ODW 286 No.

of Pages 13

orthodontic waves xxx (2018) xxx –xxx

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Original article

Considerations for placement of mandibular buccal

shelf orthodontic anchoring screw in Class III
hyperdivergent and normodivergent subjects – A
cone beam computed tomography study

Sikkared Parinyachaiphun a, Sirima Petdachai a, *,

Vannaporn Chuenchompoonut b
a
Department of Orthodontics, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
b
Department of Radiology, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand

article info abstract

Article history: Purpose: The study simulated a mandibular buccal shelf (MBS) orthodontic anchoring screw
Received 20 October 2017 insertion path and determine the effect of vertical skeletal pattern, insertion site, vertical
Received in revised form level and insertion angle on the slope, cortical bone thickness and distance from molar root to
6 December 2017 the insertion path.
Accepted 5 January 2018 Materials and methods: Forty CBCT images of Class III subjects were divided equally into
Available online xxx hyperdivergent and normodivergent groups. The slope of the MBS was measured at four
different sites of insertion. Cortical bone thickness along the orthodontic anchoring screw
insertion path and distance from molar root to the path were measured at different
Keywords:
combinations of sites of insertion, vertical levels and insertion angles. Measured outcomes
Buccal shelf
were compared between hypodivergent and normodivergent groups at different combina-
Orthodontic anchoring screw
tions of variables using factorial repeated ANOVA.
CBCT
Results: The cortical bone thickness and the slope of the MBS were not different between
Hyperdivergent
hyperdivergent and normodivergent groups. However, posterior sites had a flatter slope than
Normodivergent
that of the anterior. Higher vertical level and insertion angle resulted in thicker cortical bone
and higher distance from molar root. The mesial aspect of second molar site gave a higher
distance from molar root than first/second molar contact point site.
Conclusion: The mesial aspect of the second molar appears to be a safe site for placement of
MBS orthodontic anchoring screw as its slope was flatter and gave greater distance from
molar root. Increasing vertical level or insertion angle resulted in a higher cortical bone
thickness and distance from the molar root.
© 2018 Elsevier Ltd and The Japanese Orthodontic Society. All rights reserved.

* Corresponding author.
E-mail addresses: sikkared@outlook.com (S. Parinyachaiphun), sirima.c@chula.ac.th (S. Petdachai), cvannapo@yahoo.com
(V. Chuenchompoonut).
https://doi.org/10.1016/j.odw.2018.01.001
1344-0241/ © 2018 Elsevier Ltd and The Japanese Orthodontic Society. All rights reserved.

Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
ODW 286 No. of Pages 13
2 orthodontic waves xxx (2018) xxx –xxx
1. Introduction
A type of Class III malocclusion with mild to moderate skeletal
discrepancy can be corrected by orthodontic treatment alone
to obtain a good and stable result [1]. Extraction of lower
premolars can be done in order to retract lower anterior teeth
and achieve a Class I canine relationship. However, there are
circumstances where extraction cannot be done, such as
already missing premolars and too little Class III discrepancy.
The whole mandibular arch distalization is another option to
correct a Class III relationship. However, it is considered one of
the most difficult tooth movements in orthodontics [2].
The development of temporary anchorage devices (TADs),
so-called orthodontic anchoring screws (OASs), has increased
the effectiveness of lower arch distalization as demonstrated by
a number of case reports [3–5]. These screws can be placed at
different sites, such as the retromolar area and ramus of the
mandible [3,5]. The mandibular buccal shelf (MBS) is another
proposed area for OASs placement [6–9]. It is the buccal alveolar
bone of the mandible from the first molar region to the external
oblique ridge and is covered with the thickest cortical bone in
the mandible [10–14]. OASs can be placed extraradicularly in this
area and does not interfere with distalization [9]. Chang et al. [7]
found that the slope of the MBS became flatter from anterior to
posterior. As it became flatter, insertion of OASs is easier.
However, the degree of this slope varies among different
individuals [9]. Class III patients with a hyperdivergent vertical
skeletal pattern often have a dental open bite tendency [6].
Biomechanical force from distalization may be beneficial to
these patients as the distalizing force from the MBS orthodontic
anchoring screws passes above the center of resistance of the
mandibular dentition. This tends to rotate mandibular occlusal
plane counterclockwisely and thus closes the bites [9].
Further study on the consideration of the MBS orthodontic
anchoring screws placement in Class III hyperdivergent
patients is needed since previous studies were not exclusively
conducted in Class III hyperdivergent subjects [7,15]. More-
over, a number of studies [12,14] mentioned a difference in
thickness of cortical bone in hyperdivergent patients. Horner
et al. [12] reported a thinner cortical bone in second
mandibular molars to first mandibular premolars regions of
hyperdivergent patients compared to those of hypodivergent
patients. Similar results were presented by Ozdemir et al. [14]
in which mandibular buccal cortical bone at all interradicular
sites from canine to second molar was thinner in hyper-
divergent than in normo- and hypodivergent patients.
Moreover, contact of OASs with root is considered one of the
most frequent causes of failure [16]. Thus, finding a method for
inserting OASs without contacting the root is also crucial for
longevity of the OASs.
The purposes of this study were, firstly, to compare the
slope of MBS between Class III hyperdivergent and Class III
normodivergent patients at different sites. Secondly, to
compare the cortical bone thickness of MBS between and
within these two groups at different sites, different vertical
levels and different insertion angles. Finally, to find the most
appropriate site, vertical level, and insertion angle for
placement of a MBS orthodontic anchoring screw without
contacting the roots.
Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
2. Materials and methods
Cone beam computed tomography (CBCT) images were
obtained from the Department of Radiology, Faculty of
Dentistry, Chulalongkorn University, Bangkok, Thailand. In
order to minimize radiation exposure to subjects, a protocol
of ALARA (As Low As Reasonably Achievable) was used in
the Department of Radiology; the CBCT images did not
cover the Nasion and Sella point. Thus, Wits appraisal and
palatal plane to mandibular plane angle (PP-MP) were used
to identify sagittal and vertical skeletal relationships. The
inclusion criteria of the patients were: (i) age higher than 16
years, (ii) Wits appraisal showing Class III malocclusion
(value less than 4.1mm) [17], (iii) presence of lower first
and second molars, (iv) no alveolar bone loss, and (v) no
posterior crossbite or scissor bite. There were two “groups”
of patients categorized by their vertical skeletal relation-
ship. Subjects with PP-MP of 17.2–25.4 and 18.4–27.4 for
male and female, respectively, were classified into the
normodivergent group. While subjects with higher PP-MP
than this were categorized as hyperdivergent [17]. There
were 20 subjects in each group.
Each CBCT image was reconstructed and oriented with
1
Infinitt PACs software (Infinitt Healthcare Co., Ltd., Seoul,
Korea). In the coronal view, the image was adjusted to make
the axial plane parallel to the coronal occlusal plane which
passed through mesiobuccal cusps of two contralateral
mandibular first molars (Fig. 1). In the axial view, the image
was rotated until the sagittal plane passed through the central
groove of the mandibular first and second molars (Fig. 2).
Finally, in the sagittal view, the image was adjusted until the
axial plane parallel to the sagittal occlusal plane that passed
through the occlusal contact point of the first premolar and
first molar (Fig. 3). Because the same cortical bone thickness
between left and right side of an individual was reported
[13,18], all of the measurements were made on the side which
had the best alignment of first and second mandibular molars.
After selecting the side with the best alignment, the measure-
ment were done on the right side in 25 patients and on the left
side in 15 patients. Both of the Class III hyperdivergent and
normodivergent groups underwent three measurements as
follows:
1. The slope of the mandibular buccal shelf (Fig. 4).
This slope was the angle formed by a line tangent to the
MBS and the axial plane, and was measured at four
different “sites of insertion”. These were (i) the distal aspect
of the mandibular first molar (the coronal plane in the
sagittal view was placed at the distal cusp of the
mandibular first molar, Fig. 4a), (ii) the mandibular first/
second molars contact point (the coronal plane in the
sagittal view was placed at the contact point of the
mandibular first and second molars, Fig. 4b), (iii) the mesial
aspect of the mandibular second molar (the coronal plane
in the sagittal view was placed at the mesial cusp of the
mandibular second molar, Fig. 4c) and (iv) the middle
aspect of the mandibular second molar (the coronal plane
in the sagittal view was placed at the buccal groove of the
mandibular second molar, Fig. 4d).
ODW 286 No. of Pages 13

orthodontic waves xxx (2018) xxx –xxx 3

Fig. 1 – Orientation of CBCT image in the coronal view. The axial plane (blue line) passed through mesiobuccal cusp of
mandibular first molar. (For interpretation of the references to color in this figure legend, the reader is referred to the web
version of this article.)

2. The cortical bone thickness (Fig. 7).
This measurement was made at 18 different combina-
tions of the following variables for both hyperdivergent and
normodivergent groups.
- Two “sites of insertion” which were mandibular first/
second molars contact point site and mesial aspect of
mandibular second molar. The coronal plane in the
sagittal view was moved mesio-distally to adjust the site
of insertion just like when measuring the MBS slope.
- Three “vertical levels” which were 3, 5 and 7mm apical
to alveolar bone crest between mandibular first and
second molars. Adjustment of vertical levels was done
by moving the axial plane in the sagittal view corono-
apically (Fig. 5).
- Three “insertion angles” (Fig. 6) which were 70 , 75 and
80 to the axial plane. Determination of insertion angle
was done by drawing the “orthodontic anchoring screw
insertion path” (green line in Fig. 6) with an angle of
desired degree to the axial plane.
After adjusting the site of insertion, vertical level and
insertion angle, the cortical bone thickness (green line in
Fig. 7) was measured from the intersection of the axial
plane and the MBS outline to the innermost of the cortical
bone along the OAS insertion path.
3. The distance from molar root (Fig. 8).
The distance from molar root was defined as the shortest
distance from the root drawn perpendicularly to the OAS
insertion path (green line in Fig. 8). Similar to the cortical
bone thickness, this measurement was also made at 18
different combinations of three variables for both hyper-
divergent and normodivergent groups. For the mandibular
first/second molars contact point site, this distance was
measured from distal root of the first molar. This was to
ensure that the OAS would not be in contact with the root
during distalization. For the mesial aspect of mandibular
second molar site, this measurement was made from the
mesial root of second molar to ensure that the OAS would
not be in contact with the root and cause root injury while
inserting. According to Lin [9], the recommended diameter
of MBS orthodontic anchoring screw is 2mm and the
periodontal ligament space width was reported to be
between 0.15 and 0.21mm [19]. Therefore, in order to avoid
root contact with OAS during insertion or distalization, a
distance of at least half of the diameter of OAS plus the
periodontal ligament space width, which was 1.21mm
(rounded up to 1.5mm), should be available.

Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
ODW 286 No. of Pages 13

4 orthodontic waves xxx (2018) xxx –xxx

Fig. 2 – Orientation of CBCT image in the axial view. The sagittal plane (pink line) passed through central grooves of molars. (For
interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

2.1. Statistical analysis
All statistical analyses were performed with SPSS 22.0 (IBM
Corp, Armonk, NY, USA). Ten samples were randomly selected
and re-measured with 2-week interval. Intra-class correlation
(ICC) was used to assess intra-examiner reliability. Kolmogor-
ov–Smirnov test was applied to determine the normality of the
data. Comparison of the MBS slope between Class III hyper-
divergent and normodivergent groups at different sites as well
as the comparison of cortical bone thickness between the two
groups at different sites, vertical levels and insertion angles
were done by the factorial repeated ANOVA.
Descriptive statistics were used to analyze the distance
from the molar root to the OAS insertion path at each
combination of site of insertion, vertical level, insertion angle,
and group. A factorial repeated ANOVA was used to find the
effect of these four factors on the distance from the molar root.
The results were evaluated at the p<0.05 significance level,
with a 95% confidence interval.
3. Results
Intra-class correlation analysis showed a good intraexaminer
reliability, with a value of 0.854–0.942 for all measurements. All
data were normally distributed. There were no statistically
significant differences between groups regarding age, sex and
sagittal skeletal relationship. However, subjects in the hyper-
divergent group showed a significantly higher PP-MP angle
compared to the normodivergent subjects (Table 1).
Table 2 showed the means (SD) of the MBS slopes at
different sites of insertion of the two groups. No interaction
was found between the groups and the sites of insertion
(p=0.608). The slope of the MBS was not significantly different
between the hyperdivergent and normodivergent groups
(p=0.615). However, among the sites of insertion, the MBS
slopes were significantly different (p<0.001). The slope of more
posterior sites was flatter than that of the anterior sites
(Table 3).
Table 4 showed the means (SD) of cortical bone thickness
at different sites of insertion, vertical levels and insertion
angles of the two groups. While the groups had no interaction
with any other factors and their effects were also negligible
(p=0.925), we found a statistically significant three-way
interaction among sites, vertical levels and insertion angles
(p=0.009). Thus, the effect of one factor at each combination of
the remaining factors was evaluated. The cortical bone
thickness, when analyzed at the vertical level of 3 and
5mm, was not different between first/second molars contact
point and mesial aspect of second molar sites of insertion at

Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
ODW 286 No. of Pages 13

orthodontic waves xxx (2018) xxx –xxx 5

Fig. 3 – Orientation of CBCT image in the sagittal view. The axial plane (blue line) passed through first molars and first premolars
occlusal contact points. (For interpretation of the references to color in this figure legend, the reader is referred to the web
version of this article.)

Fig. 4 – Measurement of the slope of the MBS at four different sites of insertion. The coronal plane (vertical yellow line) in the
sagittal view (upper row) was moved mesio-distally to the desired site of insertion, which were distal aspect of mandibular first
molar (A), mandibular first/second molars contact point (B), mesial aspect of the mandibular second molar (C) and middle aspect
of the mandibular second molar (D). The slope of the mandibular buccal shelf was the angle formed by a line tangent to the MBS
and the axial plane in the coronal view (an angle formed by two yellow lines in images on the lower row). (For interpretation of
the references to color in this figure legend, the reader is referred to the web version of this article.)

Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
ODW 286 No. of Pages 13

6 orthodontic waves xxx (2018) xxx –xxx

Fig. 5 – Adjustment of the vertical level. The axial plane (purple horizontal line) in the sagittal view was moved corono-apically to
the desired vertical level, which were three millimeter apical to alveolar bone crest (A), five millimeter apical to alveolar bone
crest (B) and seven millimeter apical to alveolar bone crest (C). (For interpretation of the references to color in this figure legend,
the reader is referred to the web version of this article.)

Fig. 6 – Determination of the insertion angle by drawing an orthodontic anchoring screw insertion path (green line) with an
angle of desired degree to the axial plane (horizontal line), which were 70 (A), 75 (B) and 80 (C). (For interpretation of the
references to color in this figure legend, the reader is referred to the web version of this article.)

any insertion angle. However, at the 7mm vertical level, the
cortical bone thickness at first/second molar contact point site
was significantly less than at mesial aspect of second molar
site at every insertion angle (Table 5). Both vertical levels and
insertion angles had a statistically significant effect on cortical
bone thickness in which the higher number of these factors
yielded the thicker cortical bone (Tables 6 and 7).
With respect to the distance from molar roots, the insertion
angles had no interaction with any other variables. It was
found that inserting at higher angles resulted in higher
distance than at lower ones (p<0.001). Three-way interactions
were found among sites, vertical levels, and groups (p=0.036).
The mesial aspect of second molar site gave a longer distance
than first/second molar contact point site at any combination
of group and vertical level (Table 8). Higher vertical levels
resulted in an increased distance than lower ones in any
combination of group and site (Table 9). However, there were
no differences of distance from molar root between hyper-
divergent and normodivergent groups at almost of all
combinations of sites and vertical levels. Yet, hyperdivergent
subjects revealed a significantly shorter distance from molar
root than normodivergent subjects at the combination of
mesial aspect of second molar site and vertical level of 7mm
(Table 10). Nonetheless, at the vertical level of 7mm, both
groups gave far more than 1.5mm distance which is supposed
to be adequate for a safe OAS placement. Thus, we combined
the two groups for descriptive statistics (Table 11). Eleven out
of 18 combinations gave a distance higher than 1.5mm from
the molar root.
4. Discussion
4.1. Slope of the MBS
We found that the MBS slope between Class III hyperdivergent
and normodivergent subjects was not significantly different.
This suggests that placing the MBS orthodontic anchoring
screw in both groups should have a comparable difficulty. The
slope of the MBS is critical to the OAS placement since it is
easier to insert the OAS on a flatter MBS [9], especially when the
clinician tries to place it as perpendicular to the occlusal plane
as possible. Our results suggest that the MBS slope had a flatter
trend toward the posterior area with statistically significant
differences among all sites. This was consistent with previous
studies [7,9].

Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
ODW 286 No. of Pages 13

orthodontic waves xxx (2018) xxx –xxx 7

Fig. 7 – Measurement of the cortical bone thickness of the mandibular buccal shelf (green line). (For interpretation of the
references to color in this figure legend, the reader is referred to the web version of this article.)

The standard deviations of the slopes were relatively high
for each site we measured, ranging from as low as 8.40mm at
distal aspect of first molar to the highest of 11.60mm at middle
aspect of second molar. This finding seems to support the
statement of Lin [9] who noted that the slope of the MBS greatly
varies between different individuals.
4.2. Cortical bone thickness
Our results revealed that the cortical bone thickness was not
different between Class III hyperdivergent and normodiver-
gent group at any site, vertical level and insertion angles. A
recent study [14] reported results different from ours. These
authors found that mandibular buccal cortical bone at all
interradicular sites from canine to second molar of normodi-
vergent subjects was thicker than in hyperdivergent subjects.
Our results were more similar to the following studies. First,
Masumoto et al. [20] found the buccal cortical bone thickness
to be significantly different between hyperdivergent and
normodivergent groups only at two out of nine vertical levels
of the mid-second molar site. Second, Swasty et al. [21]
reported the cortical bone thickness at first and second
mandibular molars of long-faced and average-faced subjects
to be not statistically different. A possible explanation for the
differences in results may be because we were able to use only
PP-MP as the criteria for vertical skeletal classification due to
small field of view of our CBCT images. The other two studies
[14,21] used different criteria, such as SN-mandibular plane,
FMA and gonial angle. Another reason was that we measured
the cortical bone thickness at different angulations to the
occlusal plane. These measurements were more perpendicu-
lar to the occlusal plane compared to other studies that
measured in a more horizontal direction. It is obvious that the
thickness of the cortical bone is a crucial parameter for a
successful placement of OASs. Motoyoshi et al. [22] suggested
that a cortical bone thickness of more than one millimeter was
essential for a success rate of 6 months. The cortical bone
thickness we found ranged from 3.270.69 to 6.372.48mm.
This thickness appears to be adequate for a success rate of at
least 6 months.
The cortical bone at the mesial aspect of the second molar
site was thicker than that of the first/second molar contact
point site only at 7mm vertical level. This diverts somewhat
from data presented previously in which the authors described
thicker bone at all vertical levels (3, 5 and 7mm) [7]. Our results
showed that the cortical bone thickness significantly in-
creased at the more apical area, and this was apparent at all
combinations of site and insertion angle. Ono et al. [13]
measured the shortest cortical bone thickness between first
and second mandibular molars at 15 vertical heights with a
1mm interval and reported similar results to ours as the
cortical bone tended to be thicker as the height increased.
However, Deguchi et al. [18] angulated the OAS at 45 and did
not find a significant difference in the buccal cortical bone

Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
ODW 286 No. of Pages 13

8 orthodontic waves xxx (2018) xxx –xxx

Fig. 8 – Measurement of the distance from molar root to OAS insertion path.

Table 1 – Comparisons of general information of subjects Table 2 – Slope of the MBS at different sites of insertion
in hyperdivergent and normodivergent groups. between hyperdivergent and normodivergent groups.

Hyperdivergent Normodivergent p-value Site Hyperdivergent Normodivergent

a
Age 23.65 25.85 0.417 Distal aspect of first molar 64.20 8.84 63.41 8.14
Sex 11:9 8:12 0.342c First/second molars 55.47 11.26 54.96 8.20
(male:female) contact point
Wits 9.25 7.37 0.076a Mesial aspect of second 49.24 11.84 46.92 8.65
PP-MP 31.48 22.29 <0.001b molar
a Middle aspect of second 41.79 13.65 39.31 9.31
Independent t-test showed no statistically significant difference.
b molar
Independent t-test showed statistically significant difference.
c
Chi-square test showed no statistically significant difference. The data are expressed as mean degree (SD).
Factorial repeated ANOVA revealed no interaction between groups
and sites of insertion (p =0.608) and no differences in the slope of the
MBS at any site of insertion between hyperdivergent and normo-
thickness at the occlusal level and apical level. The effect of
divergent groups (p =0.615).
insertion angles was in the same trend as vertical levels. As the
insertion angle increased, the cortical bone thickness mea-
sured along the OAS insertion path also increased. Deguchi
et al. [18] reported a significant difference in the buccal cortical
bone thickness at the angulation of 30 , 45 and 90 to the tooth lower molars is the final goal. Nucera et al. [15] stated that
long axis in which angling at 30 gave a 1.5 times higher cortical buccal bone thicker than 5mm was adequate for placement of
bone contact. Inaba [23] also revealed that the implant-cortical OASs that were inserted perpendicular to occlusal plane and
bone contact was higher when placing the OAS with more considered to be a suitable placement site. They found that at
angulation to cortical bone surface. 11mm below the CEJ of the mandibular second molars, a
thicker buccal bone was present than at 6mm, and recom-
4.3. Distance from molar root mended to place at the former vertical level. However, our
criteria for a safe placement of MBS orthodontic anchoring
Placement of MBS orthodontic anchoring screws with no root screws differs from their criteria. We determined the distance
contact is essential when a successful distalization of the from molar root to the OAS insertion path. Our criteria seems

Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
ODW 286 No. of Pages 13

orthodontic waves xxx (2018) xxx –xxx 9

Table 3 – Comparison of the slope of the MBS at different sites of insertion.

Site Distal aspect First/second molars Mesial aspect of Middle aspect of
of first molar contact point second molar second molar
Slope of the MBS 63.81 8.40 55.21 9.72 48.0810.30 40.5511.60

Since the slope of the MBS of the hypodivergent and normodivergent was not different, the data was pooled together to find if the slope was
different among sites.
The results were statistically significant different among all sites (p <0.001).

Table 4 – Cortical bone thickness at different sites of insertion, vertical levels and insertion angles between hyperdivergent
and normodivergent groups.

Site Vertical level Insertion angle Hyperdivergent Normodivergent


First/second molars contact point 3 mm 70 3.27 0.69 3.36 0.95
75 3.70 0.99 3.65 0.89
80 4.28 1.27 4.19 0.99
5 mm 70 3.91 1.04 3.80 0.95
75 4.28 1.15 4.11 1.09
80 5.15 1.68 4.62 1.41
7 mm 70 4.37 0.96 4.39 1.25
75 4.85 1.09 4.89 1.82
80 5.55 1.60 5.81 2.17
Mesial aspect of second molar 3 mm 70 3.51 0.91 3.38 1.00
75 4.05 1.11 3.64 1.04
80 4.36 1.15 3.90 1.17
5 mm 70 3.98 0.84 3.90 1.19
75 4.32 0.84 4.30 1.46
80 4.87 1.16 4.79 1.89
7 mm 70 4.46 0.90 4.75 1.68
75 4.99 1.09 5.43 2.13
80 5.99 1.93 6.37 2.48

The data are expressed as mean millimeters (SD).

Factorial repeated ANOVA revealed that cortical bone thickness was not different between hyperdivergent and normodivergent at any
combination of sites of insertion, vertical levels and insertion angles (p =0.925).

Table 5 – The effect of sites of insertion on cortical bone thickness at each combination of vertical level and insertion angle.
Vertical level Insertion angle Mean difference Standard error p-value
(first/second molars contact point site
mesial aspect of second molar site)
3 mm 70 0.135 0.122 0.274
75 0.166 0.135 0.226
80 0.097 0.112 0.394
5 mm 70 0.092 0.102 0.374
75 0.114 0.121 0.354
80 0.048 0.11 0.780
7 mm 70 0.311 0.167 0.036*
75 0.339 0.133 0.015*
80 0.496 0.173 0.007*
*
Repeated ANOVA showed a statistically significant difference (p < 0.05).
The mean differences are expressed in millimeters (SD).

to be more suitable for finding the root-contact-free site when
the MBS orthodontic anchoring screw is inserted with an
angulation that is not perpendicular to the occlusal plane.
The distance from molar root was not different between
Class III hyperdivergent and normodivergent groups except
when placing at 7mm vertical level on mesial aspect of second
molar site. Under these conditions, both groups gave more
than 1.5mm of distance from molar root which should be safe
for MBS orthodontic anchoring screw placement.
Factors that highly affected the distance from molar roots
were sites, vertical levels, and insertion angles. The mesial
aspect of the second molar seemed to be a more suitable site
for insertion of the MBS orthodontic anchoring screw as it gave
a greater distance than placing at first/second molar contact

Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
ODW 286 No. of Pages 13

10 orthodontic waves xxx (2018) xxx –xxx

Table 6 – The effect of vertical levels on cortical bone thickness at each combination of site of insertion and insertion angle.
Site Insertion angle Vertical Vertical Mean difference Standard error p-
level 1 level 2 (vertical level 1 vertical level 2) value
First/second molars 70 3 mm 5 mm 0.538 0.100 <0.001*
contact point
3 mm 7 mm 1.069 0.168 <0.001*
5 mm 7 mm 0.531 0.122 <0.001*
75 3 mm 5 mm 0.519 0.095 <0.001*
3 mm 7 mm 1.196 0.217 <0.001*
5 mm 7 mm 0.677 0.174 0.001*
80 3 mm 5 mm 0.648 0.146 <0.001*
3 mm 7 mm 1.449 0.270 <0.001*
5 mm 7 mm 0.801 0.217 0.002*
Mesial aspect of 70 3 mm 5 mm 0.494 0.123 0.001*
second molar
3 mm 7 mm 1.156 0.210 <0.001*
5 mm 7 mm 0.661 0.142 <0.001*
75 3 mm 5 mm 0.467 0.141 0.006*
3 mm 7 mm 1.369 0.273 <0.001*
5 mm 7 mm 0.901 0.173 <0.001*
80 3 mm 5 mm 0.697 0.181 0.001*
3 mm 7 mm 2.043 0.317 <0.001*
5 mm 7 mm 1.346 0.213 <0.001*
*
Repeated ANOVA showed a statistically significant difference (p <0.05).
The mean differences are expressed in millimeters (SD).

Table 7 – The effect of insertion angles on cortical bone thickness at each combination of site of insertion and vertical level.
Site Vertical level Insertion Insertion Mean difference Standard error p-
angle 1 angle 2 (insertion angle 1 insertion angle 2) value
First/second molars 3 mm 70 75 0.363 0.061 <0.001*
contact point
70 80 0.921 0.096 <0.001*
75 80 0.558 0.057 <0.001*
5 mm 70 75 0.345 0.036 <0.001*
70 80 1.031 0.109 <0.001*
75 80 0.687 0.093 <0.001*
7 mm 70 75 0.490 0.088 <0.001*
70 80 1.301 0.148 <0.001*
75 80 0.811 0.106 <0.001*
Mesial aspect of 3 mm 70 75 0.394 0.087 <0.001*
second molar
70 80 0.689 0.066 <0.001*
75 80 0.295 0.096 0.012*
5 mm 70 75 0.367 0.056 <0.001*
70 80 0.892 0.113 <0.001*
75 80 0.525 0.085 <0.001*
7 mm 70 75 0.607 0.078 <0.001*
70 80 1.576 0.169 <0.001*
75 80 0.969 0.129 <0.001*
*
Repeated ANOVA showed a statistically significant difference (p <0.05).
The mean differences are expressed in millimeters (SD).

point site regardless of different vertical levels or groups
(Table 8). Our results showed that a higher distance from molar
root could be achieved by increasing the vertical level and
insertion angle. Nevertheless, increasing these two factors
should be done with considerations. The average width of
attached gingiva at first and second molar site was reported to
be 3–4mm [24]. Placing at the 5 or 7mm vertical level, the OAS
might have a higher chance of ending up in a movable tissue.
Due to a higher probability of inflammation, this resulted in a
lower success rate than placed in firm gingival tissue [25,26].
Yet, Chang et al. [8] reported a similar 4-month failure rate of
MBS orthodontic anchoring screw placed in either movable
mucosa (7.31%) or attached gingiva (6.85%). They concluded
that as long as there was at least 5mm soft tissue clearance

Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
ODW 286 No. of Pages 13

orthodontic waves xxx (2018) xxx –xxx 11

Table 8 – The effect of sites of insertion on distance from molar root at each combination of group and vertical level.
Group Vertical level Mean difference Standard error p-value
(first/second molars contact point site
mesial aspect of second molar site)
Hyperdivergent 3 mm 1.542 0.265 <0.001*
5 mm 1.797 0.245 <0.001*
7 mm 2.009 0.264 <0.001*
Normodivergent 3 mm 1.743 0.265 <0.001*
5 mm 2.426 0.245 <0.001*
7 mm 2.546 0.264 <0.001*
*
Repeated ANOVA showed a statistically significant difference (p < 0.05).
The mean differences are expressed in millimeters (SD).

Table 9 – The effect of vertical levels on distance from molar root at each combination of group and site of insertion.
Group Site Vertical level 1 Vertical level 2 Mean difference Standard error p-
(vertical level 1 vertical level 2) value
Hyperdivergent First/second molars 3 mm 5 mm 1.638 0.120 <0.001*
contact point
3 mm 7 mm 3.182 0.200 <0.001*
5 mm 7 mm 1.544 0.121 <0.001*
Mesial aspect of 3 mm 5 mm 1.893 0.144 <0.001*
second molar
3 mm 7 mm 3.649 0.204 <0.001*
5 mm 7 mm 1.756 0.102 <0.001*
Normodivergent First/second molars 3 mm 5 mm 1.596 0.120 <0.001*
contact point
3 mm 7 mm 3.425 0.200 <0.001*
5 mm 7 mm 1.829 0.121 <0.001*
Mesial aspect of 3 mm 5 mm 2.279 0.144 <0.001*
second molar
3 mm 7 mm 4.228 0.204 <0.001*
5 mm 7 mm 1.949 0.102 <0.001*
*
The repeated ANOVA showed statistically significant difference (p < 0.05).
The mean differences are expressed in millimeters (SD).

Table 10 – The effect of groups on distance from molar root at each combination of site of insertion and vertical level.
Site Vertical level Mean difference Standard error p-value
(hyperdivergent group
normodivergent group)
First/second molars contact point 3 mm 0.224 0.419 0.597
5 mm 0.181 0.439 0.682
7 mm 0.466 0.430 0.286
Mesial aspect of second molar 3 mm 0.424 0.469 0.371
5 mm 0.811 0.438 0.072
7 mm 1.003 0.414 0.020*
*
The repeated ANOVA showed statistically significant difference (p < 0.05).
The mean differences are expressed in millimeters (SD).

from the OAS head, the OAS could be positioned in any type of
gingiva. Moreover, placing at 7mm might achieve too thick
cortical bone which might lead to overtorquing the OASs and a
reduced success rate [27–29]. This could be prevented by using
a pilot drill with a proper diameter size and length [28]. The
insertion angle of 80 might prone to slippage during insertion
in a patient with steep MBS. Finally, we found 11 of 18
combinations that gave more than 1.5mm of distance from
molar root (Table 11). These combinations can be considered
as a guide for placement of MBS orthodontic anchoring screws.
Therefore, clinicians should evaluate each individual's MBS
slope and amount of attached gingiva and select the most
appropriate site, vertical level and insertion angle for insertion
of MBS orthodontic anchoring screws.

Please cite this article in press as: S. Parinyachaiphun, et al., Considerations for placement of mandibular buccal shelf orthodontic
anchoring screw in Class III hyperdivergent and normodivergent subjects– A cone beam computed tomography study, Orthod Waves
(2018), https://doi.org/10.1016/j.odw.2018.01.001
ODW 286 No. of Pages 13

12 orthodontic waves xxx (2018) xxx –xxx

Table 11 – Distance from molar root of each combination of site of insertion, vertical level and insertion angle.
Site Vertical level Insertion angle Combination Clearance from molar root (mm)

MeanSD Minimum Maximum

First/second molars contact point 3mm 70 1 0.89 1.40 4.09 2.89
75 2 0.20 1.28 3.13 3.00
80 3 0.46 1.29 2.22 3.61
5mm 70 4 0.86 1.42 2.03 4.58
75 5 1.44 1.37 1.31 5.05
80 6 1.93 1.36 0.74 5.44
7mm 70 7 2.71 1.41 0.37 6.18
75 8 3.08 1.36 0.38 6.45
80 9 3.49 1.34 1.07 6.80
Mesial aspect of second molar 3mm 70 10 0.94 1.57 1.78 5.85
75 11 1.46 1.49 1.34 6.17
80 12 1.89 1.43 1.04 6.45
5mm 70 13 3.22 1.50 0.62 7.39
75 14 3.53 1.41 1.06 7.57
80 15 3.80 1.39 1.33 7.72
7mm 70 16 5.16 1.47 2.52 8.93
75 17 5.40 1.41 2.90 8.92
80 18 5.55 1.32 2.99 8.79

The data are expressed as mean millimeters (SD).

Further study should include higher number of subjects

with larger field of view of CBCT images. This will allow Ethical approval
assessment of sagittal and vertical skeletal pattern using
other parameters, such as ANB and SN-MP. In addition, This study was approved by the Ethics Committee of the
since this study have already reported the slope of the MBS Faculty of Dentistry, Chulalongkorn University under approval
in Class III hyperdivergent and normodivergent subjects, number HREC-DCU 2017-080.
further studies investigating the slope of the MBS in Class
III hypodivergent or other type of subjects would be
valuable. Conflicts of interest

5. Conclusions The authors declare that they have no conflicts of interest.

1.
Between Class III hyperdivergent and normodivergent
subjects, no differences were found for slope and cortical
bone thickness of the mandibular buccal shelf.
2. A similar distance from cortical bone to molar root was
found between subjects with Class III hyperdivergent and
normodivergent. This was apparent with any combination
of site, vertical level and insertion angle, except for a
combination of mesial aspect of second molar and vertical
level of 7mm in which the distance was higher in the
normodivergent group.
3. Increasing the vertical level or insertion angle resulted in a
higher cortical bone thickness and distance from molar
root.
4. The mesial aspect of the mandibular second molar was a
safe site for placement of mandibular buccal shelf
orthodontic anchoring screw as its slope was flatter and
gave more distance from molar root than the first/second
molar contact point site.
Acknowledgement
We would like to express our gratitude to Prof. Vincent Everts
for a dedicated revision of our English manuscript. This study
was supported by The Faculty Research Grant (Grant number
DRF 61001), Faculty of Dentistry, Chulalongkorn University.
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(2018), https://doi.org/10.1016/j.odw.2018.01.001
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