김종배 유재하 * 최병호* 계명대학교의과대학치과학교실, 연세대학교치과대학구강악안면외과학교실 ( 원주기독병원 )* Abstract CONSERVATIVE CARE OF NONUNION OWING TO OSTEOMYELITIS ASSOCIATED WITH FRACTURE OF MANDIBLE: REPORT OF 3 CASES. Jong-Bae Kim, Jae-Ha Yoo*, Byung-Ho choi* Department of Dentistry, College of Medicine, Keimyung University Department of Oral and Maxillofacial Surgery, College of Dentistry, Yonsei University( Wonju Christian Hospital)* Failure to use effective methods of reduction, fixation, and immobilization may lead to nonunion with osteomyelitis, owing to the compound nature of most fractures of the mandible. Nonunion results in fibrous pseudoarthrosis at the fracture site with instability that, once formed, does not improve spontaneously. Once the nonunion with osteomyelitis secondary to fractures has become established, intermaxillary fixation and drainage of infected tissue should be instituted as early as possible, because the fixation & drainage enhances the patient comfort and hinders ingress of microorganisms & debris by movement of bone fragments. The authors treated three cases of nonunion with osteomyelitis by intermaxillary fixation, incision & persistent drainage on the previous fistula site and endodontic drainage of infected teeth in the fracture site of mandible. The localization & sequestration of the infected bone around the fracture was better performed persistently by natural homeostatic mechanism in 8 10 weeks and the bony union was then attained without bone grafting. Key words : Mandible fracture osteomyelitis, Nonunion, Endodontic drainage, Persistent drainage. Ⅰ. 서론 악골골절부수술후비유합 (nonunion) 의원인으로는골편고정의불량, 분쇄골절편의변위, 골절편의무균적괴사, 골절편사이에연조직의게재 (interposition), 골수염과골흡수, 전신상태의불량등이고려된다 1,2). 하악골절에서비유합의결과는하악골의연속성이상실되고, 골절편의흡수로인한하악골길이의감소와섬유성위관절증으로저작, 연하, 발성, 심미, 심지어호흡기능에까지장애를초래하게된다 3,4). 하악골절부골수염에의한비유합의 1 차적인치료로는우선악간고정술을시행하여골절편이동에의한미생물의 유입을방지하고, 감염의원인이되는골절선상부치아나이물을제거하며, 골수염부위에배농로를설정하는보존적인방법들이제시되고있다 5,6). 그러나 1 차적인치료에도불구하고비유합이지속될경우에는골절편사이의염증성섬유조직, 반흔조직, 화골 (eburnated bone) 등을제거하고골이식을활용한재건술을시행케되는뎨, 이는환자에게큰부담과고통을주고기능적, 심미적결함도초래될가능성이높아 7,8) 1 차적인보존적처치가선호되고있다. 골절부골수염치료에서보존적처치의생물학적원리는하악골수염치료에서가장중요한열쇠가적절하고지속적인연조직배농로설정에있는만큼, 배농로가장기간확보 471
대한악안면성형재건외과학회지 : Vol. 23, No. 5, 2001 되면서전신상태가개선되면감염골은정상골에서부골로분리되어치유된다는것이다 3,6). 이원리를이용하여저자등은골절부골수염으로인해비유합된 3 증례를보존적인방법으로치료하여양호한치유를보였기에이를보고한다. 1. 증례 1 Ⅱ. 증례보고 61 세남자환자로 1999 년 9 월 2 일경운기전복사고로인해하악골정중부골절이발생되어타병원성형외과에서관혈적정복술을시행받았으나창상감염이있어절개및배농술을시행했음에도지속적인농배출및골절부골수염소견 Fig. 1. Submental fistula at the first maxillofacial examination : Purulent pus is more discharged Fig. 2. Panoramic view at the first examination : The nonunion is showed around the tooth(#42) in the fracture of mandible. Fig. 3. Postoperative feature:intermaxillary fixation is showed with incision & drainage on the oral fistula and endodontic drainage of the tooth (#42) on the line of mandibular fracture. Fig. 4. The final submental wound:good healed wound is showed without the exudate discharge. 472
을보였다. 그리하여술후 32 일째전신마취하에감염창상을절개하여금속판과나사를제거하고감염조직을소파했는데, 그후에도배농로가잔존하고골절부비유합소견을보여본치과 ( 구강악안면외과 ) 로의뢰되었다 (Fig. 1, 2). 1999 년 11 월 19 일 (2 차수술후 38 일째 ) 상하악치아에 arch bar 를장착하여비관혈적정복술및악간고정술을시행했고, 다음날국소마취하에골절선상부치아인하악우측측절치의 1 차근관치료 ( 발수및배농술 ) 및구강내외의농루 (fistula) 부위를통한절개및배농술을실시했다 (Fig. 3). 그후지속적인창상세척 (dressing) 을지속한결과 12 월 12 일 ( 본원에서치료후 23 일째 ) 구강외부창상 (submental wound) 내부에서작은부골편이자연탈락되면서 3 일후창상내삼출액유출없이정상적인창상치유를보였다 (Fig. 4). 악간고정술시행 40 일째에하악골절부유합을확인한후악간고정상태를제거했으며, 약 2 주일간유동식섭취를계속하다 arch bar 제거후일반식이로교체했고, 이어서골절선상부치아 (#42) 의근관치료를 2 주일간지속해종결했다. Fig. 5. The first maxillofacial examination: The wound of paramedian mandibulotomy & radical neck dissection is showed. Fig. 6. The first oral examination : Nonunion & fistula are showed between the tooth (#32) and the tooth(#33). Fig. 7. Postoperative feature : The intermaxillary fixation is showed with incision & drainage on the oral fistula and endodontic drainage teeth (# 32, 33). Fig. 8. Panoramic view at about 10 weeks after the intermaxillary fixation: The clinical bony union is attained with the remained plate & screws. 473
대한악안면성형재건외과학회지 : Vol. 23, No. 5, 2001 2. 증례 2 67 세남자환자로설부에발생된편평상피세포암의외과적인처치를위해 2000 년 3 월 8 일본원이비인후과에서 paramedian mandibulotomy 를이용한광범위적출술과경부곽청술을시행받고이어서 6 주간방사선치료 (4800rad) 를받았다. 그후저작장애지속되어 2000 년 6 월 9 일본치과 ( 구강악안면외과 ) 로내원하였다 (Fig. 5). 구강악안면검사및방사선사진검사로하악좌측측절치와견치사이에서하방으로계단상으로의도적골절을시행하고고정한부위에서비유합및구강내농루형성이관찰되었다 (Fig. 6). 그리하여본과에서는우선골절부비유합에원인이된골절선상치아 ( 하악좌측측절치및견치 ) 의 1 차근관치료 ( 발수및배농술 ) 와농루형성부위를이용한절개및배농술을시행했고, 악간고정술을위해상하악치열에 arch bar 를장착하고서지속적인창상세척을실시했다 (Fig. 7). 그후악간고정시행 73 일째에골절편의완전유합을확인하고서 arch bar 를제거했고, 이어서골절선상부치아 (#32, 33) 의근관치료를약 3 주일간시행해양호한치유를확인했다 (Fig. 8). Fig. 9. The first oral examination : The more inflammatory reaction is showed around the teeth(#33,34) of the paramedian mandibulotomy. Fig. 10. Postoperative panoramic view: The extraction of the tooth(#34) is showed with endodontic drainage of the tooth(#33). Fig. 11. Postoperative feature: Arch bars are applied onto the lingual & buccal aspects of the mandibular teeth with the drainage via extraction wound of the tooth(#34). Fig. 12. The oral & maxillofacial feature at the postoperative 45 days : The clinical bony union is attained with the more improved function of mastication. 474
3. 증례 3 57 세여자환자로설부와구강저부에발생된편평상피세포암에대해 1999 년 9 월 27 일본원이비인후과에서 paramedian mandibulotomy 를통한광범위적출술, 경부곽청술, 전완유리피판재건술을시행받았으나, 피판부울혈이있어혈전절제술과재혈관화유도술을받았다. 그러나술후 49 일째에도도저히음식물을제작할수없을정도로치아가맞지않아본치과 ( 구강악안면외과 ) 로내원한바, 구강악안면검사및방사선사진검사에서골절부골수염및비유합소견을관찰할수있었다 (Fig. 9). 저작장애가상당기간지속되어전신상태가약화되었기에입원하에수액및약물요법과함께골절선상치아로감염의원인이된하악좌측견치의 1 차근관치료 ( 발수및배농술 ) 와제 1 소구치의발치를시행하고서 (Fig. 10), 발치창을배농로로활용하기위해 rubber & iodoform gauze 배농술을시행했다. 그러나환자가악간고정술에큰공포감 ( 과거장기간악간고정술에따른음식물섭취곤란으로상당한정서장애발생 ) 을가지고있어, arch bar 부착을협측치아면과설측치아면양측에시행하고악간고정은설정하지않았다 (Fig. 11). 그후구강내발치창상을활용한지속적인배농술과전신상태의개선을위한지지요법등으로술후 45 일째하악골절부유합을확인했고발치창상치유도양호하여 arch bar 를제거한다음, 초기단계에 1 차근관치료만시행했던하악좌측견치의근관치료를 2 주일간지속하여비교적양호한 Table 1. Factors predisposing to infection of mandibular fracture site [1] Local factors 1. Poor oral hygiene, gingivitis, calculi, pyorrhea and local infection 2. Devitalized, infected or abscessed teeth in the area of the fracture 3. Hematoma in the fracture area -ideal medium for infection 4. Delayed immobilization with moving open wounds 5. Lymphatic stasis due to direct injury 6. Edema and local tissue damage 7. Destruction of periosteum 8. Foreign bodies in wound: dirt, glass, wood, metal and so on 9. Devitalization and abscess of fractured teeth [2] General factors 1. Age 2. Malnutritiion 3. Debilitating disease 4. Constitutional disease, i.e., diabetes, blood dyscrasia, and so on 저작기능의회복을달성했다 (Fig. 12). Ⅲ. 총괄및고찰 하악골절에서골수염이유발될우려가있는감염의원인으로는골절의양상이복합적일경우구강내열창, 골절선상치아주위염, 구강외창상감염, 골절편주위혈종등이고려되며, 선행소인으로는국소요소와전신적인요소들이있다 (Table 1) 1,2,4). 그러므로임상에서는골절발생시감염방지를위해우선초기고정을위한 1 차강선고정, 견고고정, 항생소염요법의조기시행, 적절한배농로설정, 골절선상치아의감염, 전신상태의개선과구강위생관리등에주력하게된다 8,9). 그러나본증례들처럼환자들이고령으로전신상태가약화되고, 골절편의고정이불량하며악성종양의수술로인한스트레스과다와면역기능감퇴 (RND 의경우경부임파절제거로인한면역약화 ) 10-12) 등은골절부주위에감염을초래해골절편의비유합을초래할우려가높다. 하악골절부골수염에의한비유합의치료법에는우선악간고정술을시행하고, 감염의원인이되는이물 ( 봉합사, 금속판과나사, 강선등 ), 실활조직, 관련치아들을제거하며, 철저한세균검사와배농로설정이중요시된다 5,13,16). 따라서 ( 증례 1) 의경우타병원성형외과에서하악골절편의고정에이용된금속판과나사를제거하고서배농로를설정했음에도비유합이초래된것은우선악간고정술이불량한상태에서골절선상치아주위염에대한처치를시행치않은데그원인이있었을것으로추정된다. 왜냐하면골절부골수염에의한비유합발생시악간고정술은골절편의운동에의한미생물의내부침투를방지하며, 골절선상치아의경우감염된치수는퇴행성변화와괴사과정을거처골절부골수염을유발하는원인이되기때문이다. 그리하여 Lieblich 등은골절선상치아들이다음의상태에있다면반드시발치할것을권유했는데 4,14,15) (Table 2), 본증례들모두에서는발치의적응증범주에있던치아들도치근관신경치료 ( 발수및배농술을장기간시행한후골절유합되면신경치료완결 ) 로서발치를하지않고보존할수있었기에의미가크다고사료된다. 왜냐하면치근관신경치료의원리자체가일반외과학의원리처럼 1 감염조직에서좌멸괴사조직의제거 ( 근관확대로치수내감염조직제거 ) 2 배농 ( 치근관개방을통한배 Table 2. Indications of removing teeth in the line of fracture 1. The tooth is loose 2. The tooth is grossly carious or periodontally involved 3. More than 50 percent is exposed in the fracture line 4. Adequate reduction is mechanically blocked by its retention 475
대한악안면성형재건외과학회지 : Vol. 23, No. 5, 2001 농 ) 3 염증이완전히해소된후무균적처치로생체적합성물질로채움 ( 근관충전 ) 과같기때문이다 17). 따라서본증례들에서근관신경치료는우선골절선상치아의발수및치근관개방을통한배농술을장기간 ( 약 1 개월 ) 시행한상태를유지하다가, 골절부골수염이억제되고골유합이확인된후근관확대및근관충전을시행하는단계를통해성공하였다. 한편 ( 증례 1) 에서는골절편고정에사용된금속판과나사를제거한상태에서악간고정술, 골절선상치아의근관치료, 연조직배농술등으로골절부골수염의조절과골절부유합을유도한반면, ( 증례 2 와 3) 에서는골절편고정에사용된금속판과나사를남겨둔채골절선상치아의근관치료및장기간의연조직통한골절부골수염주위배농술로서골절부유합을달성했음이대조가된다. 저자등이 ( 증례 2 와 3) 에서골절편고정에사용된금속판과나사를남겨두기로결정했던이유는이론적으로는골절편고정에사용된금속판과나사도이물이므로감염시골용해 (osteolysis) 를야기하고골절부골기질의흡수를야기한다고하지만 16,18), 골절부골수염의경우골수염이골절부주위에한정되는경향이있고금속판과나사의존재가골절편의고정에매우긴요하다고판단했기때문이다. 이는 Topazian 등의주장대로금속판과나사가골절부골수염유발에직접적인원인이아니라면골절편의고정시악간고정술만으로는저작근육이관련된골절부고정에한계가많으므로금속판과나사를남겨둔채로배농로를지속적으로설정하여골수염억제및골유합을유도함이타당하다는원리 5,19) 를따른것이다. 만약본증례들에서금속판과나사가골수염의원인이되었다면골수염억제및골유합달성후에도금속판과나사주위에염증성육아조직의형성과방사선소견상골흡수소견이관찰될수있었겠지만, 본증례들에서는이런소견없이깨끗이치유되어금속판과나사는이물이지만감염의직접적인원인이아님을알수있었다. 한편 ( 증례 1) 에서처럼하악골복합골절부주위의골수염이지속되고금속판과나사도제거된상태로골편고정도불량하여비유합또는섬유성유합이예견되는경우의치료에대해서는학자들마다견해차이가있는게사실이다. Rowe 등 4,19) 은하악골절에서비유합이발생될것으로판단되면골절편고정을위한악간고정술을오래시행하여시간을소비하는것보다는가능한한골이식을빨리시행하는것이낫다고한반면, Peacock 등 5,6,20) 은외과의사들이골이식술을너무쉽게시행하는경향이있음을지적하면서골절부주위의감염된하악골의국소화와부골화는골절부골수염주위연조적배농로의설정이정확히지속적으로시행되면자연적인치유기전즉인체의항상성 (homeostasis) 에의해훨씬더잘일어나므로비유합이예견되어도일단은 wait & see 의자세로배농술을지속해볼것을주장했다. 저자등도환자의입장에서생각해서둘러골이식을시행치 않고인내심을가지고 Peacock 의의견에따라꾸준히구강내외로배농술을시행한결과약 1 개월경에부골편이자연탈락되면서창상감염의조절및골유합을확인할수있었다. Ⅳ. 결론 저자등은하악골절부관혈적정복술과악성종양의수술을위해하악골절단및정복고정술을시행했으나비유합이발생된 3 증례를골절편고정용금속판과나사를남긴채악간고정술시행, 골절선상치아의근관통한배농술, 골수염주위연조직의지속적인배농술을통한자연적인부골분리유도등의보존적관리로서양호한골유합과창상치유를치험했다. 참고문헌 1. Conley, JJ: Complications of head & neck surgery. W.B. Saunders, 1979, p360. 2. Kaban, LB, Pogrel, MA, Perrott, DH : Complications in oral and maxillofacial surgery. W.B. Saunders, 1997, p121. 3. Fonseca, RJ, Walker, RV: Oral and maxillofacial trauma. Vol 2. W.B.Saunders, 1991, p 1150. 4. Williams, JL: Rowe and Williams maxillofacial injuries, 2nd ed. Churchill livingstone. 1994, p871. 5. Topazian, RG, Goldberg,MH: Management of infections of the oral and maxillofacial regions. W.B. Saunders, 1981, p247. 6. Peacock, EE: Wound repair, 2nd ed. W.B. Saunders, 1976, p624-629. 7. Kim YK, Yeo HH, Lee HB, Kim KW:Complications associated with monocortical titanium miniplate used in rigid fixation of mandibular fractures. Kor J Maxillofac Plast Reconstr Surg 16:438, 1994 8. Heo NO, Park JH, Shin YG, Pang SJ, Jeon IS, Yoon KH: The case of treatment of osteomyelitis following the open reduction of mandibular fracture. Kor J Maxillofac Plast Reconstr Surg 18:712, 1996 9. Jeong JC, Kim KJ, Choi JS, Sung DK, Kim HS, Lee GH: Treatment of compound comminuted mandibular fractures. Kor J Maxillofac Plast Reconstr Surg 20:101, 1998 10. Little, JW, Falace, DA, Miller, CS, Rhodus, NL: Dental management of the medically compromised patient, 5th ed. C.V.Mosby, 1997, p516. 11. Thoronton, JB, Wright, JT: Special and medically compromised patients in dentistry. PSG publishing Co, 1989, p185. 12. Kim CS, Kim SK: The application of neck dissection in the treatment of oral cancer. Kor J Maxillofac Plast Reconstr Surg 14:97, 1992. 13. Flynn TR, Hoekstra CW, Lawrence FR: The use of drains in the oral and a new approach. J. Oral Maxillofac Surg 41:508, 1983 14. Lee W, Nam IW : Statistical analysis of teeth in the line of jaw and alveolar bone fracture: based on dental health capacity in orthopantomogram. Kor J Oral & Maxillofac Surg. 21:310, 1995 15. Choi BH, Ahn SH: Prognosis of teeth involved in the line 476
of mandibular fractures. Kor J Oral & Maxillofac Surg, 21:442,1995 16. Johansson B, Krekmanov L, Thomasson M : Miniplate osteosynthesis of infected mandibular fractures. J. Craniomaxillofac Surg 16:22, 1988 17. Rhim SS: Grossman s endodontic practice, 10th ed, Medical & Dental Publication Co, 1987. P146 18. Tucker, MR, Terry, BC, White, RP, Van Sickels, JE: Rigid fixation for maxillofacial surgery. J.B. Lippincott Co, 1991, p54. 19. Krüger, E, Schilli, W, Worthington, P: Oral and maxillofacial traumatology, VolⅡ. Quintessence Co. 1986, p423. 20. Laskin DM, Best AM: Current trends in the treatment of maxillofacial injuries in the United States. J. Oral Maxillofacial Surg 46: 595,1988 저자연락처우편번호 700-712 대구광역시중구동산동 194 계명대학교의과대학부속동산의료원치과김종배 원고접수일 2001 년 7 월 20 일게재확정일 2001 년 8 월 24 일 Reprint requests Jong-Bae Kim Dept. of Dentistry, College of Medicine, Keimyung Univ. Dongsan Medical Center #194, Dongsan-Dong, Jung-Gu, Daegu, 700-712, Korea. Tel. 82-53-250-7801 Fax. 82-53-250-7802 E-mail : jbkim@dsmc.or.kr Paper received 20 July 2001 Paper accepted 24 August 2001 477