International Journal of Applied Dental Sciences 2017; 3(1): 35-41

ISSN Print: 2394-7489

ISSN Online: 2394-7497
IJADS 2017; 3(1): 35-41
CBCT evaluation of interdental cortical bone thickness
© 2017 IJADS
www.oraljournal.com
at common orthodontic miniscrew implant placement
Received: 10-11-2016 sites
Accepted: 11-12-2016

NM Uday
Consultant Orthodontist. MDS NM Uday, Kamath Prashanth and AR Vinod Kumar
#348, 22nd cross, 9th main, 7th sector
H.S.R Layout, Bengaluru,
Karnataka, India
Abstract
Introduction: The aim of this study was to assess cortical bone thickness available for accurate
Kamath Prashanth placement of orthodontic miniscrew implants in different interdental areas and in different age groups,
Professor [Head of the Department] thereby benefiting in accurate placement of an orthodontic implant, suitable site for placement, its
Department of Orthodontics and
stability and better information to avoid any injury to vital structures in and around the site of implant.
Dentofacial Orthopaedics.
Dr. Syamala Reddy Dental College Material & Method: Pre-treatment cone beam computed tomography of maxilla and mandible of 10
Hospital & Research Centre. adult patients aged between 18-35 years and 10 adolescent patients aged between 12-17 years with equal
#111/1 SGR College Main Road, distribution of males and females were taken using Kodak 9300(France). Cortical bone thickness in the
Munnekolala, Marathalli (post) interdental areas between first and second premolar, second premolar and molar, first and second molars
Bengaluru, Karnataka
India at maxillary buccal and palatal sides and mandibular buccal sides only was measured at three different
levels (at 2mm intervals each) from approximately 6 mm away from alveolar crest.
AR Vinod Kumar Results: The cortical bone thickness was found to be statistically significant (P<0.001) between
Consultant Oral and Maxillofacial adolescents and adults and between sites in each region. Higher cortical bone thickness is seen in adult
Radiologist. ORAL-D (Digital Dental
Diagnostic Centre.)
mandibular buccal cortex region between first and second molars and at 10mm from the CEJ, followed
#108, K.H. Road, Bengaluru, by maxillary buccal region and maxillary palatal region, which increases from anterior to posterior sites.
Karnataka, India Conclusion: The results indicated that adult mandibular buccal cortical bone to be thickest and
adolescent palatal cortical bone thinnest among the sites evaluated. Hence CBCT provides reliable
diagnostic information in accurate placement of mini-implants.

Keywords: CBCT (cone beam computed tomography), cortical bone thickness, mini-implants

1. Introduction
The law of nature that underlies orthodontic tooth movement is Newton’s third law of motion:
For every action there is an opposite and equal reaction. In most cases anchorage is produced
within the orthodontic appliance with the strategy to dissipate the reaction forces over as many
teeth as possible and thereby control anchorage. Pressure in the periodontal ligaments of the
anchor teeth are thereby kept to a minimum [1-5].
Modern technologies have elevated implants as the method for absolute orthodontic
anchorage, which is a critical consideration when planning treatment for patients with dental
and skeletal malocclusions [6, 7].
For most dental practitioners, the use of advanced imaging has been limited because of cost,
availability and radiation dose considerations; however, the introduction of cone-beam
computed tomography (CBCT) for the maxillofacial region provides opportunities for dental
practitioners to request multi-planar imaging. Most dental practitioners are familiar with the
thin-slice images produced in the axial plane by conventional helical fan-beam CT [8-10].
CBCT allows the creation in “real time” of images not only in the axial plane but also 2-
dimensional (2D) images in the coronal, sagittal and even oblique or curved image planes a
process referred to as multiplanar reformation (MPR). In addition, CBCT data are amenable to
reformation in a volume, rather than a slice, providing 3-dimensional (3D) information [8-14].
Correspondence Critical factors include the quantity (bone volume) and quality (bone density) of alveolar bone
NM Uday for the stability of implants. Structurally, maxilla has relatively thin cortices that are
Consultant Orthodontist. MDS
#348, 22nd cross, 9th main, 7th sector interconnected by network of trabaculae. However the mandible is composed of thick cortices
H.S.R Layout, Bengaluru, and has more radially oriented trabaculae. Thus anatomical characteristics such as thickness of
Karnataka, India
cortical bone might differ between the two jaws. By angulating the miniscrew, the thickness of
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Cortical bone contact with the miniscrew might increase. In CBCT images of maxilla and mandible are obtained which are
addition, cortical bone thickness might have some effect on calibrated and measured for the bone quantity (interdental
implant success rate [15-23]. area) between the two premolars, second premolar and first
molar, first molar and second molar.
2. Materials & Method
2.1 Source of data 2.4 Method
This study was carried out on a sample containing 20 patients, Before measurement, each site was oriented in all 3 planes of
presenting to the Department of Orthodontics & Dentofacial space (figure: 2). for the measurements made in the posterior
Orthopaedics, Dr. Syamala Reddy Dental College, for the interradicular areas of the maxilla and mandible, the sagittal
treatment of malocclusion. This group of patients showed a slice was used to locate the interradicular area of interest. The
definite indication that they would benefit from this modality slice was then oriented so that the vertical reference line
of treatment. bisected the interradicular space and was parallel to the long
axis of the roots. The axial slice was then used to ensure that
2.2 Method of collection of data the horizontal reference line traversed the thinnest area of
Twenty consecutive patients, including 2 groups namely cortical bone while bisecting the interradicular area.
Group І, 10 adolescents (5 girls, 13-17 years of age; 5 boys, To determine reliability and repeatability of this method,
13-17 years of age) and Group ІІ, 10 adults (5 men and 5 measurements were taken by two operators, an orthodontist
women, 18-35 years of age), who presented to the Department and by a radiologist (time interval-1 day) on the original
of Orthodontics, Dr. Syamala Reddy Dental College, were reoriented volumetric image, and the mean of the two readings
subjected to Pre-treatment Cone Beam Computed Tomography was considered.
(CBCT) Scans (Kodak 9000, France) at Oral –D diagnostic Insertion of miniscrew at an oblique angle allows for the use of
centre, Bangalore, India. (Figure: 1) more space, reduces the possibility of root injury and increases
the surface in contact with cortical bone.
The ethical and review committee of, Dr. Syamala Reddy
Dental College which follows the guidelines from the Rajiv
Gandhi University of Health Sciences, Bangalore, India; and
has approved this study based on latest trends, its importance
in the field of orthodontics and the benefits it offers to the
patients and the orthodontists.
Informed and written consent of the patients was obtained
before they were subjected for the study.

Fig 1: Cone Beam Computed Tomography Machine

[CARESTREAM 9300]

2.3 Exclusion criteria

 Periapical or periradicular pathologies or radioluciences of
either periodontal or endodontic origin.
 A significant medical or dental history (ex. Use of
bisphosphonates or bone altering medications or diseases)
 Severe facial or dental asymmetries. Fig 2: Reconstructed 3-Dimensional Image.

The CBCT scans were imported into 3-D software [version 2.5 Statistical Analysis
10.5, Kodak (Care Stream) CS9300, 3D Imaging Software, 2.5.1 Null Hypothesis: There is no significant difference in the
France] for analysis as Digital Imaging and Communications mean cortical bone thickness of the three groups i.e. µ1 = µ2 =
in Medicine (DICOM) multi-files. µ3
The study was carried out to find out the bucco-lingual cortical
bone thickness for an appropriate location of implant 2.5.2 Alternate Hypothesis: There is a significant difference
placement on buccal (A) and palatal (B) sides in the maxilla in the mean cortical bone thickness of the three groups i.e. µ1 ≠
and only on mandibular buccal (C) side. The buccal and µ2 ≠ µ3
palatal cortical bone thickness from Group A, B & C was
measured at three different levels (at 2mm intervals each) from 2.5.3 Level of significance: α=0.05
approximately 6 mm away from alveolar crest towards the
apex on buccal and palatal sides. 2.5.4 Statistical technique used: Analysis of Variance
Either right or left side was randomly selected for taking (ANOVA).
measurements. These measurements were taken on the
computer display monitor with DICOM measuring software 2.5.5 Decision criterion: The decision criterion is to reject the
tool (in millimetre). null hypothesis if the p-value is less than 0.05. Otherwise we
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International Journal of Applied Dental Sciences

accept the null hypothesis. If there is a significant difference buccal region and maxillary palatal region, which increases
between the groups, we carry out multiple comparisons (post- from anterior to posterior sites.
hoc test) using Bonferroni test. In adult mandibles, higher mean cortical bone thickness was
recorded at 10mm distance followed by 8mm and 6mm
3. Results distance respectively (figure:5). The difference in mean
The cortical bone thickness was found to be statistically cortical bone thickness between the three distances was found
significant between adolescents and adults and between sites to be statistically significant (P<0.001). Further, it was found
in each region. Higher cortical bone thickness is seen in adult that significant difference existed between 6mm & 8mm
mandibular buccal cortex region between first and second distance (P<0.01) as well as 6mm & 10mm distance (P<0.001)
molars and at 10mm from the CEJ, followed by maxillary according to Bonferroni test. (Graph-1)

Graph 1: Mandibular Buccal side

Adults Adolescents
6mm 1.26 1.12
Between PMs 8mm 1.62 1.46
10mm 1.60 1.72
6mm 1.35 1.48
PM & 1M 8mm 1.87 1.82
10mm 1.98 1.94
6mm 2.04 2.26
1M & 2M 8mm 2.60 2.57
10mm 2.90 2.72

Cortical bone at premolar-molar region was thicker than 6mm respectively. The difference in mean cortical bone
between premolars, at the premolar-molar region, the cortical thickness between the three distances was found to be
bone was thicker at 10mm distance followed by 8mm and statistically significant (P<0.001). (Graph-2)

Graph 2: Maxillary Buccal side

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International Journal of Applied Dental Sciences

Adults Adolescents
6mm 1.09 0.79
Between PMs 8mm 1.35 0.84
10mm 1.23 0.95
6mm 1.05 1.05
PM & 1M 8mm 1.14 1.27
10mm 1.08 1.24
6mm 0.87 0.92
1M & 2M 8mm 1.14 1.08
10mm 1.17 1.10

Whereas the interradicular bone thickness between premolars Buccal maxillary bone thickness unlike the palatal side
was thicker at 8mm followed by 10mm and 6mm respectively, showed maximum thickness at the premolar-molar site and
and it was found that significant difference existed between 8mm distance from the CEJ.
6mm & 8mm distance (P<0.05).
Maxillary adult bone thickness showed variation among buccal
and palatal sides, among the palatal side thickness of bone was
highest between the premolars and premolar-molar site at
10mm with a mean of 1.11 and 1.07 respectively and
significant difference existed between 6mm & 8mm distance
(P<0.05) as well as 8mm & 10mm distance (P<0.01).
Among the maxillary buccal and palatal bone thickness, the
interdental cortical bone thickness between the premolars at
8mm and 10mm was highest in the buccal and palatal sites
respectively. Least cortical thickness was recorded b/w the
molars at 8mm from the CEJ, with a mean of 0.73mm along
the palatal side. (Figure: 3 & 4)
The adolescent bone thickness showed similar results in the
mandible, although in the maxilla maximum thickness was
found along the buccal surface at 8mm b/w premolar-molar
site but in the adult sample it was b/w the premolars. There Fig 3: Maxillary buccal cortical bone thickness
was significant difference in the mandibular cortex b/w 6 and
10 mm with P<0.001.
Maxilla along the palatal surface showed decreasing thickness
from the anterior towards the posterior region, also the
thickness decreased with increase in the distance apically.
Highest reading was found in the premolar-molar site at 6mm
with a mean value of 0.95mm. (Graph-3)

Fig 4: Maxillary palatal cortical bone thickness

Graph 3: Maxillary Palatal side

Adults Adolescents
6mm 0.75 0.82
Between PMs 8mm 0.75 0.69
10mm 1.11 0.76
6mm 0.83 0.95
PM & 1M 8mm 1.03 0.81
10mm 1.07 0.88
6mm 0.94 0.79
1M & 2M 8mm 0.73 0.72
10mm 1.03 0.72
Fig 5: Mandibular buccal cortical bone thickness.
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4. Discussion age-related differences in cortical bone thickness might also be

Anchorage is a major concern and a pre-requisite in the design explained by changes in functional capacity, because
of orthodontic appliance for the successful treatment of dental maximum bite forces, masticatory muscle size, and muscle
and skeletal dysgnathia. It is essential in order to avoid activity all tend to change with age and sex [37-40].
possible anchorage loss, maximizing desired tooth movement The adult mandibular buccal region had the thickest cortical
and minimizing undesirable side effects. bone of all regions evaluated. Mandibular buccal cortex also
With the introduction of skeletal anchorage system in has a higher bone mineral density than buccal alveolar bone in
orthodontics, the orthodontist could expect absolute or definite the maxilla [33, 41]. Thicker cortical bone in the buccal region of
anchorage for tooth movement without depending on the the mandible might be explained biomechanically. Whereas
patient's compliance. The use of osseointegrated implants, the mandible is under torsional and bending strains, the maxilla
onplants, direct wiring from zygomatic arch and bone plates is generally subjected to more compressive forces [42, 43].
did help, but the bulk of the attachments led to gingival Cortical bone thickness in the mandibular buccal region was
problems & failures and also proved to be inexpensive, time thickest posteriorly and became progressively thinner
consuming and had limited application in orthodontics [24-27]. anteriorly, this pattern might be explained by the higher
On the other hand, mini implants were smaller in diameter & functional demands placed on the posterior teeth [16].
length, and also could be inserted in any desired location Interestingly we found differences in cortical bone thickness
(including inter radicular bone) and loaded immediately. It between maxillary lingual and buccal regions in the adult
could withstand the orthodontic force applied during the entire group especially between the premolars unlike the work of
treatment; osseointegration was not necessary and could be Peterson et al [41].
retrieved easily after the treatment completion by the Differences in cortical bone thickness were also evident
orthodontist. In addition, these are less expensive, reduce between sites in the various regions. Cortical bone was thicker
treatment time, allow early force application and are more in the premolar-molar site at both buccal and palatal aspect
popular as compared to other types of orthodontic implants. followed by premolar region and between the molars
These mini implants can be placed without raising the flap and respectively in the adolescent group [20, 41].
it may be inserted with a pre drill or may be a self-tapping But in the adult group the maxilla along the buccal surface was
screw [27, 28]. found to be thicker between the two premolars at 8mm from
Miniscrew can be placed into the alveolar bone in an oblique the alveolar crest, followed by the premolar-molar site and
direction without causing any damage to the surrounding between the molars respectively. These results were in line
tissue (root, blood vessels & nerves, maxillary sinus). This will with studies conducted by Deguchi et al [20], this finding could
allow for use of more space, reduces the possibility of root probably be explained/attributed to the differences in the
injury and increases the surface in contact with cortical bone. occlusal forces, and to the maximum bite forces which have
It was therefore suggested, that miniscrews should be placed in are known to increase from anterior to posterior towards the
the apical region. However, the problem with this was that molars [44-46].
screws placed in unattached gingiva can lead to periodontal The buccal surface of the maxilla at 8mm site was thicker than
soft tissue complications because of the difficulties in the 6mm and the 10mm sites. In case of palatal surface the,
maintaining proper oral hygiene. Placement in the attached or 6mm site was comparatively thicker then the 8mm and 10mm
on the junction between attached and unattached gingiva with sites respectively, according to the bone volume and anatomy
thinner soft tissue is therefore preferable [29-32]. of the palate [47-49].
To locate an appropriate site for implant placement, it is The results of this study showed that in the maxilla the buccal
necessary to measure the vertical distance from occlusal plane cortical thickness had a certain pattern: the thickness increased
to the site of implant placement using OPG and then as the cuts moved apically from the CEJ to the 6mm site, and
fabricating a resin template on the patient working model and / then they decreased again at the 8mm site and followed by an
or using a dental X-ray (peri-apical radiograph) or CT with increased thickness at the 10mm. This is in similar observation
acrylic surgical stent / guide bar / brass wire attached to the with the study of Baumgaertel and Hans [50] on dry skulls. In
teeth [29]. Locating a site with comparatively thick cortical the mandible, the thickness increased gradually in the apical
bone and thin soft tissue area without nerves or vessels for direction, the highest was between the first and second molar.
implantation would be ideal [32]. Lingual and palatal cortical bone thicknesses showed a gradual
These stents should be retained during implant insertion, increase as the cuts moved apically.
which helps in placement of the mini implant exactly at the Based on the findings of previous studies, the optimal site for
desired location. Therefore the main criterion for stability of mini-implant placement was between the second premolar and
an implant is the quality and quantity of cortical bone and thin the first molar for the maxilla and between the first and second
soft tissue. From this perspective this study has been taken up molars for the mandible [32, 34, 51].
to find out the cortical bone thickness on the buccal and palatal Palatally, the optimal site is between the premolar-molar site
sides at the posterior region of the maxilla, and buccal sides at followed by the first and second premolars at 8mm and 10mm
the posterior region of mandible [11, 25, 28]. as it has the advantage of the highest cortical bone thickness
Similar to previous studies adult cortical bone thickness was and the position of the first molar’s palatal root and the buccal
higher than the adolescent cortical bone, also there were no angulation of the second premolar provide excellent access for
differences in cortical bone thickness between right or left side direct insertion for miniscrew [52]. But Baumgaertel et al
of the jaws [33-35]. However, we found no sex differences in suggests bone depth and cortical bone thickness of the palate
cortical bone thickness in either he maxilla or the mandible, were most favourable for temporary anchorage device
which is consistent with the results of Ono et al [36]. placement at the level of the first and second premolars [53].
Difference in cortical bone thickness between younger and Bone depth decreased with higher measurement levels at about
older patients might be explained by proportionate increases in 12mm and was smallest at the most posterior-superior
overall body size and the size of the body parts. The age measurement points and possibilities of perforation into the
effects appear to be partially hormonally based [36]. Sex and maxillary sinus [54, 55].
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International Journal of Applied Dental Sciences

5. Conclusion 11. Cone-beam computed tomography for routine orthodontic

The use of mini implant has widely been accepted because of treatment planning: A radiation dose evaluation. Am J
its reliability and advantages over the conventional anchorage Orthod Dentofacial Orthop. 2008; 133:640.e1-640.e5
concern. Placement of mini implant is crucial and is largely 12. Development of dento-maxillofacial cone beam X-ray
dependent upon the bone availability and its thickness. Recent computed tomography system. Orthod Craniofacial Res 6
imaging techniques such as CBCT, MRI etc in the field of (Suppl. 1), 2003; 160-162.
orthodontics have helped the clinician to overcome the 13. Dental CT. and orthodontic implants: imaging technique
previously encountered difficulties. Thus maxillofacial and assessment of available bone volume in the hard
imaging determines the anatomy of the proposed implant site palate. European Journal of Radiology. 2004; 51:257-262.
and how best to optimize the implant placement considering 14. A new cone-beam computed tomography system for dental
the needs and anatomic constraints. applications with innovative 3D software (Int J CARS.
In the present study, we found the adult mandibular cortical 2007; 1:265-273 DOI 10.1007/s11548-006-0062-4)
bone to be the thickest (2.9mm) and adolescent palatal bone 15. Schwartz-Dabney CL, Dechow PC. Variations in cortical
thinnest (0.69mm), among all the other regions evaluated. material properties throughout the human dentate
Among the different sites considered, favourable position of mandible. Am J Phys Anthropol. 2003; 120:252-77
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bone thickness was sufficient for mini-implant placement, computed tomographic scanning for orthodontic implants.
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