ORIGINAL ARTICLE

Effects of monocortical and bicortical

mini-implant anchorage on bone-borne
palatal expansion using nite element
analysis
Robert J. Lee,a Won Moon,b and Christine Hongb
San Francisco and Los Angeles, Calif

Introduction: Bone-borne palatal expansion relies on mini-implant stability for successful orthopedic expansion.
The large magnitude of applied force experienced by mini-implants during bone-borne expansion may lead to
high failure rates. Use of bicortical mini-implant anchorage rather than monocortical anchorage may improve
mini-implant stability. The aims of this study were to analyze and compare the effects of bicortical and
monocortical anchorages on stress distribution and displacement during bone-borne palatal expansion using
nite element analysis. Methods: Two skull models were constructed to represent expansion before and after
midpalatal suture opening. Three clinical situations with varying mini-implant insertion depths were studied in
each skull model: monocortical, 1-mm bicortical, and 2.5-mm bicortical. Finite element analysis simulations
were performed for each clinical situation in both skull models. Von Mises stress distribution and transverse
displacement were evaluated for all models. Results: Peri-implant stress was greater in the monocortical
anchorage model compared with both bicortical anchorage models. In addition, transverse displacement was
greater and more parallel in the coronal plane for both bicortical models compared with the monocortical model.
Minimal differences were observed between the 1-mm and the 2.5-mm bicortical models for both peri-implant
stress and transverse displacement. Conclusions: Bicortical mini-implant anchorage results in improved
mini-implant stability, decreased mini-implant deformation and fracture, more parallel expansion in the
coronal plane, and increased expansion during bone-borne palatal expansion. However, the depth of
bicortical mini-implant anchorage was not signicant. (Am J Orthod Dentofacial Orthop 2017;151:887-97)

T
ransverse maxillary deciency has been reported midpalatal suture and the decreased elasticity of bone
to affect 8% to 23% of adolescent patients and in adults.9-11 Therefore, in adults, skeletal orthopedic
fewer than 10% of adult patients.1-5 Rapid expansion is necessary to prevent these issues and to
palatal expansion (RPE), which typically uses a tooth- correct transverse maxillary deciency.12-14
borne appliance with a center jackscrew, is a well- Surgically assisted RPE is the conventional treatment
established and reliable technique to correct this prob- of choice to correct transverse maxillary deciency in
lem for adolescent patients.6-8 For adults, however, adults.9-11,15 However, surgically assisted RPE is an
nonsurgical RPE with a tooth-borne appliance can result invasive process that can result in lateral rotation of
in dentoalveolar tipping that may cause unfavorable the 2 maxillary halves with minimal horizontal
periodontal effects because of the interdigitated translation.9-11 In addition, surgically assisted RPE may
be detrimental to the periodontium and has been
a
Division of Orthodontics, University of California at San Francisco, San Fran- shown to result in a large amount of relapse during
cisco, Calif.
b
Section of Orthodontics, University of California at Los Angeles, Los Angeles, the postretention period.16,17
Calif. Recently, bone-borne palatal expanders have been
All authors have completed and submitted the ICMJE Form for Disclosure of Po- reported in several case presentations to have the capa-
tential Conicts of Interest, and none were reported.
Address correspondence to: Christine Hong, 10833 Le Conte Ave, Los Angeles, bility to correct transverse maxillary deciency in adults,
CA 90095; e-mail, [email protected]. making it a potential alternative to surgically assisted
Submitted, April 2016; revised and accepted, October 2016. RPE.18-21 Bone-borne expanders have also been shown
0889-5406/$36.00
2017 by the American Association of Orthodontists. All rights reserved. to prevent the dentoalveolar tipping seen in adults
http://dx.doi.org/10.1016/j.ajodo.2016.10.025 when attempting to use traditional tooth-borne RPE
887
888 Lee, Moon, and Hong

appliances.20,22,23 For adolescent patients, bone-borne MATERIAL AND METHODS

expansion has been shown to produce greater transverse A nite element model was generated using volu-
skeletal expansion while minimizing dental side effects metric data from a cone-beam computed tomography
such as dental tipping, alveolar bending, and vertical scan (slice thickness, 0.30 mm) of a dry adult skull us-
alveolar bone loss compared with tooth-borne RPE ap- ing Mimics software (version 15.0; Materialise, Leuven,
pliances.24 Bone-borne expansion also has been com- Belgium). Threshold segmentation was performed
bined with a facemask for maxillary protraction, which generating a 3-dimensional (3D) virtual surface model
has been shown to reduce adverse effects such as mesi- of the dry skull. Individual masks of sutures 1.5 to
alization of anterior teeth.25 2 mm wide were manually generated for the midpala-
Bone-borne palatal expansion relies on skeletal tal, median nasal, lateral nasal, pterygomaxillary, zygo-
anchorage obtained through mini-implants to directly maticotemporal, and zygomaticomaxillary sutures.40-42
apply force to the basal bone. Thus, mini-implant stabil- The thicknesses of the cortical bone and the
ity is essential for successful skeletal orthopedic expan- masticatory mucosa in the hard palate were
sion. Mini-implant loss and loosening rates for determined using the studies by Farnsworth et al43
orthodontic tooth movement range from 6.9% to and Studer et al,44 respectively. Two 3D surface models
28.0%, and their success depends on several factors of the dry skull were generated. The rst model con-
including the magnitude and direction of the applied tained the interlocking midpalatal suture and repre-
force; operator experience; insertion site; quality of sented the skull before midpalatal suture opening
cortical bone; surface contact area in cortical bone; (Fig 1, A). The second model did not contain the inter-
length, depth, diameter, thread conguration, and shape locking midpalatal suture and represented the skull af-
of the mini-implant; and patient's age.26-35 Although no ter midpalatal suture opening without sutural
specic reports have analyzed mini-implant failure rates resistance against expansion force (Fig 1, B). Bicortical
during bone-borne expansion in mature patients, such and monocortical anchorages were compared in both
failure rates are likely to be higher than in orthodontic models using measurements at 3 points (Fig 1, B).
tooth movement because of the increased magnitude These 3D skull surface models were imported into 3-
of the applied force necessary to split the interlocking matic software (version 7.0; Materialise) to generate a
suture. Therefore, new approaches to improve mini- nite element volumetric mesh.
implant stability during bone-borne expansion are The mini-implant (diameter, 1.5 mm; length,
needed. 11.0 mm) (ACR Series; BioMaterials Korea, Seoul, Korea)
Bicortical mini-implant anchorage has been demon- and a specic design of bone-borne palatal expander,
strated in orthodontic tooth movement applications to the maxillary skeletal expander (MSE; BioMaterials Ko-
be biomechanically more favorable than monocortical rea) used in this study were constructed with
anchorage. As such, bicortical anchorage should be computer-aided design software (SolidWorks, version
considered for clinical situations requiring heavy 2011; Dassault Systemes, Velizy, France) with the design
anchorage.32,36 Bone-borne expanders, which require specications provided by the manufacturer. These
heavy anchorage, represent a good clinical situation for models were exported from SolidWorks as 3D surface
bicortical anchorage that has not yet been explored in stereolithography les. The stereolithography les of
the literature. In this study, we sought to determine the the mini-implant and the maxillary skeletal expander
differences between bicortical and monocortical mini- were then also imported into the 3-matic software for
implant anchorage on skeletal orthopedic expansion. nite element volumetric mesh generation.
Finite element analysis (FEA) is a numeric approxi- In the 3-matic software, the expander was positioned
mation technique that is widely used to assess biome- similar to a patient using clinical photos and cone-beam
chanical problems. FEA has been applied to study computed tomography scans as positioning aids (Fig 1).
different aspects of bone-borne expanders, primarily The mini-implants were positioned, using posteroante-
focusing on stress distribution and displacement of rior cephalograms as a positioning aid, to have varying
different expander designs as well as its biomechanical insertion depths representing 3 clinical situations:
effects on craniofacial sutures.37-41 However, no study monocortical, 1-mm bicortical, and 2.5-mm bicortical
has compared bicortical and monocortical anchorage (Fig 2). The expander was in the same position for all 3
for bone-borne expanders using FEA. Thus, the aim of clinical situations with only the vertical position of the
this study was to analyze and compare the effects of bi- mini-implants varying between each clinical situation.
cortical and monocortical anchorage on stress distribu- All 3 clinical situations were analyzed in both skull
tion and displacement during bone-borne palatal models.
expansion using FEA.

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Lee, Moon, and Hong 889

Fig 1. Three-dimensional virtual models of a dry skull with bone-borne expander: A, model to be used
for FEA simulation of expansion before midpalatal suture opening; B, model to be used for FEA simu-
lation of expansion after midpalatal suture opening. Transverse displacement will be measured at
points A, B, and C.

Fig 2. Coronal plane cut view of mini-implant positions in 3 clinical situations: monocortical, 1-mm bi-
cortical, and 2.5-mm bicortical. The expander is in the same position for all 3 clinical situations with only
the vertical position of the mini-implants varying between each situation.

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890 Lee, Moon, and Hong

calculated for each model: 476,000 MPa for the mono-

Table I. Material properties
cortical model, 234,000 MPa for the 1-mm bicortical
Young's modulus (MPa) Poisson's ratio model, and 227,000 MPa for the 2.5-mm bicortical
Cortical bone 13,700 0.30 model. The difference between the monocortical model
Cancellous bone 1,370 0.30 and the 1-mm bicortical model was 68.17%, whereas the
Suture 10 0.49
difference between the monocortical model and the 2.5-
Masticatory mucosa 25 0.30
Titanium 113,000 0.33 mm bicortical model was 70.84%, and that between the
Stainless steel 210,000 0.30 1-mm and 2.5-mm bicortical models was 3.04%.
Von Mises stress of the mini-implants was also
measured in the skull model containing the interlocking
Tetrahedral elements were used for volumetric mesh
midpalatal suture and was found to be signicantly
generation. Each skull was composed of about
higher in the monocortical model compared with both bi-
4,500,000 elements and 1,200,000 nodes. For the skull
cortical anchorage models (Fig 4). In all models, the Von
generation, the maxilla and the sutures were locally re-
Mises stress on the implant was localized at the bone-
meshed to contain more ne elements than elsewhere
implant interface around the initial cortical bone layer.
on the skull. Each mini-implant was composed of about
Total Von Mises stress values were measured at the
85,000 elements and 16,000 nodes. The expander was
bone-implant interface and were determined to be
composed of approximately 30,000 elements and
5,831,000 MPa for the monocortical model,
9,000 nodes.
3,576,000 MPa for the 1-mm bicortical model, and
The nite element models of the skull, mini-
3,845,000 MPa for the 2.5-mm bicortical model. The dif-
implants, and expander were imported into Abaqus
ference between the monocortical model and the 1-mm
FEA software (version 6.13; Dassault Systemes) to
bicortical model was 47.94%, the difference between
perform FEA simulations. The material properties used
the monocortical model and the 2.5-mm bicortical model
are shown in Table I.37,45,46 Each material was
was 41.05%, and that between the 1-mm and the 2.5-
considered to be homogeneous and isotropic. The
mm bicortical models was 7.25%. For the monocortical
boundary conditions applied were setting the nodes of
model, the maximum principal stress at the bone-
the foramen magnum to be completely xed in all
implant interface was 664.49 MPa, and the minimum
degrees of freedom.47
principal stress was 229.94 MPa. For the 1-mm bicortical
In the model simulating bone-borne expansion
model, the maximum principal stress at the bone-implant
before midpalatal suture opening, the expander was
interface was 270.246 MPa, and the minimum principal
activated transversely by 0.5 mm in the transverse plane
stress was 53.95 MPa. For the 2.5-mm bicortical model,
and was unxed in the sagittal and coronal planes to
the maximum principal stress at the bone-implant inter-
prevent interference with the resultant movement.37,38
face was 289.87 MPa, and the minimum principal stress
In the model simulating bone-borne expansion after
was 75.94 MPa. Bending of the mini-implants was clearly
midpalatal suture opening, the expander was activated
evident. Bending in all 3 mini-implants was measured for
transversely by 0.25 mm for 20 steps resulting in a total
all 3 models, and the mean amounts of bending were
of 5 mm of expansion. Similar to the rst model, the
calculated to be 4.55 for the monocortical model,
expansion was also activated in the transverse plane
1.94 for the 1-mm bicortical model, and 1.71 for the
and was unxed in the sagittal and coronal planes to
2.5-mm bicortical model.
prevent interference with the resultant movement. In
Transverse displacement was measured on the left
both models, Von Mises stress distribution and trans-
side of the skull model not containing an interlocking
verse displacement were evaluated.
midpalatal suture and was determined for each step,
20 steps in total (Fig 5). These 20 steps were equivalent
RESULTS
to 20 turns of 0.25 mm each, for a total of 5 mm of
Von Mises stress at the peri-implant site was expansion (2.5 mm on each side). Left-side transverse
measured for the skull model containing the interlocking displacement was measured at points A, B, and C (Fig
midpalatal suture and was found to be clearly higher in 1, B) and plotted in Figure 6. The total and mean trans-
the monocortical anchorage model compared with both verse displacements are recorded in Table II. At point A,
bicortical anchorage models (Fig 3). In all models, the the total transverse displacements were 1.608 mm for
Von Mises stress was localized around the initial cortical the monocortical model, 1.988 mm for the 1-mm bicort-
bone layer. Minimal difference was observed between ical model, and 2.067 mm for the 2.5-mm bicortical
the 1-mm and the 2.5-mm bicortical models. The total model. The difference at point A for total transverse
Von Mises stress at the bone-implant interface was displacement between the monocortical model and the

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Lee, Moon, and Hong 891

Fig 3. A, Von Mises stress of the peri-implant site for the skull model with midpalatal suture for the
monocortical, 1-mm bicortical, and 2.5-mm bicortical models; B, bar graph showing total Von Mises
stress in megapascals for all 3 anchorage models.

Fig 4. A, Von Mises stress of the mini-implant for the skull model with midpalatal suture for the mono-
cortical, 1-mm bicortical, and 2.5-mm bicortical models, with the degree of bending of the mini-implants
reported; B, bar graph showing total mini-implant Von Mises stress in megapascals for all 3 anchorage
models.

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892 Lee, Moon, and Hong

Fig 5. Frontal and occlusal views of step 20 (5 mm of expansion) of the skull model simulation after
midpalatal suture opening with a contour map showing transverse displacement.

1-mm bicortical model was 21.13%, the difference be- 0.701 for the 2.5-mm bicortical model. The difference
tween the monocortical model and the 2.5-mm bicorti- between the monocortical model and 1-mm bicortical
cal model was 24.98%, and that between the 1-mm and model was 8.72%, the difference between the mono-
the 2.5-mm bicortical models was 3.90%. At point B, the cortical model and the 2.5-mm bicortical model was
total transverse displacements were 2.215 mm for the 10.06%, and that between the 1-mm and the 2.5-mm
monocortical model, 2.744 mm for the 1-mm bicortical bicortical models was 1.34%.
model, and 2.848 mm for the 2.5-mm bicortical model.
The difference at point B for total transverse displace- DISCUSSION
ment between the monocortical model and the 1-mm Bone-borne palatal expanders have been shown to
bicortical model was 21.33%, the difference between be a viable treatment option to correct a transverse
the monocortical model and the 2.5-mm bicortical maxillary deciency in adults in several reports showing
model was 25.00%, and that between the 1-mm and evidence of clinical success.18-21,48-50 Since bone-borne
the 2.5-mm bicortical models was 3.72%. At point C, expanders rely on skeletal anchorage obtained by mini-
the total transverse displacements were 1.141 mm for implants applying force directly to the basal bone, mini-
the monocortical model, 1.444 mm for the 1-mm bicort- implant stability is integral to successful skeletal
ical model, and 1.442 mm for the 2.5-mm bicortical orthopedic expansion. Bicortical mini-implant
model. The difference at point A for total transverse anchorage has been demonstrated to be superior
displacement between the monocortical model and the compared with monocortical mini-implant anchorage
1-mm bicortical model was 23.44%, the difference be- for orthodontic tooth movement but has not been
tween the monocortical model and the 2.5-mm bicorti- explored for bone-borne palatal expansion.32,36
cal model was 23.31%, and that between the 1-mm and Therefore, this study was designed to evaluate whether
the 2.5-mm bicortical models was 0.14%. bicortical anchorage likewise increased stability and
The total transverse displacement at step 20 was improved skeletal orthopedic expansion compared with
measured at levels D and E, located at the coronal mid- monocortical anchorage.
plane of the bone-borne palatal expander (Fig 7). The ra- We used 2 skull models to study the effects of bicort-
tio between D and E was calculated to compare the ical and monocortical anchorage before and after mid-
amount of displacement measured at levels D and E. palatal suture opening. The midpalatal suture was
The closer the ratio was to 1.000, the more parallel the removed in the model that represented postmidpalatal
expansion. The ratios were 0.634 for the monocortical suture opening to allow for expansion in the FEA simu-
model, 0.692 for the 1-mm bicortical model, and lation. Three clinical situations of varying mini-implant

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Lee, Moon, and Hong 893

Fig 6. Line graphs showing transverse displacement at each step during expansion.

Table II. Left-side transverse displacements (mm) after midpalatal suture opening
Monocortical Monocortical Monocortical Bicortical Bicortical Bicortical Bicortical Bicortical Bicortical
A B C 1-mm A 1-mm B 1-mm C 2.5-mm A 2.5-mm B 2.5-mm C
Total 1.608 2.215 1.141 1.988 2.744 1.444 2.067 2.848 1.442
Mean 0.080 0.111 0.057 0.099 0.137 0.072 0.103 0.142 0.072

Fig 7. Cut view at the coronal midplane of the bone-borne palatal expander. Total displacements at
levels D and E were measured for each model.

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894 Lee, Moon, and Hong

insertion depth were used for both skull models: a suggest that mini-implant fracture is most likely to occur
monocortical model, a 1-mm bicortical model, and a at the initial cortical bone layer and demonstrate that
2.5-mm bicortical model. In all 3 clinical situations, mini-implant deformation and fracture in bone-borne
the expander was in the same position, and only the expansion are more likely to occur with monocortical
mini-implants varied in vertical position. All 3 of these anchorage rather than bicortical anchorage and that
clinical situations have been observed in patients treated the depth of bicortical anchorage has little impact on
at the University of California at Los Angeles School of mini-implant deformation and fracture.
Dentistry and were chosen to explore the differences be- Transverse displacement was measured in the skull
tween monocortical and bicortical anchorage as well as model that did not contain the interlocking midpalatal
to determine whether the depth of bicortical anchorage suture for 20 steps. Each step was equivalent to a
is signicant. Operator experience may also play a role in 0.25-mm turn of the palatal expander for a total of
the varying depths of implantation seen clinically and 5 mm of simulated expansion. Analyzing the bone-
has been reported to be a factor in mini-implant stabil- borne expansion for multiple turns of the expander al-
ity.27,29 lowed for more in-depth analysis than previous FEA
Overloading of the peri-implant bone can lead to loss studies of expansion using only 1 static step. Further-
of primary stability of orthodontic mini-implants.51 In more, this stepwise model was more representative of a
addition, there is a decreased risk of mini-implant loos- clinical situation.
ening if the stress in the cervical region of the Transverse displacement was found to be signi-
peri-implant bone region is low.52 In the skull model cantly lower in the monocortical model at all 3 points
containing the midpalatal suture, this study demon- of measurement and after every turn compared with
strated that there is signicantly lower stress at the both bicortical models. Minimal differences in transverse
peri-implant site in the bicortical models compared displacements were observed between the 2 bicortical
with the monocortical model, suggesting that mini- models. The difference in transverse displacement be-
implants placed bicortically decrease the risk of mini- tween the monocortical and bicortical models may be
implant loosening. Minimal differences were observed due to the greater surface contact area in cortical bone
between the 2 bicortical models. These ndings are of the bicortical models; this allowed for more uniform
consistent with previous studies showing that in bone- force transfer. Mini-implant contact surface area in
borne expansion, bicortical anchorage is more favorable cortical bone has been shown to be a more signicant
than monocortical anchorage and that the depth of bi- contributor to mini-implant stability than cancellous
cortical anchorage has a minimal impact on stabil- bone.33,55 In addition, the monocortical model may
ity.32,36 In addition, this nding is also supported have experienced less transverse displacement because
through Wolff's law and the maximum principal stress of its increased bending. This increased amount of
values reported in this study.53 The monocortical model bending created a greater discrepancy between the
had an increased maximum principal stress value mini-implant orientation and the line of applied force.
compared with the bicortical models. A high principal Any discrepancy between mini-implant orientation and
stress value, as in the monocortical model, may place line of applied force has been shown to decrease load
the bone remodeling in the pathologic overload win- distribution uniformity leading to disproportionate
dow in which stress fractures and bone resorption, load distribution at the bone-implant interface that
not coupled to formation, occur, leading to overloaded would most likely decrease transverse displacement.56
implants and implant loosening. These ndings therefore demonstrate that bicortical
A greater magnitude of force experienced by mini- anchorage leads to increased expansion compared with
implants increases the likelihood of deformation and monocortical anchorage and that the depth of bicortical
mini-implant fracture.54 The authors of this study found anchorage has minimal impact on the amount of expan-
that monocortical mini-implants experienced signi- sion.
cantly greater stress at the bone-implant interface, spe- The ratios between levels D and E were signicantly
cically around the initial cortical bone layer, compared greater for both bicortical models compared with the
with bicortical mini-implants. There were minimal dif- monocortical model. There was a minimal difference be-
ferences between the mini-implant stress levels of the tween the ratios of the 2 bicortical models. A larger ratio
2 bicortical models. In addition, the monocortical between levels D and E indicated more parallel expan-
mini-implants were found to have more than double sion in the coronal plane. These results demonstrate
the bending compared with the 2 bicortical models. that bicortical engagement produces more parallel
Again, there was a minimal difference between the expansion of the maxillary complex in the coronal plane
bending in the 2 bicortical models. These ndings compared with monocortical engagement.

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Lee, Moon, and Hong 895

The V-shaped expansion in the coronal and occlusal CONCLUSIONS

planes with traditional tooth-borne expanders makes it Within the limitations of this study, the following
difcult to attain precise width coordination between conclusions were drawn.
the maxillary and mandibular basal bones without
causing excessive dentoalveolar expansion.54,55 The 1. Bicortical mini-implant anchorage results in
monocortical model, similar to previous bone-borne improved mini-implant stability, decreased mini-
expansion models, produced signicantly more parallel implant deformation and fracture, more parallel
expansion than traditional tooth-borne ex- expansion in the coronal plane, and increased
panders.11,45,57,58 More parallel expansion is favorable expansion in bone-borne palatal expansion.
for patients because it improves stability and increases 2. The depth of bicortical mini-implant anchorage has
the amount of expansion in the posterior region of little impact on mini-implant stability, deformation,
the maxilla where expansion is often necessary and and transverse displacement in bone-borne palatal
difcult to achieve.11,56,59 However, whereas the expansion.
monocortical model and previous bone-borne expan-
sion models were better than tooth-borne expanders,
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