ORIGINAL ARTICLE

Bone depth and thickness of different

infrazygomatic crest miniscrew insertion
paths between the first and second
maxillary molars for distal tooth
movement: A 3-dimensional assessment
Bingran Du,a Jiuyu Zhu,b Lutao Li,a Tiancheng Fan,a Jinchuan Tan,a and Jianyi Lic
Guangdong and Henan, China

Introduction: This research aimed to measure the bone depth and thickness of different insertion paths for
safe placement of infrazygomatic crest miniscrews between the first (U6) and second maxillary molars (U7)
by 3-dimensional (3D) reconstruction and to explore their clinical significance. Methods: Cone-beam
computed tomography data from 36 adult orthodontic patients were obtained to generate 3D models
(n 5 72) of the infrazygomatic crest region. For each model, the bone depth and thickness of 27 different inser-
tion paths were measured in the region between U6 and U7. The relationship between bone depth and thick-
ness was statistically analyzed. The clinical risk for each insertion path was assessed according to the impacts
of bone depth and thickness on insertion failure. Results: Maximum bone depth (median, 7.41 mm; mean,
8.42 mm) was present at 13 mm insertion sites with a gingival tipping angle of 50 and a distal tipping angle
of 30 . Maximum bone thickness (median, 3.73 mm; mean, 4.00 mm) was present at 17 mm insertion site with
a gingival tipping angle of 70 and a distal tipping angle of 30 . There was a significant negative correlation
between bone depth and bone thickness (rs 5 0.569, P \0.001). Failure rates were significantly different
among different insertion paths (P \0.001). Conclusions: Because the bone depth and thickness may affect
the safe insertion of infrazygomatic crest miniscrews in the region between U6 and U7 and they are negatively
related, a safe insertion protocol design for distal tooth movement should take both into consideration. (Am J
Orthod Dentofacial Orthop 2021;160:113-23)

M
a
Department of Anatomy, Guangdong Provincial Key Laboratory of Medical
iniscrews are commonly used for anchorage in
Biomechanics, School of Basic Medical Sciences, Southern Medical University, distal movement of the maxillary molars for
Guangdong, China.
b
treatment of Class II malocclusion,1-5 because
Department of Stomatology, the Third Affiliated Hospital of Xinxiang Medical
University, Henan, China.
of their advantages of minimal anatomic limitation,
c
Department of Anatomy, Guangdong Provincial Key Laboratory of Medical simple placement, and limited complications.6,7 Place-
Biomechanics, School of Basic Medical Sciences, Southern Medical University, ment of miniscrews in the buccal interradicular region
and Nanhai Hospital, Southern Medical University, Guangdong, China.
All authors have completed and submitted the ICMJE Form for Disclosure of
is one of the most common approaches used in distal
Potential Conflicts of Interest, and none were reported. tooth movement.8,9 Although the interradicular minis-
This work was supported by the National Natural Science Foundation of China crews may reduce complications related to soft tissue irri-
(no. 31771330), National Key Research and Development Program of China
(no. 2017YFC0110602), and the Science and Technology Program of Guangzhou
tation, the limited interradicular space can obstruct tooth
and Guangdong (nos. 2015B010125006, 201704020129, and 201704020069). movement. Therefore, the infrazygomatic crest region is
Address correspondence to: Jianyi Li, MD, PhD, Department of Anatomy, School frequently selected for miniscrew insertion,10,11 because
of Basic Medical Sciences, Southern Medical University, No.1023, South Shatai
Road, Baiyun District, Guangzhou, Guangdong, China 510515; e-mail,
it not only has the thickest maxillary cortical bone12 but
[email protected]. also is far from the dentoalveolar region.13 The anatomic
Submitted, September 2019; revised and accepted, March 2020. advantages of the infrazygomatic crest region contribute
0889-5406/$36.00
Ó 2021.
to better primary stability of miniscrews and provide the
https://doi.org/10.1016/j.ajodo.2020.03.036 possibility for unobstructed tooth movement. However,
113
114 Du et al

because no well-accepted insertion protocol or sophisti- area; (2) no radiographic signs of periodontal disease
cated assistive device has been available for operators, or severe crowding of the dental arch; (3) no craniofacial
anatomic research is needed for safe miniscrew insertion anomaly or systemic disease; (4) no history of orthodon-
in this region. tic treatment. Informed consent signed by the patients
Miniscrew insertion in the infrazygomatic crest re- was waived because of the observational nature of the
gion is often restricted by surrounding anatomic struc- study and the anonymity and deidentification of per-
tures, like molar roots and maxillary sinus. To provide sonal information before data analysis. This study was
a clinical guide for miniscrew insertion, Liou et al14 approved by the medical ethical committee of the Third
measured the bone depth from an insertion site to the Affiliated Hospital of Xinxiang Medical University.
sinus floor at different gingival tipping angles and inser- The CBCT images, taken with KaVo 3D eXam i (KaVo
tion heights. They suggested that miniscrews should be Dental, Biberach, Germany) at these settings: 5 mA,
inserted at special angles and heights to achieve a bone 120 kV, exposure time of 6 seconds, voxel size of 0.2
depth of 6 mm. However, their study only considered the mm, axial slice thickness of 0.2 mm, and scanning area
importance of bone depth but ignored the effect of bone of 140 mm 3 85 mm, were saved in Digital Imaging
thickness at the buccal side of the roots on the safe inser- and Communications in Medicine format and recon-
tion of miniscrews. The bone thickness related to the structed with continuous slices at 0.2-mm thickness us-
diameter of a miniscrew affects not only the mechanical ing Mimics 14.01 software (Materialise, Leuven,
strength of a miniscrew but also the risk for root dam- Belgium). For each patient, two 3D models were recon-
age. Reducing the diameter of a miniscrew might structed for bilateral infrazygomatic crest regions. Alto-
decrease the risk of root damage, but the failure rate gether, 72 models were produced for the 36 patients.
might increase with decreased mechanical strength.15,16 Geomagic Studio 12.0 (3D Systems, Morrisville, NC)
Therefore, it is necessary to take the bone depth and was used to create insertion paths by constructing char-
thickness of each insertion path into account in the acteristic, and reference planes in the 3D reconstructed
evaluation of the clinical risk in infrazygomatic crest models. The 5 characteristic planes (buccal root plane,
miniscrew use. distal plane of U6, mesial plane of U7, alveolar bone
Moreover, studies have demonstrated that U6 does plane, and bisection plane of U6 and U7) were con-
not seem to be an ideal insertion zone in the infrazygo- structed by self-contained functions of the software.
matic crest region because of its thinner buccal alveolar In detail, using the Best Fit function, the part of the
bone and deeper sinus floor.17,18 Instead, the region be- buccal surface above the root furcation plane (parallel
tween the first (U6) and second maxillary molars (U7) has to the posterior occlusal plane20 and through the root
been suggested as an alternative zone for miniscrew furcation point) of the distobuccal root of U6 (DR6)
placement.18 and the mesiobuccal root of U7 (MR7) was selected to
Currently, cone-beam computed tomography (CBCT) fit the buccal root plane (Fig 1, A and D). Using the
has been commonly used to evaluate the 3-dimensional same function, the part of the distal surface above the
(3D) craniofacial anatomy and dental morphometrics,19 root furcation plane of DR6 and the part of the mesial
because it can provide more objective data about surface above the root furcation plane of MR7 was
anatomic structures and thus result in more accurate used to fit the distal plane of U6 and the mesial plane
measurements than two-dimensional radiography. of U7, respectively (Fig 1, B and D). Similarly, the part
Therefore, this study aimed to explore how the bone of alveolar bone from 11 mm to 19 mm above the pos-
depths and thicknesses of different insertion paths in the terior occlusal plane (POP) between the distal plane of
region between U6 and U7 may affect the infrazygo- U6 and the mesial plane of U7 was selected to fit the
matic crest miniscrew use by 3D reconstruction models alveolar bone plane (Fig 1, C and E). Using the 2-
because of CBCT data. Plane Average function, the bisection plane of U6 and
U7 was constructed by averaging the distal plane of
MATERIAL AND METHODS U6 and the mesial plane of U7 (Fig 1, D). In this study,
CBCT data from 36 adult orthodontic patients the POP was used to represent the horizontal reference
(16 men and 20 women; mean age, 23.1 years; range, plane and a plane that was at a right angle to the hori-
20-28 years) were obtained from the Department of zontal plane and the alveolar bone plane through the
Orthodontics in the Third Affiliated Hospital of Xinxiang contact point between the crowns of U6 and U7 was
Medical University, Xinxiang, Henan, China. The CBCT used to represent the vertical reference plane (Fig 1, F).
data included for this study met the following criteria: In each of the 3D models, 27 different insertion paths
(1) no missing (except the third molar), supernumerary were created at 3 insertion heights, 3 gingival tipping
or defective tooth in the maxillary posterior-tooth angles, and 3 distal tipping angles. Because of the

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Du et al 115

Fig 1. Characteristic and reference planes in a 3D model of infrazygomatic crest region at the right
side. A, the fitting part (red area) of buccal root plane; RF plane, root furcation plane; RF point, root
furcation point. B, the fitting parts (red areas) of the distal plane of U6 and mesial plane of U7; MS,
mesial surface; DS, distal surface. C, the fitting part (red area) of alveolar bone plane; DP, distal plane;
MP, mesial plane. D, buccal root plane (BRP) and the bisection plane (BP) of DP of U6 and MP of U7. E,
alveolar bone plane (ABP). F, vertical reference plane (VRP) and horizontal reference plane (HRP).

characteristic and reference planes, 3 insertion sites cor- measuring planes met at the bottom of the maxillary si-
responding to the midpoints between the roots of U6 nus (Fig 2, F). Hence, 3 insertion sites at different heights
and U7 were designed at heights of 13, 15, and produced 27 insertion paths in one specific 3D model.
17 mm above the horizontal reference plane on the To our knowledge, 1.6 mm is the minimum diameter
buccal alveolar bone (Fig 2, A). At each insertion site, recommended to avoid miniscrew fracture in dense
2 measuring planes were designed parallel to the hori- cortical bone,17 3.8 mm the minimum effective length
zontal and vertical reference planes, respectively (Fig 2, (length in bone) recommended for miniscrew stability,21
B). Then, 2 perpendicular lines of the horizontal and and 0.5 mm the minimal safety distance from a minis-
vertical reference planes at each insertion site were crew to any adjacent anatomic structure.22 Therefore,
constructed as a vertical axis and a horizontal axis, insertion failure in this study was defined as an effective
respectively (Fig 2, C). The 3 distal tipping angles length of miniscrew (length in bone) less than 3.8 mm
were obtained by rotating the vertical measuring plane (Fig 3, A) or a minimum distance less than 0.5 mm
by 0 , 15 , and 30 distally around the vertical from a 1.6 mm miniscrew to roots (Fig 3, B) during the
axis, respectively (Fig 2, D). Similarly, the 3 gingival distal tooth movement. Bone depth and thickness of
tipping angles were obtained by rotating the horizontal each insertion path were measured respectively as 2 in-
measuring plane by 50 , 60 , and 70 gingivally dexes closely related. The bone depth was defined as
around the horizontal axis, respectively (Fig 2, the distance from an insertion site to the intersection
E). Finally, 9 insertion paths at each insertion site were point at the bottom of the maxillary sinus (Fig 4, A),
obtained. The paths connected 1 specific insertion site whereas the bone thickness as the radius of a cylinder
with 9 intersection points where the 3 rotated vertical with an insertion path as its axis, tangent to the distal
measuring planes and the 3 rotated horizontal movement trajectory of roots (Fig 4, B). If insertion

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116 Du et al

Fig 2. Construction of insertion paths in the region between U6 and U7 at the right side. A, midpoints
(M, red points) between the roots of U6 and U7 and the corresponding insertion sites (S, white points)
on the buccal alveolar bone at heights of 13, 15, and 17 mm. B, measuring planes at 3 insertion heights:
vertical measuring plane (VMP) and horizontal measuring plane (HMP). C, 2 rotation axes at the 13 mm
insertion height: horizontal axis (H axis) and vertical axis (V axis). D, distal tipping angles at the 13 mm
insertion height. E, gingival tipping angles at the 13 mm insertion height. F, 9 insertion paths at the
13 mm insertion height.

Fig 3. Insertion failure: A, the effective length of a miniscrew less than 3.8 mm; IZ crest, infrazygomatic
crest. B, the minimum distance less than 0.5 mm from a 1.6 mm miniscrew to roots. MT, movement
trajectory of roots.

path passed below the distal movement trajectory of designed as 3.2 mm.23 We simulated the distal move-
roots, the value of bone thickness was 0. In this study, ment at a trajectory from 0.0 mm to 0.8 mm to
the maximum distal movement of molar roots was 1.6 mm to 2.4 mm and 3.2 mm.

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Du et al 117

Fig 4. Measurement metrics. A, bone depth (BD), the distance from the insertion site (white point) to
the intersection points (black point) at the bottom of the maxillary sinus. B, bone thickness (BT), the
radius of a cylinder with insertion path (IP) as its axis, tangent to the distal movement trajectory of roots.
MT, movement trajectory of roots.

In short, an insertion failure might arise in a path Friedman test was used to evaluate the differences in
when its bone depth is less than 3.8 mm or its bone bone depths and thicknesses of different paths, and Co-
thickness less than 1.3 mm (miniscrew with 0.8 mm chran’s Q test to analyze the insertion failure rates of
radius added the 0.5 mm minimal safety distance). different paths. The significant analysis was followed
The insertion failure rate for each insertion path by the post-hoc test with the Bonferroni correction. Cor-
was calculated according to its bone depth and relation between bone depths and bone thicknesses was
thickness. analyzed by Spearman’s rank correlation coefficient. In-
To determine whether the sample size was sufficient, terrater reliability for measurement was examined using
CBCT data from 20 adult orthodontic patients were the interclass correlation coefficient.
collected in the pilot study, and the bone depths and In our pilot study, bone depths and thicknesses of
thickness of forty 3D models (20 people, each with left forty 3D models from 20 patients were measured 27
and right sides) were measured using the same method times at different insertion paths. For a 2-sided hypoth-
described above. Finally, CBCT data from 36 adult ortho- esis test, 1080 measurements (multiplying 40 3 27)
dontic patients were obtained, and the bone depths and could yield a 100% power to detect a Spearman correla-
thickness of seventy-two 3D models (36 people, each tion of 0.51 between the depths and thicknesses with a
with left and right sides) were measured in this study. significance level (a) of 0.05. Therefore, seventy-two 3D
Of all the 3D models measured by a rater, 16 were selected models of infrazygomatic crest region from 36 patients
randomly by another rater for reevaluation in the same in our study were sufficient for statistical analysis.
way.
RESULTS
Statistical analysis Because no statistically significant differences were
Statistical analysis was conducted with SPSS software found between different sides (P .0.05) or genders
(version 20; IBM, Armonk, NY). A level of P \0.05 was (P .0.05), the following evaluations were performed
considered statistically significant. We tested the normal on the pooled data without any distinction in laterality
distribution using the Shapiro-Wilk test and found that or gender.
the measurements were not normally distributed. Statistical analysis showed that the interclass correla-
Wilcoxon signed-rank test was used to analyze dif- tion coefficient was 0.942 (P \0.001) and 0.936
ferences between measurements of the left and the right (P \0.001) respectively for bone depths and bone thick-
sides. Mann-Whitney U test was used to analyze differ- nesses, demonstrating a high reliability of measurements
ences between measurements of the males and females. in this study.
For each measurement index, multiple comparisons This study found that the bone depths of different
were made only between variables of the same category, insertion paths were significantly different (P \0.001).
whereas those of the other 2 categories were controlled. Significant differences in bone depth were observed

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118 Du et al

between any 2 insertion heights at the same insertion angles of 60 and 70 were significantly lower than
angle (P \0.001). From 13 mm to 15 mm and 17 mm, those at 50 (P \0.001 [60 vs 50 ]; P \0.001 [70 vs
the bone depths decreased significantly. Regarding the 50 ]). No significant differences in insertion failure
gingival tipping angle, only at 13 mm insertion height rate existed between 13 and 15 mm insertion heights
and distal tipping angle of 30 , a significantly greater when the gingival tipping angles were 60 (P .0.05)
bone depth was observed at 50 than 60 (P \0.001) and 70 (P .0.05). At the 17 mm insertion height, the
and 70 (P \0.001). In the other paths, significantly failure rate of each path was not less than 50%, signifi-
greater bone depths were observed at 70 than 60 cantly higher than that at the 15 mm insertion height
(P \0.05). Although the bone depth increased with the when the gingival tipping angles were 60 (P \0.05)
increased distal tipping angle at the same insertion and 70 (P \0.01). Although significant differences in
height and gingival tipping angle, no significant differ- failure rate were not observed among the 3 distal tipping
ence in bone depth existed among the 3 distal tipping an- angles at all paths other than the path with the gingival
gles at 15 mm insertion height and gingival tipping angle tipping angle of 50 and 17 mm height (P \0.01), the
of 70 (P 5 0.067). In the other paths, significantly failure rate of each path at the distal tipping angle of
greater bone depths were observed at 30 than 30 tended to be lower than that at the other 2 angles.
0 (P \0.05) and 15 (P \0.05). In Table I, bone depths As shown in Table III, the lowest failure rate (19.4%)
of different paths were expressed as median (25th-75th was observed at a disposition of 15 mm insertion site,
percentile) and mean 6 standard deviation. The gingival tipping angle of 70 , and distal tipping angle
maximum bone depth (median, 7.41 mm; mean, of 30 .
8.42 mm) was present at a disposition of 13 mm insertion
site, gingival tipping angle of 50 , and distal tipping
DISCUSSION
angle of 30 .
We found that bone thicknesses at different insertion To provide a clinical guide for the safe insertion of
paths were significantly different (P\0.001). Significant miniscrews in the infrazygomatic crest region, this study
differences in bone thickness were observed between explored the impacts of both bone depth and thickness
any 2 insertion heights at the same insertion angle on insertion failure to determine the clinical risk for
(P \0.001). From 13 to 15 and 17 mm, the bone thick- each insertion path. The bone depths and thicknesses
nesses increased significantly. Significant differences in of different insertion paths were measured in 3D recon-
bone thickness were also observed between any 2 struction models in which the insertion paths were simu-
gingival tipping angles at the same insertion height lated at different insertion heights, gingival tipping
and distal tipping angle (P \0.001). From 50 to 60 angles, and distal tipping angles between U6 and U7
and 70 , the bone thicknesses increased significantly. in the infrazygomatic crest region. The correlation be-
No significant differences in bone thickness were found tween bone depths and thicknesses was also analyzed.
among the 3 distal tipping angles at the same insertion In clinical practice, a miniscrew is usually inserted at
height and gingival tipping angle (P .0.05). In Table II, or above the mucogingival junction in the infrazygo-
the bone thicknesses of different paths were expressed as matic crest region.14,18,22,24 Now that the crown height
median (25th-75th percentile) and mean 6 standard de- of the maxillary molars is around 8.1 mm25 and the
viation. The maximum bone thickness (3.73 mm on me- thickness of the attached gingiva 4-5 mm26 in the
dian and 4.00 mm on average) was present at a maxilla, the points corresponding to the midpoints be-
disposition of 17 mm insertion site, gingival tipping tween the roots of U6 and U7 on the buccal alveolar
angle of 70 , and distal tipping angle of 30 . bone at 13, 15, and 17 mm heights above POP were
There was a statistically significant and negative cor- designated as insertion sites in this study. Moreover, to
relation between bone depths and bone thicknesses simulate a real clinical scenario, measurements at
(rs 5 0.569, P \0.001). Therefore, consideration different distal tipping angles (0 , 15 , and 30 ) were
should be given to both in the analysis of the clinical also analyzed. It is different from previous studies that
risk for each insertion path in the infrazygomatic crest bone thickness was also considered in our study.
region. We found the failure rates were significantly Although a miniscrew is to be inserted between the re-
different among different insertion paths (P \0.001). gion of U6 and U7, the roots may be potentially injured
At the 13 mm insertion height, the failure rates of the during the distal movement of the tooth. Therefore, we
insertion paths at the gingival tipping angle of 70 simulated the distal tooth movement to measure the
were significantly lower than those at 50 (P \0.001) bone thicknesses of different paths in this study.
and 60 (P \0.05). At the 15 mm insertion height, the The bone depth of each path in the infrazygomatic
failure rates of the insertion paths at the gingival tipping crest region is often limited by the maxillary sinus.27

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Du et al
Table I. Bone depths (in millimeters) of different insertion paths (n 5 72)
Angles Insertion sites at different heights

13 mm (a1-i1) 15 mm (a2-i2) 17 mm (a3-i3)

Occlusogingival Mesiodistal Median Median

direction direction Median (25th-75th) Mean 6 SD (25th-75th) Mean 6 SD (25th-75th) Mean 6 SD
50 0 (a) 6.70 (5.16–8.47)a2,a3,d1,c1 8.00 6 4.54 5.01 (3.60–6.57)a1,a3,c2,g2 5.72 6 2.92 3.49 (2.41–4.94)a1,a2,c3,g3 4.04 6 2.32
15 (b) 6.87 (5.25–9.03)b2,b3,e1,c1 7.82 6 3.85 5.15 (3.70–6.61)b1,b3,c2,h2 5.76 6 2.96 3.64 (2.44–4.86)b1,b2,c3,h3 4.11 6 2.31
30 (c) 7.41 (5.76–9.35)c2,c3,f1,i1,a1,b1 8.42 6 4.10 5.52 (4.05–7.15)c1,c3,f2,b2,a2 6.34 6 3.64 3.91 (2.57–5.36)c1,c2,a3,b3 4.38 6 2.45
60 0 (d) 6.56 (5.29–8.24)d2,d3,f1,a1,g1 7.16 6 2.61 5.02 (3.82–6.39)d1,d3,f2,g2 5.52 6 2.38 3.53 (2.53–4.77)d1,d2,f3,g3 4.02 6 2.12
15 (e) 6.68 (5.29–8.32)e2,e3,f1,b1,h1 7.19 6 2.56 5.13 (3.80–6.45)e1,e3,f2,h2 5.54 6 2.34 3.62 (2.51–4.91)e1,e2,f3,h3 4.05 6 2.07
30 (f) 6.94 (5.55–8.53)f2,f3,c1,d1,e1 7.45 6 2.62 5.37 (3.85–6.69)f1,f3,d2,e2,c2,i2 5.75 6 2.41 3.72 (2.54–4.92)f1,f2,i3,d3,e3 4.20 6 2.16
70 0 (g) 6.81 (5.56–8.34)g2,g3,d1,i1 7.33 6 2.44 5.23 (4.02–6.74)g1,g3,a2,d2 5.73 6 2.28 3.75 (2.67–5.07)g1,g2,a3,d3,i3 4.24 6 2.08
15 (h) 6.97 (5.56–8.26)h2,h3,e1,i1 7.31 6 2.39 5.22 (4.07–6.65)h1,h3,b2,e2 5.72 6 2.24 3.76 (2.68–5.11)h1,h2,b3,e3,i3 4.26 6 2.09
30 (i) 7.02 (5.63–8.30)i2,i3,c1,g1,h1 7.40 6 2.40 5.35 (4.05–6.75)i1,i3,f2 5.80 6 2.27 3.87 (2.69–5.21)i1,i2,f3,g3,h3 4.32 6 2.10

Note. Bone depths were compared between variables of the same category (eg, insertion height) when the other 2 categories were controlled (eg, distal and gingival tipping angle). Superscript letters
indicate significant differences between the group that the cell represents and the group that the letter represents (P \ 0.05).
SD, standard deviation.
a1:13mm-50 -0 group; b1:13mm-50 -15 group; c1:13mm-50 -30 group; d1:13mm-60 -0 group; e1:13mm-60 -15 group; f1:13mm-60 -30 group; g1:13mm-70 -0 group; h1:13mm-
70 -15 group; i1:13mm-70 -30 group.
a2:15mm-50 -0 group; b2:15mm-50 -15 group; c2:15mm-50 -30 group; d2:15mm-60 -0 group; e2:15mm-60 -15 group; f2:15mm-60 -30 group; g2:15mm-70 -0 group; h2:15mm-
70 -15 group; i2:15mm-70 -30 group.
a3:17mm-50 -0 group; b3:17mm-50 -15 group; c3:17mm-50 -30 group; d3:17mm-60 -0 group; e3:17mm-60 -15 group; f3:17mm-60 -30 group; g3:17mm-70 -0 group; h3:17mm-
70 -15 group; i3:17mm-70 -30 group.
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120
Table II. Bone thicknesses (in millimeters) of different insertion paths (n 5 72)
Angles Insertion sites at different heights

13 mm (a1-i1) 15 mm (a2-i2) 17 mm (a3-i3)

Occlusogingival Mesiodistal Median Median Median

direction direction (25th-75th) Mean 6 SD (25th-75th) Mean 6 SD (25th-75th) Mean 6 SD
50 0 (a) 0.82 (0.00-1.55)a2,a3,d1,g1 0.89 6 0.85 1.93 (1.11-3.04)a1,a3,d2,g2 2.04 6 1.15 3.13 (2.35-4.39)a1,a2,d3,g3 3.30 6 1.32
15 (b) 0.78 (0.00-1.61)b2,b3,e1,h1 0.91 6 0.87 1.94 (1.12-3.01)b1,b3,e2,h2 2.06 6 1.11 3.16 (2.36-4.39b1,b2,e3,h3 3.33 6 1.32
30 (c) 0.84 (0.00-1.63)c2,c3,f1,i1 0.91 6 0.87 1.98 (1.14-3.01)c1,c3,f2,i2 2.07 6 1.10 3.11 (2.38-4.44)c1,c2,f3,i3 3.33 6 1.31
60 0 (d) 1.42 (0.60-2.18)d2,d3,a1,g1 1.42 6 0.96 2.45 (1.64-3.31)d1,d3,a2,g2 2.42 6 1.12 3.41 (2.63-4.59)d1,d2,a3,g3 3.59 6 1.32
15 (e) 1.44 (0.63-2.15)e2,e3,b1,h1 1.46 6 0.93 2.43 (1.67-3.32)e1,e3,b2,h2 2.46 6 1.07 3.38 (2.61-4.60)e1,e2,b3,h3 3.60 6 1.31
30 (f) 1.50 (0.63-2.19)f2,f3,c1,i1 1.47 6 0.93 2.46 (1.64-3.27)f1,f3,c2,i2 2.47 6 1.05 3.42 (2.63-4.58)f1,f2,c3,i3 3.63 6 1.36
70 0 (g) 2.01 (1.26-2.62)g2,g3,a1,d1 1.96 6 0.92 2.86 (2.01-3.61)g1,g3,a2,d2 2.76 6 1.10 3.73 (2.88-5.01)g1,g2,a3,d3 3.99 6 1.53
15 (h) 2.01 (1.28-2.65)h2,h3,b1,e1 1.99 6 0.91 2.89 (2.02-3.60)h1,h3,b2,e2 2.79 6 1.09 3.71 (2.89-5.08)h1,h2,b3,e3 3.99 6 1.51
30 (i) 2.00 (1.30-2.68)i2,i3,c1,f1 2.03 6 0.89 2.84 (2.02-3.59)i1,i3,c2,f2 2.80 6 1.08 3.73 (2.89-5.10)i1,i2,c3,f3 4.00 6 1.50

Note. Bone thicknesses were compared between variables of the same category (eg, insertion height) when the other 2 categories were controlled (eg, distal and gingival tipping angle). Superscript
letters indicate significant differences between the group that the cell represents and the group that the letter represents (P \ 0.05).
SD, standard deviation.
a1:13mm-50 -0 group; b1:13mm-50 -15 group; c1:13mm-50 -30 group; d1:13mm-60 -0 group; e1:13mm-60 -15 group; f1:13mm-60 -30 group; g1:13mm-70 -0 group; h1:13mm-
American Journal of Orthodontics and Dentofacial Orthopedics

70 -15 group; i1:13mm-70 -30 group.

a2:15mm-50 -0 group; b2:15mm-50 -15 group; c2:15mm-50 -30 group; d2:15mm-60 -0 group; e2:15mm-60 -15 group; f2:15mm-60 -30 group; g2:15mm-70 -0 group; h2:15mm-70 -
15 group; i2:15mm-70 -30 group.
a3:17mm-50 -0 group; b3:17mm-50 -15 group; c3:17mm-50 -30 group; d3:17mm-60 -0 group; e3:17mm-60 -15 group; f3:17mm-60 -30 group; g3:17mm-70 -0 group; h3:17mm-70 -
15 group; i3:17mm-70 -30 group.

Du et al
Du et al 121

Liou et al14 concluded that an effective bone depth of conditions was 1.3 mm by calculation. Our data showed
6 mm could be reached for miniscrew stability in the in- that the median bone thickness of each path at 13 mm
frazygomatic crest region without perforating the maxil- height was less than 1.3 mm when a simulated minis-
lary sinus. Their conclusion is consistent with our results crew was implanted at a gingival tipping angle of 50 .
at the 13 mm insertion level. However, according to the These data suggest that a miniscrew should be inserted
median bone depths at 15 and 17 mm insertion levels in at a gingival tipping angle as large as possible when
our study, it could be inferred that the effective bone the insertion height is close to the mucogingival junc-
depth of 6 mm may greatly limit the choice of a safe tion.
insertion trajectory in this region. Instead, we believe In this study, a statistically significant and negative
that 3.8 mm, rather than 6 mm, is the minimal bone correlation was observed between the bone depths and
depth for miniscrew stability, especially for a miniscrew bone thicknesses, indicating that it is not advisable to
with a diameter larger than 1.3 mm.21 In this study, analyze the risk of each insertion path by considering
the median bone depths of most paths did not reach the bone depth alone. Taking bone depths and thick-
3.8 mm only at the 17 mm insertion height, indicating nesses into consideration, we calculated the clinical risks
that more biomechanical experiments are needed to for different insertion paths. Our study shows that when a
determine the mechanical stability of miniscrews in- miniscrew is inserted at 13 mm height, the preferred
serted at the root apical level. Similarly, the bone thick- gingival angle and distal tipping angle may be respec-
ness of each path in the infrazygomatic crest region can tively 70 and 30 . Considering a 0.5 mm safety distance
be limited by the roots of molars. For a thinner bone from a miniscrew to roots22 and about 5 mm clearance
thickness, a miniscrew with a smaller diameter might from the miniscrew head to the soft tissue surface,28 a
be chosen to decrease the risk of contact between a min- miniscrew with 1.6 mm in diameter and 11 mm in length
iscrew and roots. However, the risk of miniscrew fracture may be recommended at this path because of the first
would increase. To avoid the miniscrew fracture and root quartile of bone depth and thickness. When a miniscrew
damage, a 1.6 mm miniscrew and a 0.5 mm safe distance is inserted at 15 mm insertion height, the preferred
to roots seemed necessary.17,22 The minimum bone gingival tipping angle and distal tipping angle may be
thickness for miniscrew safe insertions under the above respectively 60 -70 and 30 . Because of the lower first

Table III. Insertion failure rates (%) of different insertion paths (n 5 72)
Angles Insertion sites at different heights

13 mm (a1-i1) 15 mm (a2-i2) 17 mm (a3-i3)

Occlusogingival Mesiodistal
direction direction D T D&T Rate D T D&T Rate D T D&T Rate
50 0 (a) 1 48 0 68.1d1,g1 19 19 2 55.6d2,g2 40 3 2 62.5c3,g3
15 (b) 0 48 0 66.7e1,h1 18 19 3 55.6e2,h2 40 3 2 62.5c3,h3
30 (c) 0 47 0 65.3f1,i1 14 19 2 48.6f2,i2 33 3 1 51.4a3,b3
60 0 (d) 0 33 0 45.8a1,g1 17 7 1 34.7d3,a2 39 2 0 56.9d2
15 (e) 1 33 0 47.2b1,h1 17 6 1 33.3e3,b2 38 2 0 55.6e2
30 (f) 0 32 0 44.4c1,i1 13 5 1 26.4f3,c2 38 2 0 55.6f2
70 0 (g) 0 20 0 27.8a1,d1,g3 13 5 1 26.4g3,a2 37 2 0 54.2g1,g2,a3
15 (h) 0 19 0 26.4b1,e1,h3 12 5 1 25.0h3,b2 37 2 0 54.2h1,h2,b3
30 (i) 0 18 0 25.0c1,f1,i3 10 3 1 19.4i3,c2 34 2 0 50.0i1,i2

Note. Insertion failure rates were compared between variables of the same category (eg, insertion height) when the other 2 categories were
controlled (eg, distal and gingival tipping angle). Superscript letters indicate significant differences between the group that the cell represents
and the group that the letter represents (P \ 0.05).
D, the number of path with a bone depth less than 3.8 mm; T, the number of a path with a bone thickness less than 1.3 mm; D&T, the number of a
path with bone depth less than 3.8 mm and bone thickness less than 1.3 mm; Rate, the failure rate for each insertion path (rate 5 [(D 1 T) 1 (D
& T)]/72 3 100).
a1:13mm-50 -0 group; b1:13mm-50 -15 group; c1:13mm-50 -30 group; d1:13mm-60 -0 group; e1:13mm-60 -15 group; f1:13mm-60 -
30 group; g1:13mm-70 -0 group; h1:13mm-70 -15 group; i1:13mm-70 -30 group.
a2:15mm-50 -0 group; b2:15mm-50 -15 group; c2:15mm-50 -30 group; d2:15mm-60 -0 group; e2:15mm-60 -15 group; f2:15mm-60 -
30 group; g2:15mm-70 -0 group; h2:15mm-70 -15 group; i2:15mm-70 -30 group.
a3:17mm-50 -0 group; b3:17mm-50 -15 group; c3:17mm-50 -30 group; d3:17mm-60 -0 group; e3:17mm-60 -15 group; f3:17mm-60 -
30 group; g3:17mm-70 -0 group; h3:17mm-70 -15 group; i3:17mm-70 -30 group.

American Journal of Orthodontics and Dentofacial Orthopedics July 2021  Vol 160  Issue 1
122 Du et al

quartile of bone depth and thickness at a gingival tipping 4. Mohamed RN, Basha S, Al-Thomali Y. Maxillary molar distalization
angle of 60 rather than 70 , considering the 0.5 mm with miniscrew-supported appliances in Class II malocclusion: a
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safety distance and 5 mm clearance, the diameter and
5. Ali D, Mohammed H, Koo SH, Kang KH, Kim SC. Three-dimen-
length of a miniscrew may be recommended as 2.3 mm sional evaluation of tooth movement in Class II malocclusions
and 9 mm respectively because of the measurements at treated without extraction by orthodontic mini-implant
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mini-implants for orthodontic anchorage: A study of 414 samples
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diameter beyond 3 mm still needs further study. spective analysis of the failure rate of three different orthodontic
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554-69.
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analysis, we believe that the knowledge of anatomic
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