ORIGINAL ARTICLE

Success of infrazygomatic crest bone

screws: patient age, insertion angle, sinus
penetration, and terminal insertion
torque
Chris H. Chang,a Jia-Hong Lin,a and W. Eugene Robertsb
Hsinchu, Taiwan, Indianapolis, Ind, Loma Linda, Calif, and St Louis, Mo

Introduction: The aim of this study was to assess the 6-month survival (success) rate for infrazygomatic crest
(IZC) bone screws relative to patient age, insertion angle, sinus penetration, and terminal insertion torque.
Methods: One hundred consecutive patients (27 males, 73 females; mean age 25.8 years; age range,
11.0-53.8 years) received IZC temporary anchorage devices (TADs) bilaterally (n 5 200). Each TAD was routinely
loaded with up to 14 oz (397 g or 389 cN), reactivated monthly, and followed for 6 months. Terminal insertion tor-
que was measured, and radiographs were assessed to determine the length of the TAD engaged in bone and
depth of penetration into the maxillary sinus. Results: Compared with nonpenetrating IZC TADs, the mean results
for the 96 (48%) TADs that did penetrate the sinus were: 3.23 mm of sinus penetration, 21.3% decrease in terminal
insertion torque, and 31.5% less bone contact at the TAD osseous interface. Perforation prevalence increased
with age from 35.7% (11-19 years) to 62.5% (.30 years) (P \0.01). Terminal insertion torque increased from
11-19 years to 20-29 years because of increasing bone density with age but then decreased at .30 years
because of increased incidence of sinus penetration (P \0.05). Sinus penetration had no significant effect on
IZC TAD survival. About 5% of the devices did fail when the final insertion torque was significantly (P \0.05)
decreased to 7.37 N-cm compared with the mean torque of 11.63 N-cm for successful TADs. Conclusions:
Both sinus perforation and IZC bone quality increased with age. Sinus penetration did not significantly affect
the 6 month survival rate of IZC TADs because the loss of bone quantity at the interface was offset by the age-
related increase in bone quality at the IZC site. (Am J Orthod Dentofacial Orthop 2022;161:783-90)

S
keletal anchorage was a major advance in the
1990s1,2 that largely offset the need for extraoral
anchorage.3 Temporary anchorage devices (TADs)
provide firm osseous anchorage, but they may move
within supporting bone.4 Clinical procedures and TAD
specifications that affect movement within bone and de-
vice failure are unclear. TADs have proven effective for
retraction of the arches, require minimal patient compli-
ance, and are readily removed after completion of treat-
ment.5,6 Terminal insertion torque is a reliable index for
a
Private practice, Hsinchu, Taiwan.
b
Indiana University and Purdue University, Indianapolis, Ind; and Loma Linda
University, Loma Linda, Calif; and Saint Louis University, St Louis, Mo.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Jia-Hong Lin, 4400 Spruce St, Apt D5, Philadelphia,
PA 19104; e-mail, alexlinjh@gmail.com.
Submitted, October 2020; revised and accepted, January 2021.
0889-5406/$36.00
Ó 2022.
https://doi.org/10.1016/j.ajodo.2021.01.028
bone quality (density and osseous contact) at an implant
interface.7,8
Interradicular TADs are commonly inserted between
the roots of teeth,9-11 but infrazygomatic crest (IZC)
bone screws (BS) are extraalveolar devices placed
buccal to the roots of the maxillary molars.12-14
Extraalveolar TADs are designed to avoid interfering
with the path of tooth movement, particularly during
arch retraction.15 Increased cortical bone engagement16
is directly related to the terminal insertion torque that
provides stability to anchor retraction of entire arches.17
Adults commonly require intermaxillary correction, so
reliable extraalveolar TADs for patients aged .30 years
are a priority.15 Patients with \6 mm of alveolar bone
thickness inferior to the floor of the sinus are susceptible
to perforation with $ 8 mm IZC TADs.12,14 The relation-
ship of sinus penetration to IZC TADs stability and fail-
ure is unknown.
Kravitz and Kusnoto18 reported that a small penetra-
tion (\2 mm) through the Schneiderian membrane heals
783
784 Chang, Lin, and Roberts

Fig 1. A, Ideal insertion site (pink) is shown for IZC TAD. B, A TAD is placed at the IZC eminence on the
buccal aspect of the posterior maxillary alveolar process. C, The maxillary sinus is medially adjacent to
the IZC TAD site.

Fig 2. Design specifications for IZC TADs

spontaneously. Bicortical engagement with the floor of
the sinus is thought to enhance postoperative stability
for dental implants.19,20 Jia et al. suggested the same
for TADs,21 recommending a penetration of \1 mm
into the sinus as optimal.
Compared with adolescents, adults usually have a
higher quality bone (ie, increased density and a lower
turnover rate). However, the maxillary sinuses of adults
are larger,22 so sinus penetration for TADs is more likely.
The purpose of this research is to investigate IZC TADs
survival (success) relative to patient age, TAD insertion
angle, sinus perforation, and terminal insertion torque.
The hypothesis is sinus perforation does not affect
the 6mo survival rate or the insertion torque for 2 3
12-mm IZC TADs.
MATERIAL AND METHODS
A comprehensive evaluation of IZC TAD survival (suc-
cess) was approved by an Institutional Review Board
(Institutional Review Board approval No. 1607517021).
One hundred consecutive patients requiring bilateral
IZC anchorage were retrospectively sampled. The total
sample was 200 consecutive 2 3 12-mm stainless-
steel (SS) OrthoBoneScrews (Newton A, HsinChu City,
Taiwan) that were placed bilaterally in the IZCs of 27
males and 73 females with a mean age of 25.8 years
(range, 11.0-53.8 years).
All TADs were placed buccal to the roots of the maxil-
lary molars (Fig 1) by one experienced clinician
according to a well-established clinical protocol.13
Each self-drilling TAD (Fig 2) was inserted perpendicular
to the approximately 1-mm-thick cortical plate. As the
cortex was penetrated, the TAD was gradually rotated
50 -60 to the occlusal plane (Figs 3, A-C). The final po-
sition of the screw head was about 5 mm superficial to
the soft tissue, which was near the level of the gingival
crest (Fig 4). According to the specific treatment
plan, prestretched power chains with a force range of
8-14 oz (227-397 g or 223-389 cN) were attached
immediately and reactivated every month.13,23
A dedicated torque tester (Newton) measured the
maximum insertion torque during the terminal rotation
to achieve the desired position. A CBCT (3D eXam plus,

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Chang, Lin, and Roberts 785


Fig 3. A, 90 orientation of the IZC TAD is shown at the start of the installation procedure. B, The
approximately 1-mm bone plate is penetrated on the buccal surface. C, The axial inclination of the
TAD is progressively increased about 50 -60 as it is screwed into place.

Fig 4. A, 1M: Right buccal view of a full cusp Class II malocclusion at the initiation of maxillary retrac-
tion with IZC anchorage. B, 7M: Progress after 6 mo of maxillary retraction. C, 14M: Progress after 13
mo of maxillary retraction. D, 17M: Class I molar relationship is achieved after 16 mo of maxillary retrac-
tion with IZC TAD anchorage.

KaVo Dental, Biberach, Germany) image captured imme- RESULTS

diately after placement was used to evaluate the inci-
dence and amount of sinus penetration or perforation
(Fig 5). If a perforation was evident, prophylactic antibi-
otics were administered: 250 mg of oral amoxicillin every
8 hours for 3 days. There were no signs or symptoms of
TADs contacting the roots of adjacent teeth for any of
the patients sampled. Measurements included: (1) depth
of penetration into the sinus (if any), (2) length of the
screw surface in contact with bone (osseous interface),
and (3) insertion angle of the TAD relative to the maxil-
lary first molar axis and the occlusal plane. Survival of
IZC TAD anchorage was followed for 6 months. The
data were analyzed with a 2-tailed Student t test and a
chi-square test. Probability (P \0.05) was the minimum
level of significance for mean differences between
groups.
None of the patients showed clinical signs of sinusitis
after TAD placement. The Table shows that 96 of 200
IZC TADs (48%) perforated the maxillary sinus. The final
insertion torque for TADs perforating the sinus floor was
9.97 N-cm compared with 12.67N-cm for those that did
not enter the sinus (P \0.001). Perforating TADs had
5.17 mm of linear bone contact than 7.55 mm for non-
perforating TADs (P \0.001). Overall, bone contact was
significantly greater (P \0.01) on the right (6.88 mm)
than on the left side (5.95 mm). The length of the TAD
tip penetrating the sinus was a mean of 3.23 mm, but
there was no significant difference between the right
(3.63 mm) and left (2.63 mm) sides. Angulation of
the TAD to the first molar root was significantly
(P \0.001) greater for all IZC TADs placed on the right

American Journal of Orthodontics and Dentofacial Orthopedics June 2022  Vol 161  Issue 6
786 Chang, Lin, and Roberts

Fig 5. A, A CBCT slice reveals the position of an IZC TAD. The length of the screw engaged in the bone
(LB) was measured (blue). The angle (a) is delineated between the IZC TAD axis (red) and the maxillary
first molar axis (green); the angle (b) is shown relating the IZC TAD axis to the occlusal plane (orange).
B, A CBCT slice of an IZC TAD perforating into the maxillary sinus. The length of the penetration portion
of the screw (LS) was measured (pink) in addition to the other parameters listed above.

Table. Baseline characteristics of IZC miniscrews: left vs right and perforation vs no perforation
Total Perforation No Perforation

Perforation No Perforation Left Right Left Right Left Right

Characteristics n 5 96 n 5 104 n 5 100 n 5 100 n 5 58 n 5 38 n 5 42 n 5 62

Torque mean (N-cm) 9.97 12.67*** 11.05 11.70 9.71 10.37 12.90 12.53
Perforation depth mean (N-cm) 3.23 - - 3.63 2.63 - -
Angle to maxillary first molar mean ( ) 30.71 32.61 29.61 33.80*** 29.19 32.97 30.16 34.31
Angle to occlusal plane mean ( ) 56.05 55.94 57.98 54.01** 57.65 53.66 58.42 54.23
Bony contact mean (mm) 5.17 7.55*** 5.95 6.88** 4.91 5.55 7.33 7.70

**P \0.01; ***P \0.001.

(33.8 ) than the left side (29.6 ). Angulation to the
occlusal plane was significantly greater (P \0.01) on
the left (58.0 ) than on the right side (54.0 ) (Table).
There was an inverse relationship between terminal
torque levels and depth of sinus penetration (Fig 6).
The perforation rate was significantly related to age:
$30 years (62.5%) compared with 20-29 years (46.6%;
P \0.05) and 11-19 years (35.7%; P \0.01). Terminal
torque was significantly (P \0.01) increased only for
the 20-29 year group (12.45 N-cm) (Fig 7). Among the
100 patients, 30 experienced unilateral perforation,
and the mean torque was 1.97N-cm lower (P \0.05)
on the side with the perforation.
Fourteen of the 200 TADs were not assessed 6
months postoperatively because (1) treatment was previ-
ously completed, (2) it was necessary to reposition the
TAD to avoid contact with a bracket, (3) incomplete
records, and (4) patient left the practice (Fig 8). Sinus-
perforating TADs (n 5 87) had a higher (96.55%) but
nonsignificant 6-month survival rate than nonperforat-
ing TADs (94.94%) (n 5 99) (Fig 9). The failed TADs all
showed signs of mobility and were removed or reinserted
at another location. The insertion torque for TADs that
failed was 7.37 N-cm, which was significantly
(P \0.05) lower than for those that survived (11.63
N-cm) (Fig 10). There was no significant relationship be-
tween sinus perforation and IZC TAD failure, but the
insertion torque was significantly decreased for sinus-
penetrating TADs, so the hypothesis was rejected.
DISCUSSION
For maxillary arch retraction, extraalveolar IZC TADs
were preferable to interradicular miniscrews because they
did not interfere with tooth movement.15 2 3 12 mm

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Chang, Lin, and Roberts
Fig. 6. The mean insertion torque for IZC TADs is
inversely related to sinus penetration depth.
TADs were chosen per previous literature.13,21 However,
sinus penetration was a substantial problem for IZC
TADs (48% of the sample). Motoyoshi et al.14 reported
no significant relationship between sinus perforation,
postoperative stability, or failure for 1.6 mm diameter tita-
nium IR miniscrews. Jia et al21 suggested bicortical pene-
tration to enhance clinical success. However, these studies
are either small in sample size or lack measurements for
stability such as insertion torque.
The stability of TADs depends on postoperative sta-
bility and long-term mechanical retention.24-26 The
relatively large (2 mm diameter) TADs in this study
have increased endosseous surface area and a higher
chance of penetration. It also has a much larger, more
diverse sample (n 5 200), with an age range of 11.0-
53.8 years. In addition, sinus perforations were far
more prevalent in the current sample (n 5 96, 48% of
200 TADs). Sinus penetration reduced both the length
of the osseous interface and the terminal seating
torque (Table), but it did not significantly increase the
TAD failure rate (Fig 9). These data suggest that despite
being partly compensated by bicortical stabiliza-
tion,19-21 the substantial loss of bony contact (31.5%)
because of penetration still resulted in a decrease in
insertion torque. Therefore, the evidence suggests
sinus penetration is unnecessary for enhancing primary
stability. However, it does not affect its survival as
long as there’s adequate insertion torque.
None of the present patients reported any adverse
signs or symptoms of sinus perforation, which may be
attributed to the routine use of prophylactic antibiotics.
American Journal of Orthodontics and Dentofacial Orthopedics
787
Fig. 7. The mean insertion torques (gray) are shown rela-
tive to the incidence of perforation rate (red) for patients in
3 age groups. Age 20-29 y had significantly higher inser-
tion torque than patients 11-19 y (*P \0.05). Perforation
rate was significantly greater for patients $30 y (62.5%)
than 20-29 y (46.6%; *P \0.05) and 11-19 y (35.7%;
**P \0.01).
However, small diameter (#2 mm) sinus wounds have
good healing potential,18 so antibiotics may be unneces-
sary for most patients. The previous literature21 showed
an increase in the thickness of the sinus membrane, and
a decrease of the engaged bone was observed in postre-
moval CBCT images. As these radiographs are not
deemed as indicated for our patients, this study cannot
provide data for the long-term effects of sinus penetra-
tion by TADs. An examination of the torque 6 months
after insertion may also shed light on the TAD changes.
The clinician who placed all the TADs for the current
study is right-handed. The TADs on the right side had a
significantly (P \0.05) increased angulation relative to
the first molar roots, which was associated with an
increasing tendency for sinus perforation (Table).
Although sinus penetration was not significantly associ-
ated with TAD failure, it is good practice to strive for a
more uniform, less vertical angulation on both sides to
help control the incidence of sinus perforation, particu-
larly when antibiotics are prescribed.
Decrease in insertion torque and interface bone con-
tact were associated with sinus penetration, but neither
June 2022  Vol 161  Issue 6
788 Chang, Lin, and Roberts

Fig. 8. Flow chart for the study shows patients excluded from survival analysis. See text for details.

Fig. 10. Failed IZC BSs (5%) had significantly lower ter-
Fig. 9. There was no significant difference in the failure minal insertion torque than BSs that survived for 6 mo
rate for sinus-perforating and nonperforating IZC BSs. (*P \0.05).

June 2022  Vol 161  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Chang, Lin, and Roberts
outcome was related to TAD success. Three apparent
compensating factors were bicortical stabilization,19-21
age-related increase in bone quality of the posterior
maxilla,27 and the increased surface area of 2 mm
diameter TADs (Fig 2).
Compared with previous interradicular14 and IZC28
titanium alloy miniscrews (\1.6 mm diameter), the pre-
sent sample of 2 mm diameter SS TADs had a much
higher survival rate (95 vs \80%). Bone quality and
quantity at the endosseous interface are important con-
siderations, but there is no significant advantage of SS
over titanium alloy as a material for TADs.13 Despite a
lower torque level associated with sinus involvement
(Table), the bone quality and quantity at the TAD inter-
face remained adequate to resist failure (Fig 9). The
importance of osseous engagement at the interface for
TAD stability29 was further demonstrated on patients
with unilateral perforation.
Patients aged 19-27 years had a significantly thicker
buccal plate of cortical bone in the posterior maxillary
region than patients aged 13-18 years,27 which ex-
plains the significantly higher torque values at 20-29
years than 11-19 years. Decreased torque levels at
$30 years were due to the increased prevalence of si-
nus perforation (62.5%) associated with larger sinus
volume (Fig 7). There is an age-related increase in the
volume of the maxillary antrum that delineates the
base of the alveolar process by about age 20 years,22,30
which helps explain the increased incidence of sinus
perforation in adults. The thickness of the cortical plate
is related to age,27 so patients .30 years have thicker
cortices and higher quality bone (increased density)31
at the TAD interface. Favorable osseous anatomy helps
compensate for the deceased length of bone contact at
the TAD interface and the lower torque values when the
sinus is penetrated. The outcomes of the present study
demonstrate that sinus perforation does not compro-
mise the success rate for IZC TADs in adults because
bone quality compensates for decreased quantity at
the TAD interface.
CONCLUSIONS
1. The incidence of sinus perforation increases with a
more upright insertion angle of an IZC TAD and in
adults aged .30 years.
2. Terminal insertion torque and bone engagement
decrease with sinus involvement, but they are offset
by the age-related increase in bone quality that
maintains IZC TAD stability.
3. Sinus perforation is an acceptable complication for
2 mm diameter SS TADs because it has no signifi-
cant effect on TAD survival.
American Journal of Orthodontics and Dentofacial Orthopedics
789
AUTHOR CREDIT STATEMENT
Chris H. Chang contributed to conceptualization,
methodology, and manuscript review and editing; Jia-
Hong Lin contributed to original manuscript, formal
analysis, investigation, visualization, and project admin-
istration; and W. Eugene Roberts contributed to super-
vision and manuscript review and editing.
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2021.01.028.
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