Orthodontic Waves

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Cone beam computed tomographic comparison

of infrazygomatic crest bone thickness in patients
with different facial types

Paulin Paul , Anirudh Kumar Mathur & Prasad Chitra

To cite this article: Paulin Paul , Anirudh Kumar Mathur & Prasad Chitra (2020): Cone beam
computed tomographic comparison of infrazygomatic crest bone thickness in patients with different
facial types, Orthodontic Waves, DOI: 10.1080/13440241.2020.1814523

To link to this article: https://doi.org/10.1080/13440241.2020.1814523

Published online: 09 Sep 2020.

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ORTHODONTIC WAVES
https://doi.org/10.1080/13440241.2020.1814523

Cone beam computed tomographic comparison of infrazygomatic crest bone

thickness in patients with different facial types
Paulin Paul , Anirudh Kumar Mathur and Prasad Chitra
Department of Orthodontics and Dentofacial Orthopaedics, Army College of Dental Sciences, KNR University, Secunderabad, India

ABSTRACT ARTICLE HISTORY

Purpose: To evaluate cortical bone thickness in the infra zygomatic crest region for subjects Received 4 June 2020
with low, normal and high angle facial patterns by bone mapping using cone beam computed Revised 3 August 2020
tomography. Accepted 19 August 2020
Material and methods: The study was conducted using CBCT images of 33 subjects, who were KEYWORDS
assigned to low-, normal- or high-angle groups. Cortical bone thickness was measured from the Cone beam computed
cementoenamel junction towards the maxillary sinus floor at heights of 8, 10, 12 and 14 mm tomography; infrazygomatic
along the mesial aspect of upper first molar, middle of the crown through the furcation area of crest; facial types; TAD
the maxillary first molar, inter radicular bone/interdental region between the maxillary first
and second molars, middle of the crown through the furcation area of the maxillary second
molar and distal of the maxillary second molar.
Results: Low angle patients had significantly higher values of bone thickness compared to
normal and high-angle patients between the first and second molars at a height of 12 mm and
distal to second molars at a height of 14 mm.
Conclusion: The ideal site for insertion of temporary anchorage devices in the infrazygomatic
crest region lies between the maxillary first and second molars at a height of 12 mm in all facial
types. To avoid the risk of trauma or mini-implant failure, clinicians should be aware of the
probability of thinner cortical bone in high angle patients as compared to normal and low
angle patients.

Introduction The infrazygomatic crest, located between the first

and second maxillary molars, is the chosen site for place­
Anchorage control is an important factor in the success
ment of miniplates due to its location and solid bone
of orthodontic treatment. Anchorage, defined as resis­
structure [17]. Great individual variation in the thickness
tance to unwanted tooth movement, is a prerequisite
of the infrazygomatic crest is probably due to differing
for orthodontic treatment of dental and skeletal mal­
root morphologies, pneumatization of the maxillary
occlusions [1]. Over recent years, temporary anchorage
sinus, inclination of the maxillary first molar and height
devices (TADs) have become popular because of their
of the alveolar processes among individuals studied
ease of placement and removal, low cost and non-
[18,19]. Therefore, it is important to understand the
compliance from patients [2]. They can be placed in
ana tomical variations present in this area when placing
areas where natural anchorage or conventional ortho­
mini-screws at this site for orthodontic purposes. Mini-
dontic appliances are impractical, including edentu­
implants placed in this region are referred to as extra-
lous spaces in the alveolus of either arch, the palate,
alveolar mini-implants. They are most commonly used for
the zygomatic process, the retromolar region and the
distalizing the whole maxillary dentition – because they
ramus [3–8]. Their ability to retract the whole dentition
allow better anchorage immediately after insertion (pri­
can eliminate adverse reciprocal movement and max­
mary stability). Other uses of mini-implants in the infra­
imize treatment efficiency [9].
zygomatic crest include; asymmetry correction of the
Several studies to determine factors associated with
occlusal plane and midline deviation, segmental or en
the success of TADs have shown that soft-tissue anat­
masse dentoalveolar retraction of maxillary arch, canine
omy, inter radicular distance, maxillary sinus, nerve
and premolar distalization with sliding mechanics, and
locations and bone quality should be assessed before
posterior teeth intrusion associated with retraction of the
placement of mini-implants [10–15]. Choosing sites
entire dental arch [20].
with thicker cortical bone is important for proper posi­
Previous studies provide evidence that dentoalveo­
tioning of mini implants, reducing chances of iatro­
lar compensation occurs in subjects with vertical and
genic root damage and for preventing premature
horizontal growth patterns mainly by adaptations in
implant loosening [16].
incisor, alveolar and basal heights, hence proving that

CONTACT Prasad Chitra [email protected] Department of Orthodontics and Dentofacial Orthopaedics, KNR University, Secunderabad,
India
© 2020 Japanese Orthodontic Society
2 P. PAUL ET AL.

a significant relationship exists between tooth-bearing One angular (S-N/Go-Me) and one linear (S-Go/N-Me)
regions of the jaws and various facial types [21]. Many measurement was made to determine whether the
researchers have used CBCT for assessing alveolar patient belonged to the normal-, high- or low-angle
bone morphology, with focus on the anterior region group. For S-Go/N-Me, ratio less than 61% indicated
of either the maxilla or mandible [22]. There have been increased vertical facial height, a ratio between 61%
very few studies relating cortical bone thickness of the and 69% was considered normal vertical facial height,
infra zygomatic crest to mini-implant placement sites and more than 69% was considered low vertical facial
in different facial types. The objective of this study was height [23]. For the S-N/Go-Me angle, values less than
to understand anatomical dimensions for varying facial 27° indicated low facial height, between 27°and 37°
types in the infrazygomatic region and ensure safe normal facial height, and more than 37° indicated
implant placement zones. increased facial height [24]. If the two measurements
The study evaluated cortical bone thickness in the did not indicate the same group, or if values were
infrazygomatic crest region in subjects with low, nor­ borderline, those images were excluded from the study.
mal and high angle facial patterns by bone mapping When all inclusion criteria were applied, we
using cone beam computed tomography. This would obtained cone beam computed tomography images
provide clinicians a guide to position mini-implants of 37 subjects of which 4 were excluded since their
accurately in varying facial types. linear and angular measurements did not indicate the
same group. The sample was divided into three main
groups based on skeletal pattern. Each subject’s skele­
Material and methods
tal class was determined using computerized cephalo­
The data in this retrospective study was obtained by metrics (Nemotec Dental Studio, Spain). The low angle
screening three-dimensional cone beam computed group had 12 subjects (5 males and 7 females), the
tomography images in the archives of the department normal group had 11 subjects (4 males and 7 females)
of Orthodontics. The images were selected between and high angle group had 10 subjects (4 males and 6
January 2019 and January 2020. Ethics approval was females). The mean ages of the low-, normal- and high-
obtained from the Institutional Ethics Committee angle patients were 26.5 � 3.18, 26.72 � 3.26 and
(ACDS/IEC/74/Dec 2018). Sample size calculation was 26.9 ± 3.87 years, respectively.
based on a previous study [22] by using GPower soft­ On the CBCT images, cortical bone thickness was
ware v. 3.1.9.2. The sample size for this study was measured from the cemento enamel junction towards
calculated based on a significance level of 0.05 and the maxillary sinus floor at four different heights, i.
power of 80%, indicating that 33 subjects were e. 8 mm, 10 mm,12 mm and 14 mm. The measure­
needed. The inclusion criteria were, complete perma­ ments were done perpendicular to the buccal surface
nent dentition (except third molars), no periodontal of infrazygomatic crest (Figure 1). Cortical bone thick­
disease with alveolar bone loss, no impacted or miss­ ness was measured along five planes; mesial aspect of
ing teeth in the measurement sites, no facial asymme­ maxillary first molar (6 M), through the furcation area
tries, no cleft lip or palate, no previous orthodontic of the maxillary first molar (6 Middle), interradicular
treatment and no previous history of trauma or max­ bone/interdental region between the maxillary first
illofacial surgery. and second molars (6–7), through the furcation area

Figure 1. Various measurement heights: 8mm, 10mm, 12mm and 14 mm.

 ORTHODONTIC WAVES 3

of the maxillary second molar (7 Middle) and distal of Table 1. Comparison of bone thickness according to type of
the maxillary second molar (7D) (Figure 2). Line pas­ growth.
sing through the cemento-enamel junction of both Area Slices HGP AGP VGP P value
6M 8 mm 1.35 1.42 1.26 0.654
the right and left molars was considered the horizon­ 10 mm 1.63 1.50 1.44 0.666
tal reference line and the line parallel to the long axis 12 mm 2.08 1.72 1.68 0.174
of the molars was considered the vertical reference 14 mm 1.90 1.63 1.59 0.124
6 MID 8 mm 1.53 1.42 1.29 0.342
line. 10 mm 1.70 1.66 1.50 0.602
12 mm 2.13 1.89 1.86 0.443
14 mm 2.05 1.75 1.74 0.274
6&7 8 mm 1.63 1.50 1.56 0.827
Statistical analysis 10 mm 1.90 1.75 1.80 0.670
12 mm 2.40 2.13 1.95 0.194
Statistical calculations were carried out with 14 mm 2.33 1.94 1.86 0.038*
7MID 8 mm 1.28 1.12 1.05 0.086
Statistical Package for Social Sciences [SPSS] 10 mm 1.38 1.20 1.20 0.251
forWindowsVersion22.0. In addition to descriptive 12 mm 1.63 1.61 1.56 0.936
14 mm 1.58 1.50 1.50 0.851
statistics, in the groups with normal distribution, one- 7D 8 mm 0.98 0.90 0.84 0.401
way analysis of variance was used for intergroup 10 mm 1.23 1.17 1.11 0.197
12 mm 1.55 1.39 1.29 0.158
comparisons, and the Tukey multiple comparisons 14 mm 1.68 1.28 1.29 0.023*
test was used for subgroup comparisons. One-way HGP- Horizontal Growth Pattern, AGP- Average Growth Pattern, VGP-
ANOVA was performed to test if there were any sig­ Vertical Growth Pattern
nificant differences for several variables among differ­ One-way ANOVA test; * indicates significant difference at P ≤ 0.05

ent groups. For all statistical tests, the level of

significance [P- Value] was set at P < 0.05. the highest value was measured in low-angle patients
but was not statistically significant.
In all areas measured, the lowest values were in the
Results high-angle group, followed by the normal group; the
When cortical bone thickness in the infrazygomatic highest values were measured in low-angle patients.
regions were evaluated (Table1), low-angle patients When cortical bone thickness in five different slices
had significantly higher values of bone thickness was compared at 4 different heights (Tables 2–4),
(2.33 mm) compared to normal- and high-angle a statistically significant increase in bone thickness
patients (1.94 and 1.86 mm, respectively) between from mesial of maxillary first molar (6 M) towards the
the first and second molars at a height of 14 mm. interdental region between the maxillary first
For the measurements distal to second molar, the
mean value for the high-angle group (1.29 mm) was Table 2. Comparison of bone thickness a/c to slices in
significantly lower than those of the other groups (nor­ Horizontal growth pattern.
mal, 1.28 mm; low angle,1.68 mm) at 14 mm height. Slices 6M 6 MID 6 and 7 7MID 7D p value
Bone thickness at the mesial and middle aspects of the 8 mm 1.43 1.53 1.58 1.33 0.95 0.001*
10 mm 1.58 1.75 1.85 1.48 1.18 0.001*
first molar and middle of the second molar showed 12 mm 1.83 2.03 2.25 1.50 1.42 0.001*
another but similar trend: the lowest value was found 14 mm 1.83 1.98 2.15 1.38 1.48 0.002*
in high-angle patients followed by normal patients, and One-way ANOVA test; * indicates significant difference at P ≤ 0.05

Figure 2. Measurement planes: 6M, 6MID, 6-7, 7MID, 7D.

4 P. PAUL ET AL.

Table 3. Comparison of bone thickness a/c to slices in Average which has been defined as showing no movement
growth pattern. (zero anchorage loss) as a consequence of reaction
Slices 6M 6MID 6 and 7 7MID 7D p value forces. Two key determinants of primary stability are
8 mm 1.42 1.42 1.50 1.12 0.90 0.005*
10 mm 1.50 1.66 1.75 1.20 1.17 0.005*
bone quality and quantity [25]. It has been reported
12 mm 1.72 1.89 2.13 1.61 1.39 0.014* that placement sites of mini-implants should have
14 mm 1.63 1.75 1.94 1.50 1.28 0.006* a cortical bone thickness of more than 1.0 mm in
One-way ANOVA test; * indicates significant difference at P ≤ 0.05 order to attain adequate primary stability for mini-
implant success [26].
Table 4. Comparison of bone thickness a/c to slices in vertical Using conventional imaging methods, studies have
growth pattern. shown a great range of variation in vertical bone
Slices 6M 6MID 6&7 7MID 7D p value volume and have reported that accurate measurement
8 mm 1.26 1.29 1.56 1.05 0.84 0.001* of the available bone thickness is difficult [27]. The
10 mm 1.44 1.50 1.80 1.20 1.11 0.001*
12 mm 1.68 1.86 1.95 1.56 1.29 0.017* primary implant stability of an orthodontic mini-
14 mm 1.59 1.74 1.86 1.50 1.29 0.001* implant can be estimated by computed tomography
One-way ANOVA test; * indicates significant difference at P ≤ 0.05 measurements of cortical bone thickness and trabecu­
lar bone density before treatment [28]. Dental CT, as
and second molar (6–7) was noted in all three groups. a standard imaging technique in implantology, has the
This gradually decreased from middle of second molar major advantage of not being prone to magnification
(7 Middle) towards the distal of second molar (7D). The or superimposition errors as in conventional imaging
cortical bone thickness increased from cemento- methods and thus provides more beneficial results for
enamel junction towards the maxillary sinus floor measuring bone thickness [27].
along the heights of 8 mm, 10 mm and 12 mm and Results of this study showed cortical bone thickness
decreased towards 14 mm (Figure 3). of the infra zygomatic crest region being related to
The thickest cortical bone was at the interdental various facial types. Cortical bone thickness in low-
region between the maxillary first and second molar angle subjects was significantly higher than in high-
(6–7) of 2.40 mm at a height of 12 mm from the angle subjects between first and second molars as well
cemento-enamel junction in low-angle cases. The thin­ as on the distal aspect of the second molars.
nest bone of 0.84 mm was distal to second molar (7D) Masumoto et al and Tsunori et al in their studies on
at a height of 8 mm in high angle cases. three-dimensional images of Asian cadavers found cor­
relations between facial type and mandibular cortical
bone thickness; however, the measurements were not
Discussion
made in mini-implant placement specific areas [15,29].
With the advent of TADs, the envelope of discrepancy Previous studies [22,30] have examined the relation­
has changed with treatment methods resulting in ship between facial divergence and cortical bone thick­
more predictable tooth movement. Skeletal anchorage ness. All studies focused on posterior sites in the
with mini-implant screws is widely used in orthodontic maxilla and mandible where TADs are generally
practice today because it provides infinite anchorage placed. Horner et al. [30] compared cortical bone

Figure 3. Mean values of cortical bone thickness at various heights.

 ORTHODONTIC WAVES 5

thickness in hyper-divergent and hypo-divergent bone to appear thicker or thinner than it truly is [35].
patients and concluded that cortical bone thickness Hence, this limitation of CBCT imaging should also be
in the hyper-divergent groups was significantly lower considered. Lastly, the differences in cortical bone den­
than the latter group. Ozdemir et al. [22] conducted sity were not evaluated in this study. In future research,
a similar study measuring cortical bone thickness at various factors that play a key role in initial stability
4 mm from the alveolar crest among three different such as bone density (mineralization) and soft tissue
vertical facial types. They reported cortical bone thick­ could also be evaluated.
ness in the high-angle group to be significantly lower
than in the low-angle group from the distal aspect of
the canine to the mesial aspect of the second molar in Conclusion
both maxilla and mandible. No other study has exam­ ● The ideal site for insertion of TADs in the infra­
ined the relationship between facial divergence and
zygomatic crest is the interdental region between
cortical bone thickness in the infrazygomatic region.
the maxillary first and second molars at a height
Our study confirms that cortical bone thickness at
of 12 mm in all facial types.
mini-implant sites is lower in high-angle patients than ● It is better to avoid placing TADs distal to
in normal- and low-angle patients; this would imply
maxillary second molars as cortical bone in that
higher risks of implant failure in these patients.
region is thinner comparatively.
Therefore, precautions should be taken in patients ● To avoid the risk of mini-implant failures, clini­
with less cortical bone thickness to prevent failure of
cians should be aware of the probability of thin­
mini-implants. These precautions may include use of
ner cortical bone in high angle patients as
thicker miniscrews, to monitor oral hygiene strictly or
compared to normal and low angle groups.
ensure angulated positioning of miniscrews to take ● For specific biomechanical needs, it is possible to
advantage of the longer diagonal bone surface when
consider an insertion site like the furcation area of
possible [5,31].
the maxillary first molar, but insertion will likely
In this study, cortical bone thickness values were
need to be at 12 mm height to attain adequate
highest along the region between upper first
buccal bone thickness.
and second molars at a height of 12 mm.This corre­ ● These findings are statistical evaluations of data
lated with a previous study by Ono et al. [32] where
coming from a group of patients prior to treat­
they found that in the maxilla, cortical bone thickness
ment. Because of anatomical variation among
distal to the maxillary first molar at heights of 6–15 mm
individuals, potential insertion sites should be
was thicker than that mesial to the first molar. Similar
evaluated in each individual case before minis­
results by Liu et al. [33] mentioned that the thickest
crew insertion.
buccal alveolar bone was located in the maxillary first
and second molar region above the 5-mm plane.
The results also showed decreased cortical bone Disclosure statement
thickness present distal to maxillary second molar
(7D). This is consistent with the findings of Deguchi The authors declare that they have no conflicts of interest.
et al. [34] who reported significantly less buccal cortical
bone distal to the maxillary second molar region com­
pared with the mesial and distal areas of the first ORCID
molars. Paulin Paul http://orcid.org/0000-0003-4152-7012
According to Farnsworth et al. [6], farther the dis­ Anirudh Kumar Mathur http://orcid.org/0000-0002-1880-
tance from the alveolar crest, the thicker the cortical 8767
bone tended to be, which is similar to our study find­ Prasad Chitra http://orcid.org/0000-0002-7371-0738
ings where the cortical bone thickness increased with
increase in vertical height and was highest at 12 mm. References
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