http://dx.doi.org/10.5933/jkapd.2011.38.4.385 대한소아치과학회지 38(4) 2011 의도적유치발치술에의한이소매복영구치의맹출유도 최인영 김승혜 김성오 최형준 이제호 최병재 손흥규 송제선 연세대학교치과대학소아치과학교실 국문초록맹출에관계되는여러요소가부정적으로작용할때맹출장애가유발될수있다. 맹출장애의일종인매복이발생할경우주기적인관찰, 공간확보, 외과적노출, 교정적견인, 외과적노출과교정적견인의병행, 발거후자가치아이식등의방법을고려할수있다. 첫번째증례는 9세남환에서상악좌측측절치의수평매복을발견하여상악좌측유측절치및유견치를발거후 5개월뒤개창술 (window opening) 을시행한증례로, 8개월의정기검진시치아가부분맹출하였으며 18개월후매복된상악좌측측절치가치축이개선되며자발적으로맹출하였다. 두번째증례는 10세남환에서상악우측제1소구치의이소매복을발견하여상악우측제 1 유구치를발거한증례로, 10개월뒤치아가부분맹출하였으며 19개월후매복된상악우측제1소구치가자발적으로맹출하였다. 본증례들에서이소매복된영구치는맹출경로에있는유치의의도적발거후경과관찰을한결과맹출위치의개선및자발적맹출이유도되었기에보고하는바이다. 주요어 : 맹출장애, 이소매복, 유치발치, 자발적맹출 Ⅰ. 서론치아의맹출은악골내에서치배의발육이시작되는것으로부터구강내의교합면까지의치아이동, 교합면도달이후추가적인이동등을포함한다 1). 유치열이혼합치열기를거쳐영구치열로교환되는소아및청소년기에서는맹출장애를흔히관찰할수있다. 영구치의 0.07% 가미맹출현상을보이는데상악견치, 하악제2소구치, 상악측절치의순으로호발한다고보고되고있다 2,3). 맹출장애는원인및나타나는증상에따라매복 (impaction), 일차적만기잔존 (primary retention), 이차적만기잔존 (secondary retention) 으로구분된다 1,4). 맹출장애의일종인매복의원인으로공간부족이나과잉치혹은치성종양등의물리적장애가있거나치배의위치이상, 맹출경로의이상, 형태이상, 비정상경사등을들수있다. 매복치는인접치의흡수뿐아니라우식, 치주문제, 치성낭종형성, 부정교합, 치관주위염, 동통 등을유발시킬수있다 1,5). 매복치는그발생원인, 치아의발육단계, 매복된위치및맹출경로, 환자의협조도등을고려하여치료방법을결정한다. 치료계획에는미맹출치의제거뿐아니라외과적노출, 교정적견인또는치아이식등에의한재배열과같은외과적인접근이나아무런치료를하지않는것등과같은비용, 이익평가가포함되어야한다. 본증례들에서는이소매복을보이는영구치에대해선행유치를발치하여자발적맹출을이룰수있었기에보고하는바이다. Ⅱ. 증례보고증례 1 9세남환이상악좌측측절치의수평매복을주소로본원소아치과에내원하였다. 구강검사및방사선검사결과상악좌측 교신저자 : 송제선서울특별시서대문구연세로 50 / 연세대학교치과대학소아치과학교실및구강과학연구소 / 02-2228-8800 / songjs@yuhs.ac 원고접수일 : 2011 년 06 월 01 일 / 원고최종수정일 : 2011 년 10 월 06 일 / 원고채택일 : 2011 년 10 월 19 일 385
J Korean Acad Pediatr Dent 38(4) 2011 측절치의이소맹출이관찰되었으며해당부위와관계가있는선행유치에는치아우식증및치근단병변소견이관찰되지않았다 (Fig. 1). 선행유치인상악좌측유측절치및유견치를발거하였고공간유지장치를장착하였다. 5개월의정기검진후해당부위에개창술 (window opening) 을시행하였고 8개월의정기검진후치아각도가개선되어부분맹출하였다. 11개월의정기 검진시이전보다치축개선의소견이보였고그이후 18개월까지치축개선을기대하여주기적으로검진을시행 (Fig. 2) 하였으나더이상의개선은일어나지않았다. 현재상악좌측측절치의치축개선및상악좌측견치의맹출공간부족문제를해결하기위해교정치료를계획중이다 (Fig. 3). (a) (b) (c) Fig. 1. (a) Initial periapical view. (b) Initial 3-Dimensional CT image. (c) Initial panoramic view. (a) (b) (c) (d) Fig. 2. (a) 4 months after extraction. (b) 7 months after extraction. (c) 10 months after extraction. (d) 17 months after extraction. Fig. 3. Intraoral photograph of the upper left lateral incisor(18 months after extraction). The arrow indicates the spontaneous erupted tooth. 386
대한소아치과학회지 38(4) 2011 증례 2 10세남환이작은어금니가나오지않는다는것을주소로본원소아치과에내원하였다. 임상구강검사및방사선검사결과상악우측제1소구치의이소매복소견이관찰되었으며상방의 우측제1유구치는치수절제술시행및기성금관을장착한상태였고치근단병변 (Fig. 4-6) 이관찰되었다. 우측제1유구치를발거한후상악우측제1소구치의맹출에대한정기검진을시행하였다 (Fig. 7). 발거10개월뒤어느정도자발적맹출이관찰되었고현재맹출위치개선을위한교정치료시행중이다. Fig. 4. Initial intraoral photograph. Fig. 5. Initial panoramic view. (a) (b) Fig. 6. (a) Initial 3-Dimensional CT image. (b) Initial CT image. The arrow indicates position of the ectopic tooth. (a) (b) Fig. 7. (a) 6 months after extraction. (b) 12 months after extraction. 387
J Korean Acad Pediatr Dent 38(4) 2011 (c) (d) Fig. 7. (c) 19 months after extraction. (d) 19 months after extraction. Ⅲ. 총괄및고찰치아의맹출은프로그램화되어있고정해진시기에적절한치아가맹출하게되는국소적인사건이다 6). 치아맹출에관한이론은크게 6가지로치수이론, 치근길이성장이론, 치조골성장이론, 혈관이론, 치주인대이론, 치낭이론이있다. 이중치주인대와치낭이맹출에필요한힘을제공한다는것이입증되어치주인대이론과치낭이론이제한적인정설로받아들여지고있다 7,8). Cahill과 Marks 9) 는치낭을수술적으로제거한치아에서치아가맹출하지않는다는것을밝혔고, 치낭에서파생된치주인대가설치류의절치부와같은연속성있는맹출에서중요역할을한다고하였다 6). 치낭의존재는맹출로의골흡수뿐아니라맹출중인치아의하방부에있는 trabecular bone 형성에도필수이며, 치낭에서파생된치주인대는출은후의치아맹출에관여한다고밝혀졌다 1,6). 치아가맹출하기위해서는치아의치관부를둘러싸고있는치조골의흡수를통해맹출로가형성되어야하고치아가이맹출로를통해생물학적과정에따라이동하게된다 8). 치아의맹출에는이러한 osteoclastogenesis와 osteogenesis 가필수적인데이를치낭이조절한다는것이연구에서밝혀졌다 10,11). 치낭의치관부절반을제거한경우치조골흡수가나타나지않았고치아맹출이일어나지않았다. 반면에치낭의기저부절반을제거한경우에는치조골흡수가일어났으나 bony crypt의기저부에치조골형성이일어나지않아서치아맹출이일어나지않았다 8,10). 이로써치낭의치관부위는맹출에필수적인osteoclastogenesis와치조골흡수를조절하는반면기저부위는맹출에필수적인 osteogenesis를조절한다는것을알수있다 8,10). 이는치조골흡수를위한 osteoclastogenesis의 marker gene인 receptor activator of nuclear factor kappa B (RANKL) 가치낭의치관부절반에서더많이발현되고, 치조골형성을위한 osteogenesis의 marker gene인 bone morphogenetic protein-2 (BMP-2) 가치낭의기저부절반에서 더많이발현되는것으로도알수있다 11). 맹출유도를위한방법으로는주기적인관찰, 공간확보, 외과적노출, 교정적견인, 외과적노출과교정적견인의병행, 발거후자가치아이식등이있다 7,12). 흔하지는않지만맹출경로에장애를주는요인이없는경우에한하여특히하악에서위치가바르지못한견치, 소구치, 때로는대구치에서자발적인맹출이보고되었다 7). 치아가정상적인위치로자발적인맹출을하기위해서는적절한공간이필요하고공간상실이있는경우공간의확보가선행되어야한다. Di Biase 13) 는맹출공간이확보된경우 54~75% 의치아가 18개월후자발적으로맹출한다고하였다. 선행유치의발거는맹출을촉진하는것으로밝혀졌고, 때때로정상위치에서벗어나이소맹출하는견치와소구치를정상적인위치로의맹출을가능하게도한다. 이러한맹출촉진효과는맹출하지않은치아의치근이완료되지않은상태일수록효과가크며특히유구치에서치수질환에기인한치조골파괴가있는경우에잘나타난다 7). 본증례 1에서는선행유치의치근단병변이관찰되지않았고증례 2에서는선행유치의치근단병변이관찰되었지만두증례모두선행유치의발거에의해계승영구치의자발적맹출이가능하게되었다. 유치의조기발거에의한치아맹출의촉진은후속영구치의치근발육상태와관련이있다. 대부분자발적인맹출을위한치아이동은 6개월이내에관찰할수있다 7). 그러므로영구치맹출을지연시키는방해요소제거후주기적인방사선학적관찰이필요하다. 유치발거후 6개월이경과된후에도치아이동이없거나, 치근이 2/3이상발육했으나맹출이지연될경우치관을외과적으로노출시키거나교정적인견인을고려해야한다 14). 본증례1에서도 5개월의정기검진시치아이동소견이보이지않아서개창술을시행하였다. 미맹출치아가인접치의백악법랑경계상방에위치하며, 치관의 1/2~2/3을노출하더라도백악법랑경계상방으로 2~3mm의부착치은이확보되어차후에치주적인문제를보이지않을것으로판단되는경우치관을외과적으로노출시킬수있다 15). 맹출하고있는치아는최소한의저항을받는경로를따 388
대한소아치과학회지 38(4) 2011 라이동한다. 외과적노출은맹출경로를확보할목적으로점막, 골, 때로는영구치를덮고있는치낭의일부까지제거하는것을포함한다 7). 본증례 1에서개창술시행후치아가자발적으로맹출하는것을볼수있었듯이대개맹출경로를막고있는경조직및연조직을제거하면치아는자발적으로맹출하는경향이있다 16,17). 만약치아의변위가정상적인맹출로에서 90 이상이거나심하게이동되어주기적인방사선학적관찰시자발적인위치개선이없을경우자가치아이식, 교정적견인, 발치등의치료가필요하다 5,18). 자가치아이식을시행할경우시술후교정치료의가능성을최소화하는방향으로시행되어야하고 19) 충분한공간이있는지, 매복치와인접치와의위치관계, 수술에따르는비용등을고려한후시행하여야한다 20,21). 발치를시행할경우환자의나이, 인접치의상태, 매복치의위치, 교합관계, 악궁길이등을고려해야하고, 합병증으로치근파절, 신경학적문제, 치조골결손, 인접치손상등이발생할수있다 22). 맹출장애를조기에발견하여예측할수있다면환자에게는물론술자에게도큰도움이될것이다. 맹출장애를해결하기위해서는맹출기전을이해하고맹출을조절하는여러요소에대한폭넓은이해와연구가필요하리라사료된다. Ⅳ. 요약본증례들에서이소매복된영구치는선행유치의발거후경과관찰을시행한결과맹출방향의개선과함께자발적으로맹출하였다. 맹출장애의치료법에는여러가지가있으나선행유치의제거에의한후속영구치맹출유도는맹출공간이충분하고, 이소매복영구치의변위정도가심하지않을때선택적으로고려되어질수있을것이다. 참고문헌 1. Raghoebar GM, Boering G, Vissink A, Stegenga B : Eruption disturbances of permanent molars: a review. J Oral Pathol Med, 20:159-166, 1991. 2. Kaban LB, Needleman HL, Hertzberg J : Idiopathic failure of eruption of permanent molar teeth. Oral Surg Oral Med Oral Pathol, 42:155-163, 1976. 3. Burch J, Ngan P, Hackman A : Diagnosis and treatment planning for unerupted premolars. Pediatr Dent, 16:89-95, 1994. 4. Proffit WR, Vig KW : Primary failure of eruption: a possible cause of posterior open-bite. Am J Orthod, 80:173-190, 1981. 5. Andreasen JO, K lsen Petersen J, Laskin D, et al. : Textbook and color atlas of tooth impactions. 1st ed. Munksgaard, Copenhagen, 66-85, 1997. 6. Wise GE, Frazier-Bowers S, D Souza RN : Cellular, molecular, and genetic determinants of tooth eruption. Crit Rev Oral Biol Med, 13:323-334, 2002. 7. 대한소아치과학회 : 소아, 청소년치과학. 4th ed. 신흥인터내셔날, 서울, 566-579, 2007. 8. Wise GE : Cellular and molecular basis of tooth eruption. Orthod Craniofac Res, 12:67-73, 2009. 9. Cahill DR, Marks SC Jr : Tooth eruption: evidence for the central role of the dental follicle. J Oral Pathol, 9:189-200, 1980. 10. Marks SC Jr, Cahill DR : Regional control by the dental follicle of alterations in alveolar bone metabolism during tooth eruption. J Oral Pathol, 16:164-169, 1987. 11. Wise GE, Yao S : Regional differences of expression of bone morphogenetic protein-2 and RANKL in the rat dental follicle. Eur J Oral Sci, 114:512-516, 2006. 12. 권지훈, 박호원, 이주현, 서현우 : 맹출지연영구치의자발적맹출유도. 대한소아치과학회지, 34:694-699, 2007. 13. Di Biase DD : The effects of variations in tooth morphology and position on eruption. Dent Pract Dent Rec, 22:95-108, 1971. 14. Suri L, Gagari E, Vastardis H : Delayed tooth eruption: pathogenesis, diagnosis, and treatment. A literature review. Am J Orthod Dentofacial Orthop, 126:432-445, 2004. 15. 심정호, 음종혁, 정태성, 김신 : 맹출장애를보이는상악전치의맹출유도. 대한소아치과학회지, 31:34-40, 2004. 16. Ohman I, Ohman A : The eruption tendency and changes of direction of impacted teeth following surgical exposure. Oral Surg Oral Med Oral Pathol, 49:383-389, 1980. 17. Shapira Y, Borell G, Kuftinec MM, et al. : Bringing impacted mandibular second premolars into occlusion. J Am Dent Assoc, 127:1075-1078, 1996. 18. Wagner M, Katsaros C, Goldstein T : Spontaneous uprighting of permanent tooth germs after elimination of local eruption obstacles. J Orofac Orthop, 60:279-285, 1999. 19. Frank CA : Treatment options for impacted teeth. J Am Dent Assoc, 131:623-632, 2000. 20. Moss JP : An orthodontic approach to surgical problems. Am J Orthod, 68:363-390, 1975. 21. Lownie JF, Cleaton-Jones PE, Fatti P, Lownie MA : Autotransplantation of maxillary canine teeth. A follow-up of 35 cases up to 4 years. Int J Oral Maxillofac Surg, 15:282-287, 1986. 22. Alling CC 3rd, Catone GA : Management of impacted teeth. J Oral Maxillofac Surg, 51:3-6, 1993. 389
J Korean Acad Pediatr Dent 38(4) 2011 Abstract SPONTANEOUS ERUPTION OF ECTOPIC IMPACTED TOOTH BY INTENTIONAL EXTRACTION OF DECIDUOUS TOOTH In Young Choi 1, Seung-Hye Kim 2, Seong-Oh Kim 2, Hyung-Jun Choi 2, Jae-Ho Lee 2, Byung-Jai Choi 2, Heung-Kyu Son 2, Je Seon Song 2 1 Department of Pediatric Dentistry, 2 Department of Pediatric Dentistry and Oral Science Research Center, College of Dentistry, Yonsei University When many factors involved in the eruption of the teeth act as negative effects, they can cause eruption disturbance. Periodic observation, space acquirement, surgical exposure, orthodontic traction, orthodontic traction accompanied with surgical exposure, and surgical repositioning are considered as the treatment options of an impacted tooth, which is a form of eruption disturbance. In the first case, a male patient, age 9, visited Yonsei University Dental Hospital (YUDH) with a chief complaint of ectopic impaction of the upper left lateral incisor. We extracted the upper left primary lateral incisor and primary canine, and 5 months later, a window opening procedure was executed. Eight months later, the upper left lateral incisor partially erupted, and 18 months after the extraction, the axis of the tooth improved and the tooth erupted spontaneously. In the second case, a male patient, age 10, visited YUDH with a chief complaint of ectopic impaction of the upper right first premolar. We extracted the upper right first primary molar. Ten months later, the upper right first premolar erupted partially, and 19 months after the extraction, the upper right first premolar erupted spontaneously. We reported two cases in which improvement of eruption path and spontaneous eruption of an ectopic impacted tooth was achieved by extracting the deciduous tooth which interfered with the proper eruption of it. Key words : Eruption disturbance, Ectopic impaction, Extraction of deciduous teeth, Spontaneous eruption 390