, Tsunokuma M, Hayashi H, Kakudo K. Placement of implants in distraction osteogenesis: a pilot study in dogs. The International journal of oral & maxillofacial implants. 2000;15:185-192. - 26 -
구순구개열환자의상악전방분절골신장술식을이용한교정치험례 교신저자 Jung-Yul Cha Room 726, Department of orthodontics, Yonsei University College of Dentistry, Seoul, South Korea, 250 Seongsanno, Seodaemun-gu, Seoul 120-752, South Korea Tel : +82-2-2228-3103 / Fax : +82-2-363-3404 / E-mail : jungcha@yuhs.ac Acknowledgement This study was supported by a grant from the Korea Healthcare Technology R&D Project, Ministry for Health, Welfare & Family Affairs, The Republic of Korea (A090353). - 27 -