Positional Guidelines for Orthodontic Mini-implant

Placement in the Anterior Alveolar Region:

A Systematic Review
Saeed AlSamak, BDS, MSc1/Simos Psomiadis, DDS, MD2/Nikolaos Gkantidis, DDS, MSc3

Purpose: To investigate the adequacy of potential sites for insertion of orthodontic mini-implants (OMIs) in
the anterior alveolar region (delimited by the first premolars) through a systematic review of studies that used
computed tomography (CT) or cone beam CT (CBCT) to assess anatomical hard tissue parameters, such as bone
thickness, available space, and bone density. Materials and Methods: MEDLINE, EMBASE, and the Cochrane
Database of Systematic Reviews were searched to identify all relevant papers published between 1980 and
September 2011. An extensive search strategy was performed that included the key words “computerized
(computed) tomography” and “mini-implants.” Information was extracted from the eligible articles for three
anatomical areas: maxillary anterior buccal, maxillary anterior palatal, and mandibular anterior buccal.
Quantitative data obtained for each anatomical variable under study were evaluated qualitatively with a scoring
system. Results: Of the 790 articles identified by the search, 8 were eligible to be included in the study. The
most favorable area for OMI insertion in the anterior maxilla (buccally and palatally) and mandible is between
the canine and the first premolar. The best alternative area in the maxilla (buccally) and the mandible is
between the lateral incisor and the canine, while in the maxillary palatal area it is between the central incisors
or between the lateral incisor and the canine. Conclusions: Although there is considerable heterogeneity among
studies, there is a good level of agreement regarding the optimal site for OMI placement in the anterior region
among investigations of anatomical hard tissue parameters based on CT or CBCT scans. In this context, the
area between the lateral incisor and the first premolar is the most favorable. However, interroot distance seems
to be a critical factor that should be evaluated carefully. Int J Oral Maxillofac Implants 2013;28:470–479.
doi: 10.11607/jomi.2659

Key words: anatomical parameters, computed tomography, mini-implants, orthodontic implants

C ontrol of anchorage comprises a major issue in or-

thodontics, with fundamental importance for the
majority of cases. Temporary skeletal anchorage de-
vices are a recent advance that has influenced many
aspects of contemporary orthodontics. Conventional
1PhD
Student, Department of Orthodontics, School of
Dentistry, University of Athens, Greece.
2Resident, Department of Oral and Maxillofacial Surgery,
University Hospital of Heraklion, Crete, Greece.
3Research Fellow, Department of Orthodontics and Dentofacial
Orthopedics, School of Dental Medicine, University of Bern,
Switzerland.
Correspondence to: Dr Nikolaos Gkantidis, Department of
Orthodontics and Dentofacial Orthopedics, School of Dental
Medicine, University of Bern, Freiburgstrasse 7, CH-3010 Bern,
Switzerland. Fax: +41-(0)31-632-98-69. Email: nikosgant@
yahoo.gr
©2013 by Quintessence Publishing Co Inc.
anchorage, which usually demands additional hygiene
measures by the patient and extra chair or labora-
tory time by the dentist, has tended to be replaced
by the various available types of skeletal anchorage.
Of the types of skeletal anchorage, orthodontic mini-
implants (OMIs) are probably the most convenient and
effective solution since they provide almost absolute
anchorage in all three dimensions.1
The success of OMIs can be affected by factors such
as implant geometry, surface chemistry, and surface
roughness2 or by factors related to the host,3,4 such as
bone quality and quantity. Host parameters that are
considered to express a positive influence on OMI suc-
cess rates include increased bone thickness and depth,
greater interroot distance, and higher bone density.4–8
These parameters can be thoroughly evaluated
with traditional or contemporary imaging techniques,
such as computed tomography (CT) and cone beam
CT (CBCT).9 These three-dimensional methods pres-
ent advantages over conventional two-dimensional
radiographic techniques, such as cephalometric and

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panoramic radiographs by providing detailed, accurate,
and reliable three-dimensional information,10 which is
mandatory for research purposes. The further aim of
studies that evaluate potential OMI insertion sites is to
ensure safe and efficient placement and clinical perfor-
mance. Safe placement can be achieved when no vital
organ/region is injured, and clinical efficacy is accom-
plished when the implant remains stable throughout
treatment.
Several studies have investigated these issues, and
they usually propose ideal and alternative sites for OMI
insertion. However, to date, there has been no sys-
tematic attempt to evaluate the information from all
the available studies and derive useful guidelines for
everyday clinical practice. The heterogeneity of meth-
odologies used in previous studies makes the need
for such an evaluation imperative. A previous study11
clearly identified the second premolar–second molar
alveolar region (buccally and lingually) as the most
appropriate for OMI insertion in the maxilla and the
mandible, based on the evaluation of host hard tissue
parameters. In that study, all potential OMI insertion
sites of each jaw (from second molar to second molar)
were considered under the same setup; thus, because
of the results that clearly favored posterior regions, the
anterior alveolar region did not receive much attention.
It is true that, considering the anatomical features
of the anterior mandible, it is not common to place an
OMI there, since the adjacent roots may not provide
adequate space. More specifically, the lingual side of
the anterior mandible is not indicated for OMI place-
ment because of possible irritation of the tongue or
placement difficulties because of restricted access to
the region. However, certain cases may benefit from
anterior anchorage, and for this reason the anterior
maxilla is often used for OMI placement. The mandibu-
lar buccal anterior region may also be useful in certain
cases, although this option was rarely adopted until
recently.
Thus, the purpose of the present systematic review
was to identify the applicability of potential OMI in-
sertion sites in the maxillary (buccal and palatal) and
mandibular (buccal) anterior alveolar region, delimited
by the first premolars, based on studies that evaluated
bone thickness, bone depth, interroot distance, and
bone density through CT or CBCT scans.
MATERIALS AND METHODS
Search Strategy
A specific search was conducted in MEDLINE (PubMed),
EMBASE, and the Cochrane Database of Systematic
Reviews to identify all relevant papers published be-
tween 1980 and September 20, 2011.
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AlSamak et al
The search strategy performed included one de-
tailed search for OMIs and another detailed search for
CT or CBCT (included in: “all fields”; limits: “humans,
English, German, French, Italian”). The key words with-
in each search were connected by the term “OR.” In a
final step, these two searches were combined with the
term “AND.” The search protocol was described in detail
in a previous paper.11 Case reports, case series (studies
with fewer than 10 subjects), reviews, and animal stud-
ies were excluded.
After the initial search, article titles and abstracts
were used to exclude any articles that were irrelevant
to the purpose of the study. The reference lists of the
remaining articles were then searched for additional
papers. The full text of all remaining articles was read,
and articles that evaluated only specific sites or regions
irrelevant to the topic field of interest were excluded.
Articles that used the same sample to test similar pa-
rameters were also excluded.
All stages of the article selection process were per-
formed by two authors (SA, SP) independently. In cases
of disagreement, a joint decision was made by all three
authors.
Data Extraction
Information obtained from the included articles was
divided into three categories according to the ana-
tomical region examined: (1) anterior buccal maxillary
alveolar region, (2) anterior palatal maxillary alveolar
region, and (3) anterior buccal mandibular alveolar
region. All articles were read thoroughly, and the ana-
tomical variables assessed in each of them were identi-
fied. The anatomical variables that were assigned to an
insertion site to designate it as “ideal” or the “best al-
ternative” in each article were identified and summed
separately. Thus, the site with the highest or second
highest value for a specific variable was identified and
given one point as the ideal or best alternative, re-
spectively. These sums represented the score of each
OMI insertion site under study that characterized it as
best or best alternative, respectively, in regard to bone
quality and quantity parameters.
Data extraction was performed by two authors
(SA, NG) independently. In cases of inconsistencies,
re-examination of the original studies solved any disa-
greements.
Methodologic Considerations
The parameter of buccolingual bone depth was in-
cluded in the scores of both buccal and palatal alveo-
lar bone evaluations because, for anatomical reasons,
it was assessed for both sides. If interroot distance was
measured both buccally (on the level of the buccal
surfaces of teeth) and centrally, only the central mea-
surement was considered in the analysis, as this is the
The International Journal of Oral & Maxillofacial Implants 471
AlSamak et al

Table 1   Description of the Studies Included in the Review

Study Origin Sample Age (y)
Hernández et al13 Spain (subjects recruited in Spain) 21 living humans 17–21
(14 M, 7 F)
Lim et al14* Korea (subjects recruited in Korea) 28 living humans 27 (23–35)
(14 M, 14 F)

Choi et al15 Korea; North Carolina, USA 30 living humans 25 ± 3

(15 M, 15 F)
Chun and Lim16 Korea (Korean subjects; implied by 28 living humans 27 (23–35)
discussion) (14 M, 14 F)

Lee et al17 Korea (subjects recruited in Korea) 49 living humans 28 (19–45)

(24 M, 25 F)

Lim et al18* Same as Lim et al14 Same as Lim et al14 Same as Lim et al14
Fayed et al19 Switzerland (subjects recruited in 100 living humans 20 (13–27)
Switzerland) (46 M, 54 F)

Baumgaertel and Hans20 Ohio, USA 30 skulls (NM) NM

M = male; F = female; NM = not mentioned.

*The studies of Lim et al14,18 used the same sample, but because information regarding interroot distance was not adequately provided in the ­latter,
it was obtained from the first study.

clinically relevant measurement; it was considered for
both buccal and palatal alveolar bone evaluations.
Most included studies that assessed interroot distance
measured it on both the buccal and palatal sides/roots,
since this value can differ for multiple-root teeth such
as the first premolar.
In papers in which measurements were performed
in several vertical heights, only the measurements that
were judged to correspond to a region in and near the
attached gingiva were considered for analysis. These
were judged to be located 2 to 4 mm from the alveolar
crest or the cementoenamel junction (CEJ) for the buc-
cal side of the maxilla and the mandible.12 When two
sites presented the same value for the specified region,
the adjacent available value was also considered. For
the palatal side of the maxilla, where all gingival tis-
sues are attached to the bone, all available measure-
ments at all distances from the alveolar crest or CEJ
were included in the assessments.
In cases where there was more than one available
measurement for the determined ranges, the mean
value was calculated for each specific site, and the best
or best alternative site was identified afterward. The
mean value was also calculated when several meas-
urements were obtained at different angles for the
same site. After this quantitative transformation of the
available data, further data analysis was performed
in a qualitative manner because of the heterogeneity
of methods used in the included studies. This option
was selected because the considerable variation in the
methodologies applied in the studies did not allow
for more detailed evaluation and meta-analysis of the
data (see also Discussion). Furthermore, considering
also the relatively limited number of studies included
in the present review and potential unadjusted con-
founding factors that may exist, the authors decided
to use the mean value as more representative of each
OMI insertion site and then transform the information
from quantitative to qualitative.
RESULTS
Of the 425 articles initially revealed by the MEDLINE
search, 338 were excluded by title, and a further 55
were excluded after the abstracts were read as irrele-
vant to the study subject. Hand search of the reference
lists of the remaining 32 articles revealed 2 additional
papers. Twenty-three more articles were excluded after
full-text reading because they evaluated only specific
sites or regions irrelevant to the field of interest (palate,
n = 8; posterior alveolar region, n = 6; infrazygomatic
region, n = 2; maxillary second premolar to first molar,
n = 2; canine to second molar, n = 2; lateral incisor to
canine and second premolar to first molar, n = 1; and vi-
tal anatomical regions, n = 2). Three additional articles

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 AlSamak et al

Included subjects Area

Volunteers with no missing teeth, severe crowding, or previous orthodontic treatment Alveolar (central incisor–second
molar), maxilla and mandible
Volunteers without severe skeletal discrepancies, high mandibular plane angles, Alveolar (central incisor–
asymmetric occlusions, absence of any permanent teeth except third molars, second molar), maxilla
impacted teeth, severe crowding, or radiographic signs of periodontal disease
Healthy subjects with no diseases affecting bone density and with normal occlusion, Alveolar (central incisor–second
no missing teeth, and no prosthetic crowns molar), maxilla and mandible
Volunteers without severe skeletal discrepancies, high mandibular plane angles, asymmetric Alveolar (central incisor–second
occlusions, absence of any permanent teeth except third molars, impacted teeth, moderate molar), maxilla and mandible
to severe crowding, radiographic signs of periodontal disease, or any systemic illness
Healthy subjects with normal overjet and overbite, Class I molar relationship, crowding Alveolar (central incisor–second
less than 2 mm, no periodontal disease with no alveolar bone loss, no missing teeth, molar), maxilla and mandible
no prostheses, and no previous orthodontic treatment
Same as Lim et al14 Same as Lim et al14
Dental patients without overlapping of crowns or roots of adjacent teeth, perio­dontal dis- Alveolar (central incisor–second
ease (determined via radiographic signs of alveolar bone resorption), severe ectopic molar), maxilla and mandible
eruption (ie, buccally blocked out canines), missing teeth (except third molars),
mixed dentition, or incomplete crown eruption
Adult dry skulls with no more than two missing teeth per arch (except third molars) Alveolar (central incisor–second
molar), maxilla and mandible

were excluded because they used the same sample to
test similar parameters. The remaining 8 articles were
all judged eligible for inclusion in the study.
The EMBASE database revealed 456 papers. One
hundred seventeen were immediately excluded as du-
plicate citations with MEDLINE. Of the remaining 339
papers, 329 were excluded by title, mainly as irrelevant
to study subject, and the remaining 10 were excluded
after the abstracts had been read (infrazygomatic area,
n = 1; not in area of interest, n = 1; irrelevant, n = 8).
The Cochrane Database of Systematic Reviews
search resulted in 24 papers. All were excluded by title
as irrelevant to study subject.
A detailed description of the studies included in
the systematic review13–20 and the characteristics that
were considered for data evaluation are provided in
Tables 1 and 2, respectively. In general, all studies in-
cluded subjects without severe occlusal problems, and
most used a moderate sample size of 21 to 49 subjects,
while one study19 evaluated 100 subjects. The included
studies evaluated the whole alveolar area from second
molar to second molar. Of the eight papers included
in the review, seven assessed living humans13–19 and
one used dry skull data.20 The paper on dry skulls did
not mention age or sex data, although it reported that
adult skulls were examined. On the other hand, all ob-
servations on living humans provided age and sex in-
formation.
Two of the living human studies14,18 used the same
sample to test similar parameters. In that case, infor-
mation for each parameter studied was extracted only
once and was obtained from the paper that presented
it in more detail. Two studies used CBCT scans19,20 and
the rest used CT scans13–18 as the diagnostic tool. In
four studies, subjects were recruited in Korea14,16–18;
one studied subjects in Spain,13 one studied subjects
in Switzerland,19 and two studies provided no infor-
mation.15,20
From the living human studies, one study present-
ed a wide age range (19 to 45 years),17 while the ma-
jority of the other studies evaluated young adults (17
to 35 years).13–16,18 Another study19 examined two age
groups that ranged between 13 and 27 years and re-
ported that the adult group (19 to 27 years) had thicker
palatal cortical bone (by about 13%) than the adoles-
cent group (13 to 18 years). No other significant dif-
ference was detected in any of the other parameters
evaluated in the specific study.
All the living human studies, with the exception of
Hernández et al,13 included a balanced sex distribu-
tion in their samples (Table 1). Three studies provided
appropriate data concerning potential sex differenc-
es in the parameters examined.15,16,19 Two studies
revealed no difference between sexes in maxillary and
mandibular bone density.15,16 According to a third
study, men had slightly greater buccolingual bone

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AlSamak et al

Table 2   Characteristics of the Data Evaluated in the Included Studies

Study Parameters Measurement levels
Hernández et al13 Buccal and lingual: bone depth, interroot distance 3, 6, and 9 mm from the alveolar crest

Lim et al14* Interroot distance (central) 2, 4, and 6 mm from the alveolar crest

Choi et al15 Buccal and lingual: cortical and cancellous bone 4 mm from the alveolar crest
density

Chun and Lim16 Buccal: cortical bone density 0, 2, 4, and 6 mm from the alveolar crest

Lee et al17 Buccal and lingual: interroot distance 2, 4, 6, and 8 mm from the proximal CEJ

Lim et al18* Buccal: cortical bone thickness Same as Lim et al14

Fayed et al19 Buccal and lingual: bone depth, cortical bone 2, 4, and 6 mm from the CEJ
thickness, interroot distance

Baumgaertel and Hans20 Buccal: cortical bone thickness 2, 4, and 6 mm from the alveolar crest

M = male; F = female; NM = not mentioned; FH = Frankfort horizontal; HU = Hounsfield units.

*The studies of Lim et al14,18 used the same sample, but because information for interroot distance was not adequately provided in the latter, it
was obtained from the first study.

depth (≈ 10%) in the anterior maxilla, while all the oth-
er parameters examined were similar for both sexes.19
A range of measurement levels was evaluated in
each study, and various measurement methods were
implemented (Table 2). The CEJ was used as a refer-
ence for measurements at the vertical level in two
papers,17,19 while the alveolar crest margin was used
in six papers.13–16,18,20 All the included studies tested
the reliability of measurements and, despite the het-
erogeneity of methods, reported valid results. The only
exception is the study of Hernández et al,13 which pro-
vided inadequate information.
Parameters Assessed and Interstudy
Agreement
The host hard tissue parameters evaluated were inter-
root distance,13,14,17,19 which was the most frequently
studied, followed by cortical bone thickness,18–20 bone
depth,13,19 and bone density,15,16 in decreasing order
(Table 2).
Perfect agreement between studies was detected
regarding cortical bone thickness in the maxillary and
mandibular buccal region and regarding bone depth
and interroot distance in the mandibular buccal re-
gion. Agreement on interroot distance in the maxilla
was moderate to good. Agreement on bone depth in
the maxilla was perfect, but only for the best site. Bone
density was not assessed by more than one study in a
comparable manner; thus, an estimation of agreement
was not possible (Table 3).
Dry skull data20 showed a high level of agreement
with living human data13–19 (Table 3) and thus no data
discrimination was performed for this factor.
Optimal Sites for OMI Insertion
The most favorable area for OMI insertion in the maxilla
(buccally and palatally) and the mandible (buccally) is
between the canine and the first premolar. The best al-
ternative area in the maxilla (buccally) and the mandi-
ble is between the lateral incisor and the canine, while
in the maxillary palatal area it is between the central
incisors or between the lateral incisor and the canine
(Tables 4 to 6). However, since there are important an-
atomical limitations between the central incisors, the
latter option is also preferable as best alternative in the
palatal alveolar area.
DISCUSSION
CT and CBCT have been used to evaluate anatomical
hard tissue parameters such as bone depth, cortical

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 AlSamak et al

Measurement method Method error

Bone depth: approximately vertical to the alveolar bone. Interroot distance: approximately Measurements made by two
parallel to occlusal surface. authors; no further information
provided
Interroot distance: along a line parallel to the occlusal plane, the closest distance between Intraexaminer error;
tangent lines to proximal root surfaces and parallel to the long axis of the roots. no systematic error
Simulated miniscrew placement. The angulation of the miniscrew was perpendicular to the Intraexaminer error;
bone surface horizontally and 40 degrees to FH vertically (between the maxillary canines no systematic and acceptable
parallel to FH). Measured at 1-mm intervals to a depth of 6 mm at all sites. random error
Center value, among multiple adjacent x-coordinate HU readings (similar to the mean of the Intraexaminer error;
multiple values). no systematic error
Interroot distance: parallel to the mean arch forms. Intraexaminer error;
no systematic error
Bone thickness: sagittal images were prepared along a line passing through the contact Intraexaminer error;
point and parallel to the long axis of the teeth and 0, 15, 30, and 45 degrees to the long no systematic error
axis of a tooth.
Horizontal orientation of palatal plane and vertical orientation of nasal septum. Intraexaminer error;
Cortical bone thickness and buccolingual bone depth: in the middle of the interroot distance no systematic error
between each two adjacent teeth. Interroot distance: the widest distance between each two
adjacent teeth.
In the middle of the interroot distance between each two adjacent teeth and perpendicular High intraexaminer reliability
to the bone surface.

Table 3   Agreement Between Studies Regarding the Parameters Assessed for OMI Site Evaluation
Mandible Maxilla
Parameter Buccal Buccal Palatal
Bone depth (buccolingual) [(13, 19)] [13, 19] [13, 19]
Cortical bone density 16 16 –
Cortical and cancellous bone density 15 15 15
Cortical bone thickness [(18, 19, 20)] [(18, 19, 20)] 19
Interroot distance [(17, 13, 19)] (17, [19), 13], 14 (17, [19), 13], 14
Papers/references within each cell are placed according to the ranking order of Tables 4 to 6. Brackets indicate agreement between studies re-
garding the best insertion site as determined by each corresponding parameter, while parentheses indicate the same for the best alternative site.

bone thickness, interroot distance, and bone den-
sity14,18,19 with a high level of accuracy and reliability,
especially in comparison to conventional two-dimen-
sional methods.10,21 CT provides better soft tissue visu-
alization than CBCT. However, CBCT offers lower cost
and a lower dose of radiation and provides adequate
information for hard tissues in all three dimensions
without significant distortion of the actual sizes and
shapes of structures.21,22
Previous studies indicated that the most common
placement position of OMIs is the posterior region of
both arches. Indeed, previous work demonstrated that
the best sites for OMI placement according to host hard
tissue parameters are between the second premolar and
second molar in the maxilla and the mandible.11 Howev-
er, placement of OMIs in the anterior region is frequently
helpful in certain cases. Anterior placement of OMIs
can support multiple treatment needs, including deep
bite correction,23 improvement of excessive gingival
display,24 midline correction,25 and ectopic eruption.26
Furthermore, an anterior OMI can serve as an anchorage
unit for distal or mesial posterior tooth movement, es-
pecially when a posteriorly placed screw would interfere
with the direction of planned tooth movement.27

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Table 4   Best Sites for OMI Insertion in the Anterior Buccal Maxillary Alveolar Area
Dental area
Best site
Canine–first premolar
Between central incisors
Central incisor–lateral incisor
Lateral incisor–canine
Best alternative site
Lateral incisor–canine
Between central incisors
Canine–first premolar
Central incisor–lateral incisor
Table 5   Best Sites for OMI Insertion in the Anterior Palatal Maxillary Alveolar Area
Dental area
Best site
Canine–first premolar
Between central incisors
Central incisor–lateral incisor
Lateral incisor–canine
Best alternative site
Between central incisors
Lateral incisor–canine
Canine–first premolar
Central incisor–lateral incisor
Table 6   Best Sites for OMI Insertion in the Anterior Buccal Mandibular Alveolar Area
Dental area
Best site
Canine–first premolar
Central incisor–lateral incisor
Best alternative site
Lateral incisor–canine
Central incisor–lateral incisor
Canine–first premolar
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No. of papers Parameters No. of parameters
5 Bone depth13,19 6
Cortical bone thickness18–20
Interroot distance17
2 Interroot distance13,19 2
2 Buccal cortical bone density16 2
Cortical and cancellous bone density15
1 Interroot distance14 1
4 Cortical bone thickness18–20 5
Interroot distance17,19
3 Bone depth13 3
Cortical and cancellous bone density15
Interroot distance14
3 Cortical bone density16 2
Interroot distance13
1 Bone depth19 1
No. of papers Parameters No. of parameters
3 Bone depth13,19 4
Cortical bone thickness19
Interroot distance17
2 Interroot distance13,19 2
1 Cortical and cancellous bone density15 1
1 Interroot distance14 1
3 Bone depth13 3
Cortical and cancellous bone density15
Interroot distance14
2 Cortical bone thickness19 3
Interroot distance17,19
1 Interroot distance13 1
1 Bone depth19 1
No. of papers Parameters No. of parameters
6 Bone depth13,19 9
Cortical bone density16
Cortical bone thickness18–20
Interroot distance13,17,19
1 Cortical and cancellous bone density15 1
5 Bone depth13,19 8
Cortical bone thickness18–20
Interroot distance13,17,19
1 Cortical bone density16 1
1 Cortical and cancellous bone density15 1

Most of the included studies presented various
measurements on several vertical levels. In general,
two anatomical reference points were used to define
the vertical level of measurements: the alveolar crest
and the CEJ. Normally, the CEJ is located approximate-
ly 1 mm occlusal to the alveolar crest,12 but this is not
expected to have an influence on the present results,
since the quantitative original data obtained from the
studies were transformed to qualitative information.
The authors decided to include in the analysis only the
measurements that corresponded to attached gingiva,
since the advantages of OMI placement in attached
gingiva are well established in the literature28,29 and
this is considered a standard clinical procedure.
One paper that assessed dry skulls20 was included in
the systematic review and was given the same weight
as living human studies, since a previous study that
evaluated OMI sites in the entire alveolar region11 did
not reveal any significant differences between these
two types of studies. This was also confirmed by the
present study, as a high level of agreement was evident
between the dry skull data and living human data. Sex
and age also did not seem to exert a significant influ-
ence on the results, as the differences identified by
individual studies were limited to few parameters and
sites, and even then, these were not large. One factor
that might influence hard tissue host parameters but
has not yet been addressed in the literature is the race
of the studied subjects.
In the maxilla, both buccally and palatally, the best
area for insertion—between the canine and the first
premolar—offers greater bone depth and cortical bone
thickness, while the interroot distance is adequate, al-
though measurements are not highly consistent among
different studies. The areas between the central incisors
and between the lateral and canine obtained the same
score as maxillary best alternative palatal sites. However,
an OMI between the central incisors may be uncomfort-
able for the patient because of the presence of the in-
cisive papilla and foramen.30 Furthermore, it should be
kept in mind that the position of the incisive foramen
may change during treatment of Class II malocclusion.31
Thus, the area between the lateral and canine should be
preferred as the best alternative in this case. The same
position is also the best alternative for the maxillary buc-
cal side. In the mandible, the best area of insertion is
between the canine and the first premolar and the best
alternative area is between the lateral and the canine.
Both areas provide the greatest cortical bone thickness,
bone depth, and interroot distance, while the highest
bone density is usually located at different sites. To sum-
marize, in all cases examined, the areas delimited by the
first premolar and the canine and by the lateral incisor
and the canine are the best and best alternative areas,
respectively, for OMI placement in the anterior region.
© 2013 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
AlSamak et al
The anatomical characteristics of the anterior re-
gion directly influence the selection of specific OMI
features. For instance, the relatively decreased inter-
root distance does not allow for larger-diameter OMIs
and requires more caution to avoid root damage dur-
ing insertion or during lateral displacement caused
by applied orthodontic forces.32 Previous clinical
guidelines recommended a 2-mm margin between an
OMI and a tooth root,33 but this is not possible clini-
cally, especially in the anterior region. However, oth-
ers suggested that the safe margin should be at least
0.5 mm.34 Kim et al35 considered root proximity as a
factor that may reduce primary stability and lead sub-
sequently to OMI loss. According to the present data,
the mean buccal interroot distance in the mandible
ranged from 2.1 to 3.1 mm and from 1.5 to 3 mm in
the best and best alternative areas, respectively. In the
maxilla, both buccally and palatally, the mean inter-
root distance ranged from 2.3 to 3.2 mm and from 2.3
to 3.5 mm for the best and best alternative areas, re-
spectively. In general, the standard deviations of these
measurements ranged between 0.5 and 1.3 mm. This
high variability between studies can be attributed to
the different methodologies applied (angles, levels,
tooth inclinations, etc); this is the main reason why the
authors transformed quantitative data into qualitative
information and did not perform a meta-analysis or
provide numeric values for the results. However, in any
case, because OMIs of 1 mm in diameter show lower
success rates than wider implants36,37 and because the
available space in the anterior region may not always
be adequate (even in the best site), special attention
should be given by the clinician during the evaluation
of potential OMI insertion sites when anterior anchor-
age is planned.
Bone depth is important to support the placement
of longer implants and avoid perforation of the oppos-
ing bone plate. Experimental studies demonstrated
that longer implants may increase OMI primary stabil-
ity.38,39 This is also supported by the findings of clini-
cal trials.37,40 In the studies evaluated here, the mean
bone depth in the mandible ranged between 8.5 and
9.0 mm and 7.6 and 9.0 mm in the best and best al-
ternative areas, respectively. In the maxillary arch, the
mean bone depth ranged between 9.0 and 10.0 mm
and 8.2 and 8.5 mm in the best and best alternative
areas, respectively. Accordingly, an implant length of 7
mm will, in most cases, be safely supported.
Higher bone density has been also considered to in-
crease OMI primary stability.41 The present data show
that the mean bone density in the best and best al-
ternative areas was above 900 Hounsfield units in all
cases, which is considered adequate for the holding
power of bone, ie, it offers sufficient primary stability
and subsequently promotes secondary stability.4
The International Journal of Oral & Maxillofacial Implants 477
AlSamak et al
Immediate or early loading of OMIs depends on pri-
mary stability, which is achieved via mechanical inter-
locking with cortical bone. Thus, thicker cortical bone
increases OMI primary stability, as has been shown in
vivo and in vitro.5,42 According to the evaluated stud-
ies, in the mandible, the mean cortical bone thickness
ranged between 1.1 and 2.7 mm and 1.0 and 2.4 mm
in the best and best alternative areas, respectively.
In the maxilla, buccally, the cortical bone thickness
ranged between 1.1 and 2.6 mm and 0.9 and 2.6 mm
in the best and best alternative areas, respectively. On
the palatal side, the mean cortical bone thickness was
1.7 mm in both the best and best alternative areas. Ac-
cording to a study of Motoyoshi et al,5 cortical bone
thickness of more than 1 mm is needed to support suc-
cessful orthodontic treatment; most of the time, this
requirement is fulfilled in the anterior region.
CONCLUSIONS
Despite the heterogeneity of the studies included in
this review, there was good agreement between pa-
pers that evaluated host hard tissue parameters re-
garding the best and best alternative sites for anterior
placement of an orthodontic mini-implant (OMI). Thus,
from this point of view, the most favorable area for OMI
insertion in the anterior maxilla (buccally and palatally)
and the mandible is between the canine and the first
premolar. The best alternative area in the maxilla (buc-
cally and palatally) and the mandible is between the
lateral incisor and the canine.
However, placement of OMIs in the anterior region
necessitates special consideration of specific anatomi-
cal parameters. Of the parameters that were evaluated
in the present study, including cortical bone thick-
ness, bone depth, and bone density, interroot distance
seems to be the most important limiting factor and
should be evaluated carefully when planning ante-
rior anchorage with OMIs. This suggestion is further
enhanced by the fact that interroot distance showed
moderate to good agreement between studies, where-
as the other parameters showed perfect agreement.
Acknowledgments
The authors reported no conflicts of interest related to this study.
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The International Journal of Oral & Maxillofacial Implants 479