Forced eruption 을이용한매복전치의치험례 공석배ㆍ김종수ㆍ유승훈 단국대학교치과대학소아치과학교실 국문초록 영구전치의매복은제 3 대구치나견치에비해서드물게나타나지만학령기아동에서관찰할수있다. 매복치아의원인은외상, 공간부족, 치아의맹출경로상에위치하는과잉치, 유치의치근단감염등다양하다. 매복된치아는부정교합과인접치아의치근흡수, 낭종등의병적변화를유발할수있으므로임상적검사와방사선학적검사를통해정확한위치를확인하고, 적절한치료계획을통해정상맹출을유도하여야한다. 매복된치아가병적변화를일으킨경우나인접치에손상을주었을경우에발치를시행하게된다. 그러나교정적견인을통해기능과심미성을회복시켜줄수있으므로조기발견과발견시의올바른진단과치료계획을수립하는것이중요하다. 교정적견인시에는매복치를배열할공간의확보와고정원에대한고려가선행되어야한다. 견인시적절한방향의힘을통해서치근의흡수등의부작용이일어나지않도록해야한다. 본증례는매복된전치들을 forced eruption을통해서정상적인맹출방향으로유도한치험례이다. 주요어 : Forced eruption, 매복전치 Ⅰ. 서론영구전치의매복은제 3 대구치나견치에비해서드물게나타난다. 일반적으로매복은구개측으로나타나게되지만상악영구중절치의경우는순측매복도다양하게나타나고있다 1). 매복치의발생빈도를보면제 3 대구치 (98%), 상악견치 (1.33%), 제 1 소구치 (0.22%), 제 2 소구치 (0.11%) 순으로나타나게된다 2,3). 치아가매복되는원인으로는과잉치, 복합종, 외상등이있는데외상이영구치의형태이상을유발하는가장주된요소이다 3-6). 매복치아의진단은임상적, 방사선학적인검사를통해서이루어지게된다. 8세이후부터는매년견치부위의시진, 촉진, 방사선학적검사가추천된다 7,8). 매복치아의치료방법으로는발치, 경과관찰, 교정적견인등을들수있다. 매복치아의위치가중요한해부학적구조물과근접하여성장중일때는경과를관찰한다 9). 매복된치아가심하게변위되어있거나치근이만곡되어있는경우에는교정적견인을시행하기어렵기때문에발치를시행한다. 교정적견인은외과적으로연조직과경조직을제거한후에매복치아에교정적장치를부착한후에시행한다 10). 본증례는영구전치의맹출지연을주소로내원한환아로방사선사진상영구전치의변위된매복을발견하였으며, 외과적노출후교정적견인을통해서정상적인치근발육및맹출후양호한배열을이루었기에보고하는바이다. Ⅱ. 증례보고 교신저자 : 김종수 충남천안시신부동산 7-1 단국대학교치과대학소아치과학교실 Tel : 041-550-1933 E-mail : jskim@dku.edu < 증례 1 > - 환자 : 10세 5개월여 - 주소 : 앞니가안나와요 - 방사선소견 : 파노라마와치근단방사선사진상상악좌측 409
J Korean Acad Pediatr Dent 32(3) 2005 유중절치의만기잔존과상악좌측중절치의매복을보이고있었으며치근은미완성상태였다 (Fig. 1, 2). - 치료및결과 : 상악좌측유중절치의발치후일단경과관찰하였다. 6개월후에자발적으로맹출하지않아외과적노출후 Lingual button을부착한후에 Forced eruption 을시행하였다 (Fig. 3). 1달후에치아가노출되었고, 3개월후에는치아의배열을위해서 Lingual button을 bracket 으로교환하였다 (Fig. 4 6). 5개월후에는다른치아와양호한배열을이루었다 (Fig. 7). Fig. 1. Panoramic view of pretreatment Fig. 2. Periapical view of pretreatment Fig. 3. Traction of the impacted incisor after window opening Fig. 4. Crown exposure after 1 month Fig. 5. Bracket bonding for leveling after 3 months Fig. 6. Periapical view after 3 months Fig. 7. Intraoral view after 5 months 410
< 증례 2 > < 증례 3 > - 환자 : 8세남 - 주소 : 아래앞니가안나와서 - 방사선소견 : 파노라마사진상에서하악우측유중절치의만기잔존과하악우측중절치가수평으로매복되었다 (Fig. 8). - 치료및결과 : 먼저하악우측유중절치를발치한후에 6개월간경과를관찰하였다. 자발적맹출이일어나지않아서, 외과적으로매복치아를노출후 Lingual button을부착한후에 Forced eruption을시행하였다. 맹출공간을유지하고견인을용이하게하기위해서매복치아를제외한다른전치부와제 1대구치에 Bracket을부착하였다. 9개월후에치아가구강내로노출되었다 (Fig. 9). 14 개월후에는다른전치부와양호한배열을이루었고 (Fig. 10), 20 개월후에는 debonding 하였으며 (Fig. 11), 가철성유지장치로유지하고있다. - 환자 : 8세 3 개월여 - 주소 : 앞니가안나와서 - 방사선소견 : 파노라마와치근단방사선사진상으로상악우측중절치의수평매복, 상악우측견치의맹출경로이상을보였다 (Fig. 12, 13). - 치료및결과 : Window opening후에수평매복되어있는상악영구중절치에 Linual button을부착하였다. 다른치아에 bracket을부착한후에강선과 elastic을이용해서견인하였다. 1개월후에매복치아의맹출방향이바뀌었고 (Fig. 14), 3개월후에는가철성의장치에 hook를연결해서 elastic을이용해서맹출을유도하였다 (Fig. 15). 8개월후에는다시고정성의장치를이용해서견인하였고, 1년 3 개월후에치아가구강내로노출되었다 (Fig. 16, 17). 2년 8개월후에양호한배열을이루었다. 그후견치를정상적인방향으로유도하기위해서견인을시작하였다 (Fig. 18). 3 년후에올바른맹출방향을이루었고현재배열을진행중이다 (Fig. 19). Fig. 8. Panoramic view of pretreatment Fig. 9. Crown exposure after 9 months Fig. 10. After 14 months Fig. 11. Debonding after 20 months 411
J Korean Acad Pediatr Dent 32(3) 2005 Fig. 12. Panoramic view of pretreatment Fig. 13. Occlusal view Fig. 14. After 1 month Fig. 15. Traction of impacted incisor with removable appliances after 3 months Fig. 16. After 8 months Fig. 17. Crown exposure of impacted incisor after 1 year 3 months Fig. 18. Canine retraction after Fig. 19. Leveling after 3 years incisor alignment Ⅲ. 총괄및고찰매복치아란어떤원인에의해서적절한맹출시기가지난후에도맹출되지않고구강점막하나악골내에묻혀있는치아를말한다 11). 매복치아의진단은임상적으로치아가대칭적으로동시에맹출되지않는치아로판단가능하지만, 좌우의비대칭적인맹출도일정기간까지는정상으로볼수있다. 치아의맹출 을방해하는요소로는치아의맹출로상에존재하는과잉치, 치아맹출순서의이상, 치근만곡, 치배의회전, 외상에의한영구치배의손상등을들수있다. 외상은영구치배의만곡이나변형을유발한다. 이것에의해서치아는맹출방향을바꿀수도있고, 지연맹출할수있으며치근이만곡될수도있다 12-14). 치아가매복되어있는경우에자발적인맹출이가장심미적이고생리적인치주상태를보이게되지만이런경우는많지않다. 412
매복치를방치할경우에는인접치아의이동, 외흡수, 내흡수와감염, 치열궁길이상실, 낭종형성등의부작용이나타날수있다 15). 특히영구전치부에서는심미적인문제를유발할수있기때문에조기진단과치료가이루어져야한다. 주기적인방사선사진을통한맹출방향의확인이요구된다. 매복치의맹출방향이정상으로보이는경우에는일단경과를관찰한다. 일정기간후에도맹출되지않는경우에는매복치의맹출로가정상이며치근이미완성인경우에상부의경조직과연조직을제거해서맹출을유도하게된다. 그렇지않은경우에는외과적노출후매복치를교정적으로견인하는방법을생각하게된다 16). 매복치의맹출방향이이상하거나심한변형을보일시에는발치를시행한다. 교정적치아견인은외과적인방법보다부착치은을유지하는데있어서효과적이다. Forced eruption은매복치아에있어서는치아를외과적으로노출시킨후에고정성장치부착을통해서시행한다. 견인시에는적절한힘을통해서치근흡수등의부작용을막아야한다. 치아의견인시에는수직성의정출력을받는치아만이동되면적절한힘이라면주위의치아가함입되지는않는다. 지지되는치아들이압입되기전에먼저치아가정출되게된다 17). Reintan 18) 은적절한견인력은 25 20 gm 정도라고하였다. Cooke와 Scheer 19) 는하악절치를제외한다른치아에서약 25 40 gm 정도의견인력이필요하다고하였다. Forced eruption을통해서매복영구전치의기능과심미성을회복시켜줄수있다. 견인시에는심미적인치은의형태와기능을위해서부착치은의양이중요하다. 매복치아의견인시에가철성장치를사용할것인지고정식장치를사용할것인지의여부는다음에의해서결정된다 20,21). 치아치은조직의변화, 치주낭제거, 심미성, 구강건강관리능력, 교정장치의고정력에의한 2차효과의감소, 가철성장치의효과와환자의협조도등에의해서좌우되기때문에신중하게치료방법을선택해야한다. 본증례는매복된상악과하악의영구전치를 forced eruption을통해서양호한배열을이루었다. 치근의발육은정상적이었으며생리적폭경도정상적이었다. Window opening시에는부착치은의폭경을조절하기위해서접근방법을달리하였다. Forced eruption시에사용하는장치는환자의치열발육상태에따라서달라졌으며견인력뿐만아니라치아가배열될충분한공간이있어야한다. 그래서 forced eruption과동시에공간획득을시행하였다. 원래의맹출방향으로바뀐뒤에는다른치아와의적절한배열을위해서추가적인교정치료를시행하였다. Ⅳ. 요약영구전치의미맹출을주소로내원한환자를치료한결과다음과같은결론을얻었다. 1. 영구전치의매복은드물게나타나지만조기발견과진단, 올바른치료계획이필요하고이를위해서촉진, 시진, 주기 적인방사선사진등이요구된다. 2. 교정적견인술은매복되어있는영구전치의기능과심미성을회복시켜줄수있다. 3. 교정적견인시에는적절한견인력이필요하며, 전치부의심미성을위해서주변치은의형태도고려하여야한다. 치료후에는재발을막기위해서적절한고정기간이요구된다. 참고문헌 1. Gunter JH : Concerning impacted teeth. Am J Orthod, 28:642-648, 1942. 2. Alling CC, Helfrick JF, Alling RD : Impacted Teeth. 1st ed., Sauders, Philadelpia, 1993. 3. Grover PS, Lorton L : The incidence of unerupted perma-nent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol, 59:420-425, 1985. 4. Zilberman Y, Malron M, Shteyer A : Assessment of 100 children in Jerusalem with supernumerary teeth in the premaxillary region. J Dent Child, 59:44-47, 1992. 5. Day RCB : Supernumerary teeth in the premaxillary region. Br Dent J, 116:304-308, 1964. 6. DiBiase DD : The effect of variation in tooth morphology and position on eruption. Dent Pract Dent Rec, 22:95-108, 1971. 7. Ericson S, Kurol J : Radiographic assessment of maxillary canine eruption in children with clinacal signs of eruption disturbance. Eur J Orthod, 8:133-140, 1986. 8. Ericson S, Kurol J : Longitudinal study and analysis of clinical supervision of the maxillary canine eruption. Community Dent Oral Epidemiol, 14:172-176, 1986. 9. 서정훈 : 상악매복견치의교정적고찰. 대한치과의사협회지, 25:59-69, 1987. 10. Mitchell, Bennet : Supernumerary teeth causing delayed eruption-a retrospective study. Brit J Orthod, 19:41-46, 1992. 11. 양원식 : 전치부매복치에관한교정적고찰. 대한치과의사협회지 16:37-42, 1978. 12. Crol TP, Pacson EA, Langeland K : Traumatically injured primary incisors : A clinical and histological study. ASDC J Dent Child, 54:401-422, 1987. 13. Andreason JO : Traumatic injureis of the teeth. 2nd ed., Sauders, Philadelphia, 273-275, 1981. 14. Andreason JO, Ravn JJ : The effect of traumatic injuries to primary teeth on their permanent succes- 413
J Korean Acad Pediatr Dent 32(3) 2005 sor: A clinical and radigraphic follow-up study of 213 teeth. Scand J Dent Res, 79:284-294, 1971. 15. Shafer WG : A text book of oral pathology. 3rd ed, Sauders Co., Philadelpia, 63-66, 1983. 16. Dewel BF : The upper cuspid ;Its development and impaction. Angle Orthod, 19:79-90, 1989. 17. Simon JHS : Root extrusion-rationale and techniques. Dental Clin North Am, 28:909-921, 1984. 18. Reitan K : Some factors determining the evaluation of forces in orthodontics. Am J Orthod, 43:32-45, 1957. 19. Cooke MS, Scheer B : Extrusion of fractured teeth- The way to do it-the evolution of practical clinical techniques. Br Dent J, 149:50-53, 1980. 20. Fournier A : Orthodontic management of subgingivally fractured teeth. J Clin Orthod, 15:502-504, 1981. 21. Mandel RC, Binzer W, Withers JA : Forced eruption in restoring severely fractured teeth using removable orthodontic appliances. J Prosthet Dent, 47:296-274, 1982. 414
Abstract CASE REPORT : FORCED ERUPTION FOR IMPACTED ANTERIOR TOOTH Seok-Bae Kong, Jong-Soo Kim, Seung-Hoon Yoo Department of Pediatric Dentistry, School of Dentistry, Dankook University Impaction of permanent incisor occurs rare than the canine & third molar. But it`s often observed in school age child. The causes of impaction are trauma, space deficiency, mesiodens, infections of root apex, etc. In spite of elimination of cause, normal eruption of impacted tooth is rare. Though eruption is normal, the position of tooth will be incorrect. Because the impacted tooth results in malocclusion, root resorption of adjacent tooth, pathologic cystic change, it should be confirmed the precise position by clinical and radiographic exam and found the correct location by appropriate treatment plan. In case of pathologic change of impacted tooth and injury to adjacent tooth, it will be extracted. But through orthodontic retraction, the function and esthetics of tooth can be restored. It is important that impacted tooth should be detected early and diagnosed correctly, and appropriate treatment plan should be made. Before impacted tooth is retracted, the considerations of space for alignment and anchorage should be preceded and through appropriate force and mechanics, the side effects, for example, a root resorption should be minimized. In this study, we guided impacted tooth to normal position by using a forced eruption. Key words : Forced eruption, Impacted incisor 415