ISSN 1229-5418 Implantology 2013; 17(2): 98~107 CAD/CAM Two-Piece Zirconia Abutment 를이용한상악전치부의단일임플란트식립과수복증례 이도연, 박수정, 이성복, 이석원, 안수진강동경희대학교병원치과병원생체재료보철학교실 CAD/CAM Two-Piece Zirconia Abutments Used for Anterior Single-Tooth Implant Reconstruction Do Yun Lee, Su Jung Park, Richard Leesungbok, Suk-Won Lee, Su-Jin Ahn Department of Biomaterial-Prosthodontics, Kyung Hee University Dental Hospital at Gangdong, Seoul, Korea Abstract The replacements of missing teeth with implant supported single crowns and fixed dental prostheses have become a standard treatment modality. Metal abutments made out of titanium have proven to be durable, however, it was reported to cause a grayish discoloration of the peri-implanted mucosa. For this reason, all-ceramic abutments made out of high-strength ceramics have been developed. Today, zirconia abutments with various implant-abutment connection geometries exist for different implant types. Significantly higher values were achieved for CAD/CAM zirconia abutments with internal connections via a secondary titanium insert (two-piece) than for the ones with external connections or one-piece abutment. The use of a secondary titanium insert might have a beneficial influence on the stability of zirconia abutments and appears to be clinically useful for anterior single-tooth replacement. This case report provides a clinical case of two-piece zirconia abutment using the titanium core. It may be effective as compared to that of other conventional treatments in esthetics. And further controlled clinical studies are needed to evaluate the effects and complications. Key Words: computer-aided design, dental implants, dental implant-abutment design, single tooth, zirconium oxide Reprint requests: Su Jung Park Department of Biomaterial-Prosthodontics, Kyung Hee University Dental Hospital at Gangdong, School of Dentistry, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul 134-727, Korea Tel: 82-2-440-7518, Fax: 82-2-440-7549 E-mail: romeoni@hanmail.net Received for publication: June 18, 2013 Accepted for publication: June 19, 2013 교신저자 : 박수정 (134-727) 서울시강동구동남로 892 경희대학교치과대학강동경희대학교치과병원생체재료보철학과 Tel: 82-2-440-7518, Fax: 82-2-440-7549 E-mail: romeoni@hanmail.net 원고접수일 : 2013 년 6 월 18 일게재확정일 : 2013 년 6 월 19 일 Copyright 2013. The Korean Academy of Oral & Maxillofacial Implantology This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 98 Implantology Vol. 17 No. 2, 2013
I 서론 two-piece 지르코니아어버트먼트를사용하여상악단일임플란트보철을제작하였으며, 심미적, 기능적으로만족할만한결과를얻었기에이를보고한다. 임플란트고정성보철물은임플란트주위연조직이인접연조직과자연스럽게조화를이루고보철물은자연치의적절한외형을재현해야한다 1. 타이타늄임플란트어버트먼트는우수한기계적성질로인해널리사용되고있으나, 연조직의두께가얇거나치은퇴축이발생하는경우치은에어두운색상이투과되는문제점을가진다. 이를보완하기위해알루미나또는지르코니아와같은재료를사용한올세라믹어버트먼트가개발되었고약 10여년간의문헌고찰결과알루미나보다는지르코니아어버트먼트가기계적성질이우수하고임상결과가뛰어남이입증되었다 2-4. 지르코니아어버트먼트는타이타늄어버트먼트와기계적강도가유사하고생체적합성면에서도임플란트주변연조직반응이우수하다. 또한지르코니아표면에의초기세균부착력은약하며 5, 지르코니아어버트먼트를 4 년동안관찰한결과파절이나병소가발생하지않는다는임상결과가보고되었다 6. 이에따라본증례에는 II 증례보고 1. 진단및치료계획상악좌측중절치 (#21) 의상실부위에가철성레진상임시의치를 30년간사용해온 53세남환이임플란트상담을위해내원하였다. 구강내분석결과장기간상실되어있던무치악공간의치은은 thin biotype 으로인접치은과는달리치은양이부족하고수평적골흡수가컸으며미소시 lip line 은 medium range 로순측외형의회복을위해 bone graft 및연조직 management 가필요할것으로생각되었다. 모형분석결과상악우측중절치 (#11) 와상 Fig. 1. Mesiodistal distance discrepancy compared to the contralateral tooth. Fig. 2. A distance of 6 mm or more from the alveolar crest to the contact point reduces the probability of intact papillae. 대한구강악안면임프란트학회지 17 권 2 호, 2013 99
Case Reports 실된치아 (#21) 공간의근원심폭경은각각 8.8 mm, 9.1 mm로 0.3 mm의차이가있었으며 (Fig. 1) 이에따라두치아의대칭을위해보철물에시각적인효과를줄수있는요소를삽입해야할것으로판단되었다. 치근단방사선사진을통한계측결과인접면접촉점과치조골과의 거리는 6 mm 이상이었으므로향후치간유두가차오르지않고 black triangle 이생길수있음을환자에게고지하였다 (Fig. 2). 진단왁스업을시행한뒤보철물순측변연의 3 mm 하방에임플란트가식립될것을고려하여이상적인임플란트식립위치를결정하고스텐트를제작하 Fig. 3. (A, B) Three dimensional radio graphic finding. Fig. 4. Timing of the soft-tissue conditioning process in esthetic sites. Fig. 5. Full flap elevation canine to canine. Fig. 6. Corono-apical position. 100 Implantology Vol. 17 No. 2, 2013
여 cone beam computed tomography 를촬영하였으며 (Fig. 3), 자가골과합성골을이용한골증대술과동시에임플란트식립을계획하고최종보철물은 internal 타입의 two-piece 지르코니아어버트먼트를사용한지르코니아크라운을사용하기로하였다. 치료에관한 time frame 은 Fig. 4와같다. Fig. 7. Sequential drilling. 2. 임플란트식립및보철상악우측견치에서좌측견치까지전층판막을거상하고수술용스텐트와 probe 를이용하여이상적인임플란트위치를평가하면서최대한치조골내에식립되도록순차적드릴링을시행하였다. 직경 3.5 mm, 길이 10 mm CMI bone level 임플란트 (Neobiotech Co., Ltd, Seoul, Korea) 를식립하였으며인접치의치은연을기준으로 3 mm 하방에 fixture 의상부가위치되도록 corono-apical position 을설정하고, oro-facial position 으로는최종보철물의 emergence profile 보다 1.0~1.5 mm 구개측으로위치되도록하였다 (Fig. 5~8). 식립토크는 40 Ncm 이었다. 최종드릴링이후에순측 fenentration 이발생하여 bone scraper 을사용하여 nasal spine 에서자가골을채취한뒤순측골벽과 thread 가노출된상부에충전하고그위로는합성골로풍융한외형을만들었다. 그후흡수성콜라겐막을이용하여 primary closure 가되도록봉합하였다. 2개월후순측풍융도가감소된것으로관찰되었으며이차수술과동시에위해 roll technique 을사용하 Fig. 8. Oro-facial position. Fig. 9. Screw-retained provisional restoration using plastic temporary abutment. 대한구강악안면임프란트학회지 17 권 2 호, 2013 101
Case Reports 여감소된풍융도를보상하였다. Implant stability quotient 는평균 78임을확인하였다. 10일후, 픽업인상을채득하여 temporary plastic abutment 를이용한 screw-retained provisional crown 을제작하였다. 제작시자연스러운 emergence profile 을위해순측형태를 ridge-lap 으로하였으며 (Fig. 9), flowable resin 을이용하여 chair side 에서직접수정하였다. 4개월후, 치은의안정을확인하고 (Fig. 10) provisional crown의 emergence profile 을재현하기위해 custom impression coping 을제작하여최종인상을채득하였다 (Fig. 11). 순측치은두께의측정결과 2 mm로기존의타이타늄어버트먼트를사용할경우치은의색상에영향을미칠것으로여겨져타이타늄구조물이개재된 Fig. 11. Produce a customized impression coping duplicate the gingival contour of provisional restoration. Fig. 10. (A) Abutment and provisional crown insertion state on #21. (B) Stable soft tissues after 8. weeks with the provisional insertion. Fig. 12. (A) Wax up for final prosthesis. (B) Titanium coping for mesostructure of zirconia abutment. 102 Implantology Vol. 17 No. 2, 2013
internal 타입의 two-piece 지르코니아 어버트먼트를 사 럭을 이용하여 밀링하였다(Fig. 12~15). 레진 시멘트를 용하기로 하였다. 최종 왁스업 시행 뒤 중간 타이타늄 구 이용하여 중간 타이타늄 구조물과 지르코니아 코핑을 접 조물과 최종 왁스업, 대합치열에 스캐닝 파우더를 입힌 착하여 two-piece 지르코니아 어버트먼트를 완성하였 후 스캐닝을 하였고, 지르코니아 코핑을 CAD한 뒤 지르 다. 구강 내 시적해 볼 레진 캡을 제작하기 위해 지르코 코니아 Prettau (Zirkonzahn GmbH, Bruneck, Italy) 블 니아 코핑을 다시 스캔하여 스캐닝한 최종 왁스업을 불 Fig. 13. (A, B) Scanning of a secondary metallic component for zirconia abutments. (C, D) Scanning of final prosthesis wax up model and opposite dentition. Fig. 14. Procedures of 3 dimensional scanning for CAD/CAM. Computer aided design for Zirconia coping. 대한구강악안면임프란트학회지 17권 2호, 2013 103
Case Reports Fig. 15. (A, B) Computer aided manufacturing on Prettau (Zirkonzahn GmbH, Bruneck, Italy) Zirconia block. (C) Presintered state of zirconia coping. (D) Zirconia coping after final sintering and titanium component for two-piece internal implant-abutment connection. Fig. 16. (A) Scanning of final prosthesis wax up model. (B) Milling of resin block for provisional resin cap. (C, D) Completion of two-piece zirconia abutment and provisional resin cap. 러들여레진블록상에서밀링하였고 (Fig. 16), 이를구강내적합시켜수정사항을체크한뒤최종지르코니아크 라운을완성하였다 (Fig. 17~20). 104 Implantology Vol. 17 No. 2, 2013
Fig. 17. Intraoral insertion of zirconia coping (A) and resin cap (B), and adjustment shape and contour of resin cap on chairside. Fig. 18. (A) Scanning of modified resin cap adjusted on chairside. (B) Computer aided design for zirconia cap for final zirconia-porcelain crown with consideration of porcelain space. (C, D) Milling of zirconia block. (E, F) Completed CAD-CAM zirconia cap for final prosthesis before porcelain build up. 대한구강악안면임프란트학회지 17 권 2 호, 2013 105
Case Reports Fig. 20. Zirconia crown final insertion. Fig. 19. Left: resin cap for adaptation. Right: zirconia crown for final prosthesis. III 총괄및고찰 전치부의치아상실공간을임플란트를통해재건할때, 최종보철물의장착이후완벽하게심미적인결과를보장할수있는경우는많지않다. 상실기간이길어져연, 경조직흡수량이많거나 lip line 이높은경우, 환자의심미적요구도가크고 thin gingival biotype 을가지고있는경우경, 연조직 defect 가있어서재건에대해수술적인접근을시행해야하는경우는이러한심미적인완성도에대한예측을더욱어렵게한다 7. 본증례는 ITI (International Team for Implantology) classification 을사용하였을때 straightforward, advanced, complex 중 advanced 로분류되었으며이에따라기존의회색빛을띠는타이타늄어버트먼트를사용하는것은어버트먼트의색상이치은을투과하여치은연에비칠수있다는위험요소를안고있었다. 또한환자의심미적인욕구도굉장히높아서타이타늄어버트먼트를대체하는심미적인어버트먼트를사용 해야함을치료계획시고려하였다. 임플란트와어버트먼트의연결구조는크게 external 과 internal 로나눌수있으며어버트먼트가하나의재료를이용하여일체형으로이루어진경우를 one-piece 어버트먼트, 다른연결구조가중간에개재되어있으면 two-piece 어버트먼트로분류한다. Two-piece 어버트먼트의구성은타이타늄중간구조물과 CAD/CAM 을이용한지르코니아코핑으로이루어져있으며, 중간구조물과지르코니아코핑은레진시멘트를이용해접착하게된다. 중간타이타늄구조물로연결된 internal 타입의 two-piece 지르코니아어버트먼트는 external type 혹은 one-piece 지르코니아어버트먼트보다굽힘모멘트와파절강도가우수함이여러문헌을통해밝혀졌다 6,8-10. 이는개재된타이타늄구조물이부하를적절히분산하는것이원인이라고생각되며, 중간타이타늄구조물에먼저소성변형이일어나힘을흡수하고나머지를어버트먼트에전달하므로강한파절강도를갖는것으로생각된다 9. 중간타이타늄구조물과지르코니아코핑의레진시멘트에의한접착에대해서는 air abrasion 을사용한경우임상적으로충분한유지력을나타냄이검증되었다 11. 또한중간타이타늄구조물과지르코니아코핑간의수직, 수평적 maginal gap 을평가했을때기성품으로나오 106 Implantology Vol. 17 No. 2, 2013
는임플란트시스템과비교해서큰차이가없는것으로밝혀졌다 12. IV 결론 Thin biotype 을갖는상악전치부임플란트환자에있어서중간타이타늄구조물을이용한 two-piece internal 타입의지르코니아어버트먼트는기능적, 심미적으로만족스러운결과를가져올수있다. 참고문헌 1. Belser U, Martin W, Jung R, et al. ITI treatment guide: implant therapy in the esthetic zone: single-tooth replacements. 1st ed. Chicago: Quintessence Publishing Co., Ltd.; 2007. p. 43-45. 2. Andersson B, Taylor A, Lang BR, et al. Alumina ceramic implant abutments used for single-tooth replacement: a prospective 1- to 3-year multicenter study. Int J Prosthodont. 2001; 14: 432-438. 3. Prestipino V, Ingber A. Esthetic high-strength implant abutments. Part II. J Esthet Dent. 1993; 5: 63-68. 4. Sailer I, Zembic A, Jung RE, et al. Single-tooth implant reconstructions: esthetic factors influencing the decision between titanium and zirconia abutments in anterior regions. Eur J Esthet Dent. 2007; 2: 296-310. 5. Linkevicius T, Apse P. Influence of abutment material on stability of peri-implant tissues: a systematic review. Int J Oral Maxillofac Implants. 2008; 23: 449-456. 6. Zembic A, Sailer I, Jung RE, et al. Randomized-controlled clinical trial of customized zirconia and titanium implant abutments for single-tooth implants in canine and posterior regions: 3-year results. Clin Oral Implants Res. 2009; 20: 802-808. 7. Dawson A, Chen S, Buser D, et al. The SAC Classification in Implant Dentistry. Chicago: Quintessence; 2009. p. 18-20. 8. Truninger TC, Stawarczyk B, Leutert CR, et al. Bending moments of zirconia and titanium abutments with internal and external implantabutment connections after aging and chewing simulation. Clin Oral Implants Res. 2012; 23: 12-18. 9. Leutert CR, Stawarczyk B, Truninger TC, et al. Bending moments and types of failure of zirconia and titanium abutments with internal implant-abutment connections: a laboratory study. Int J Oral Maxillofac Implants. 2012; 27: 505-512. 10. Sailer I, Sailer T, Stawarczyk B, et al. In vitro study of the influence of the type of connection on the fracture load of zirconia abutments with internal and external implant-abutment connections. Int J Oral Maxillofac Implants. 2009; 24: 850-858. 11. Baldassarri M, Hjerppe J, Romeo D, et al. Marginal accuracy of three implant-ceramic abutment configurations. Int J Oral Maxillofac Implants. 2012; 27: 537-543. 12. Ebert A, Hedderich J, Kern M. Retention of zirconia ceramic copings bonded to titanium abutments. Int J Oral Maxillofac Implants. 2007; 22: 921-927. 대한구강악안면임프란트학회지 17 권 2 호, 2013 107