Cortical bone thickness and bone density effects on miniscrew success

Accepted Article rates - A systematic review and meta-analysis

Dong-Wook Lee,a Jae Hyun Park,b R. Curtis Bay,c Sung-Kwon Choi,d Jong-Moon Chaee

aPrivate practice, Seoul, Korea

bProfessor and chair, Postgraduate Orthodontic Program, Arizona School of Dentistry & Oral
Health, A.T. Still University, Mesa, Ariz; International Scholar, Graduate School of Dentistry,
Kyung Hee University, Seoul, Korea.
cProfessor, Biostatistics, Department of Interdisciplinary Health Sciences, A. T. Still University,
Mesa, Ariz.
dGraduate student, Department of Orthodontics, School of Dentistry, University of Wonkwang,
Iksan, Korea.
eProfessor, Department of Orthodontics, School of Dentistry, University of Wonkwang,
Wonkwang Dental Research Institute, Iksan, Korea; Visiting Scholar, Postgraduate Orthodontic
Program, Arizona School of Dentistry & Oral Health, A. T. Still University, Mesa, Ariz.

Corresponding Author; Jong-Moon Chae, Department of Orthodontics, School of Dentistry,

Wonkwang University, Daejeon Dental Hospital, 77 Doonsan–ro, Seo-Gu, Daejeon, 302-120,
Korea
Tel ; +82-42-366-1103, Fax ; +82-42-366-1115
E-mail ; jongmoon@wku.ac.kr

Each author's contribution to the submission

1. Dong-Wook Lee; contributed to data collection and writing the article
2. Jae Hyun Park; contributed to critical revision of the article
3. R. Curtis Bay; contributed to the statistical analysis and critical revision of the article
4. Sung-Kwon Choi; contributed to data collection and reviewing the literature
5. Jong-Moon Chae; contributed to supervising overall project and overall responsibility

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/OCR.12453
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 Cortical bone thickness and bone density effects on miniscrew
Accepted Article success rates - A systematic review and meta-analysis

Abstract
Objective: To systematically review the effects of cortical bone thickness (CBT) and bone
mass density (BMD) on miniscrew success rates.
Methods: MEDLINE, the Cochrane Library, and Scopus were searched up to June 2020. Of
a total of 5734 articles, seven studies were finally selected for the review.
Results: The overall mean success rate weighted by the number of miniscrews was 87.21%
(89.87% in the maxilla and 79.24% in the mandible). There was a significantly higher
success rate for miniscrews placed in the maxilla compared with those in the mandible (P
< .05). CBT showed a small positive effect on the success rate of the miniscrews although it
failed to reach a statistical significance. The cortical BMD had a minimal effect on the
success of the miniscrews. The cancellous BMD demonstrated a very strong effect on the
success of the miniscrews in the maxilla, whereas, it showed a moderate negative effect in the
mandible.
Limitations: Because of the small number and clinical heterogeneity of the included studies,
the results should be interpreted with caution. Further randomized clinical studies with a large
sample size are recommended.

KEYWORDS
success rates of miniscrews, cortical bone thickness, bone density, systematic review, meta-
analysis

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Accepted Article
PROFESSOR JAE HYUN PARK (Orcid ID : 0000-0002-3134-6878)

PROFESSOR JONG-MOON CHAE (Orcid ID : 0000-0003-4594-6409)

Article type : Review Article

1. INTRODUCTION
Anchorage being the bedrock of orthodontic treatment, various attempts have been made to
reinforce anchorage in clinical orthodontic situations. Temporary skeletal anchorage devices
(TSADs) such as miniscrews and miniplates have been introduced as a nearly-absolute
anchorage system. They are widely used because with them, skeletal anchorage does not rely
on patient compliance. In particular, miniscews have been reported for a wide range of
clinical applications. They are less invasive, easy to place in various anatomical sites, and
able to withstand forces typically applied in orthodontic treatment.1 However, their relatively
low success rate (83-86.5%) compared to that of miniplates (92.7%)2-4 and dental implants
(91-95%)5 has been a concern for orthodontists. Miniscrew diameters less than 1 mm,2 non-
keratinized gingiva, and smoking3 have been indicated as risk factors in review articles.
The quantity (thickness) and quality (density) of bone have a great influence on the success
rate of a prosthetic implant. Osseointegration is considered crucial for the stability of
prosthetic implants that have to withstand strong intermittent occlusal force over a long time.6
On the other hand, in the case of the miniscrews, they can serve as TSADs with less than 10%
of the bone-implant contact for the constant loading of up to 300g. This enables immediate or
early loading, because initial mechanical locking between the bone and the miniscrew is
considered more important than osseointegration.7 Also, with prosthetic implants, patients are
edentulous, having large variations in CBT or BMD. On the other hand, with orthodontic
miniscrews, the patient population is younger, and the individual variation in bone quantity

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 and quality is relatively small. Regardless of the mentioned difference between miniscrews
Accepted Article
and dental implants, it has also been suggested that CBT and BMD help to determine the
success of a miniscrew. However, many of the studies used either cadavers8 or animals,9,10
and only a few clinical studies with humans11-17 are available. Unfortunately, the results are
conflicting, so despite the growing interest in TSADs, more bone-related study is necessary.
Computed tomography (CT) and cone-beam CT (CBCT) have become widely used due to
their ability to measure oral and maxillofacial structures three-dimensionally. The Hounsfield
units (HU), greyscale values in CT, provide a quantitative assessment of bone density,18
which can be calibrated using the density value of water (0 HU) and air (-1000 HU) as
reference. Its less expensive alternative, CBCT, has been widely employed for oral and
maxillofacial imaging due to advantages such as low radiation dose, quick acquisition time,
good spatial resolution, gray density range, and contrast. However, the greyscale values in
CBCT are relative, making it difficult to compare the results from one machine with those
from another, let alone with HU from CT.19,20
Mah et al21 reported that using the attenuation coefficients of known matters as an
intermediate step, grayscale from CBCT can be converted to HU, with the results
approximating the actual HU from CT. However, without the presence of at least three
known materials (eg. distilled water), it is hard to apply that methodology in clinical settings.
Cassetta et al22 reported that in order to convert greyscale values of CBCT into HU, the
results should be multiplied by a conversion ratio of 0.7. The author admitted, however, that
the conversion ratio may vary depending on the CBCT machine used.
Meta-analyses can combine the outcomes of multiple studies into a single quantitative
variable by integrating the effect size of the individual studies. No study has synthesized the
results from CT and CBCT with meta-analysis, a method that does not require calibration or
conversion of grayscale. The specific purpose of this systematic review was to determine the
overall success rate of miniscrews and relate it to bone quantity (CBT) and quality (BMD).

2. MATERIALS AND METHODS

This systematic review and meta-analysis complies with the Cochrane Handbook for
Systematic Reviews of Interventions and the PRISMA statement.23 Also, this review is
registered by the international prospective register of systematic reviews (PROSPERO).

2.1. Search strategy

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 The following databases were searched.
Accepted Article  PubMed (From Jan 1983 to June 2020)
 Cochrane Library (From Jan 1983 to June 2020)
 Scopus (From Jan 1983 to June 2020)
The keyword was a MeSH combination of ‘orthod’ and either of the followings:
 ‘Miniscrew’ or ‘Mini screw’ or ‘Mini-screw’
 ‘Mini-implant’ or ‘Miniimplant’
 ‘Micro-implant’ or ‘Microimplant’
 ‘Temporary anchorage’ or ‘Temporary anchorage device’ or ‘TADs’ or ‘TAD’
 ‘Skeletal anchorage’ or ‘Bone anchorage’
The reference lists of the included articles and other relevant systematic reviews were
hand-searched to complete the search process. Two reviewers (DW Lee and SK Choi)
independently performed the whole process and Cohen’s kappa statistic was used to assess
the agreement between the two authors. Any potential disagreement was resolved by a third
reviewer (JM Chae).

2.2. Inclusion /exclusion criteria

The inclusion criteria for this systematic review were as follows:
 Human controlled or randomized clinical trials
 Presents the success or failure rate of miniscrews
 Has additional data on CBT or/and BMD available
The exclusion criteria for this systematic review were as follows:
 In vitro studies, animal studies, case reports, and review articles
 Studies restricting population
In the case of unclear study designs, the authors were contacted for further information. If
there was no response from the author, the study was excluded.

2.3. Quality assessment

The quality assessment of the included studies was performed using the Newcastle-Ottawa
Scale (NOS). NOS scores the quality of the studies mainly in the following categories:
 Subject selection
 Comparability between groups
 Outcome measurement

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 It has 9 sub-categories and studies are given either 0 or 1 in each sub-category. The quality
Accepted Article
is considered as low (0−3 points), medium (4−6 points), or high (7−9 points) based on the
total score. Any potential disagreement was resolved with consensus.

2.4. Data extraction

In this review, study characteristics and outcomes were extracted using a customized data
extraction form. The data recorded were as follows: Years of publication, study designs,
number of patients, number of miniscrews, their characteristics, placement methods, loading
methods, forces applied, placement locations, CBTs, greyscale values, radiographic
modalities used, success rates, and failure criteria (Table 1).

2.5. Data synthesis and meta-analysis

Meta-analyses were conducted using Comprehensive Meta-Analysis software (V.3.3.070;
Biostat Inc, Englewood, New Jersey, USA). Random-effects models were used, and
standardized mean differences or odds ratios were reported with 95% confidence intervals.
Heterogeneity, the percentage of variability due to different study designs was assessed using
an I² statistic. An alpha of .05 was used as the criterion for statistical significance. Whenever
possible, the subgroup analysis separating the results of each jaw was performed. Sensitivity
analyses were performed to assess the impact of each study on the combined results. If the
statistical significance of the result was influenced by removing one of the studies, the
removed study was reviewed again to confirm the reason.

2.6. Publication bias

Publication bias was assessed by visually inspecting funnel plot asymmetry. However,
since the nature of this method depends on the subjective impression, Begg’s test and Egger’s
test were also used to objectively detect publication bias of the present meta-analysis.

3. RESULTS
3.1. Search results
A total of 5734 lists were considered; 2889 from MEDLINE, 2553 from Scopus, and 292
from the Cochrane Library. After excluding duplicate articles, a total of 3671 articles were
retrieved. Of these articles, 276 articles were obtained based on titles that related to the
success or failure rate of miniscrew. Again, by checking the abstracts of these papers, 6
articles related to CBT and/or BMD were selected. The reference lists of the included articles
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 and other relevant systematic reviews were hand-searched. Finally, seven studies were
Accepted Article
selected for qualitative analysis in this study. One of the studies was excluded from
quantitative analysis due to the lack of statistical information needed to compute the effect
size (Figure 1).

3.2. Quality assessment

The majority of the included studies had medium quality based on the NOS. There was one
high quality and one low quality study among the included studies (Table 2).

3.3. Miniscrew success rate (Primary outcomes)

A total of seven clinical trials included 484 patients treated with 1009 miniscrews. The
overall mean success rate weighted by the number of miniscrews was 87.21%. The weighted
mean success rate in the maxilla was 89.87%, whereas it was 79.24% in the mandible (Table
3A). Two of the seven studies were excluded from the meta-analysis because they only
looked at miniscrews inserted in the maxilla, so in the meta-analysis of five studies (319
patients, 710 miniscrews), a significantly higher success rate was discovered with miniscrews
placed in the maxilla (P < .05) (Figure 2). The I² test value for the included studies was zero,
indicating that they were statistically homogenous.

3.4. CBT effects on miniscrew success (Secondary outcomes)

In the meta-analysis investigating the difference in cortical bone thickness between the
success and failure groups, a total of four studies included 338 patients treated with 635
miniscrews (Table 3B). One of the seven studies was excluded due to a lack of information
needed to compute the effect size. Two more of the studies were excluded since they only
studied BMD effects. The success group in the remaining study showed a higher overall
cortical bone thickness although it failed to reach a statistical significance (P = .07) (Figure
3A). The sensitivity test revealed that excluding anyone of the studies did not significantly
change the result. A subgroup analysis separating the results of the maxilla and the mandible
was not possible due to the limited number of studies available (Table 3C). The I² test result
was zero showing that the included studies were homogeneous.
One study by Motoyoshi et al11 showed that cortical bone thickness less than 1mm could
be a risk factor for miniscrew success. This study was not included in the quantitative review
due to heterogeneity of the study design and data presented.

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 3.5. BMD effects on miniscrew success (Secondary outcomes)
Accepted Article
The average effect size for the mean difference in cortical bone density between the
success and failure groups was -.05, indicating a minimal effect of cortical bone density on
the success of miniscrews. Meta-analysis was not performed since it failed to reach a
statistical significance before applying the random effect model (Table 3D).
There was a total of three studies in the subgroup analysis of the maxilla investigating the
difference in cortical BMD between the success and failure groups which included 283
patients treated with 503 miniscrews. Three studies were excluded because they only studied
CBT effects. One study was excluded because BMD in the failure group was not available.
Cortical bone density in the maxilla was higher in the success group, although the result was
statistically insignificant (P = .54) (Figure 3B). The I² test result was zero, showing that the
included studies were statistically homogeneous.
There was a total of three studies in the subgroup analysis of the mandible that included
222 patients treated with 414 miniscrews. Three of the seven studies were excluded because
they only studied CBT effects, one more study was excluded because it only studied
miniscrews inserted in the maxilla. Cortical BMD in the mandible was higher in the failure
group, although it was statistically insignificant (P = .36) (Figure 3C). The I² test result was
zero.
Two studies studied the effects of cancellous bone density on the success of miniscrews.
The average effect size was 1.15 in the maxilla, indicating that the cancellous bone density
had a very strong effect on the miniscrew success. On the other hand, the average effect size
was -.65 in the mandible, a moderate negative effect on the bone density on the success of
miniscrews (Table 3E). Meta-analysis could not be performed due to the small number of
studies available.

3.6. Publication bias

Statistically, no publication bias was detected in the meta-analyses.

4. DISCUSSION
In this review, the overall mean success rate weighted by the number of miniscrews was
87.21%. The weighted mean success rate in the maxilla was 89.87%, whereas it was 79.24%
in the mandible. A significantly higher failure rate was discovered in the mandible. These
results are similar to the findings in some previous studies.2,3

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 Many factors have been suggested as the cause of the high failure rate of miniscrews in the
Accepted Article
mandible: for instance, less bone formation surrounding the miniscrew in contact with root
surfaces causes the failure of the miniscrew. Moreover, occlusal force may be transmitted to
the miniscrew in contact with the root, which may lead to its mobility and eventual loosening.
Since time-dependent displacement of a miniscrew under constant loading is possible,24,25
root proximity increases the risk of contacting a root surface and loosening the miniscrew
during treatment. Suzuki et al15 stated that root proximity may be a risk factor, especially in
the mandible, because the inter-radicular septum is narrower between second premolars and
first molars in the mandibles than it is in the maxilla. Park et al26 mentioned that the higher
failure rate in the mandible might be caused by the excessive heat during placement since the
mandible usually has thicker and denser cortical layers. Also, they felt that loosely attached
oral mucosa in the mandible and its potential to be affected by the masticatory muscle could
be factors. An animal histomorphometric study discovered fewer bone formations near the
heads of miniscrews in the mandible.27
Although many previous studies presented the overall CBT or BMD, mixing the bone-
related data of the upper and lower jaw creates several potential problems. The miniscrew
failure rate in the mandible is higher than in the maxilla. Ironically, the CBT and BMD in the
mandible are known to be higher than those in the maxilla. Since relatively more miniscrew
failures occur in the mandible, the CBT or BMD of the failure group is likely to be influenced
heavily by values from the mandible that usually have better bone-related variables. This
paradoxical discrepancy may mask the pure bone factors on the miniscrews in each jaw.
Besides, the mandible is a completely different anatomical structure with possibly more
confounding variables. For this reason, this review has also separated data from the maxilla
and mandible for subgroup analysis whenever possible.
In the meta-analysis, the success group showed overall higher cortical bone thickness
although it failed to reach a statistical significance (P = .07) (Figure 3A). The leave-out-one
sensitivity test revealed that excluding anyone of the studies did not significantly change the
result. However, separating data from the maxilla and mandible may tip the scale in favor of
the thicker cortical bone on screw success in each jaw. It was impossible to do so in the
present study due to the small number of available studies. Also, Motoyoshi et al11
demonstrated that cortical bone thickness less than 1mm could be a risk factor for miniscrew
success, although this study could not be included in the quantitative analyses. It is yet to be
studied whether CBT over a certain cut-off point acts as a risk factor. If that is the case, it

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 would be hard to see the true bone thickness effect on the screw success with the study design
Accepted Article
of the included studies, and a more elaborated study design may be needed.
Regarding cortical bone density, the average effect size for the mean difference in cortical
bone density between the success and failure group was -.05, indicating a minimal effect of
cortical bone density on the success of screws. Meta-analysis was not performed since it
failed to reach a statistical significance before applying the random effect model.
In the subgroup analysis, cortical bone density in the maxilla was higher in the success
group, although it was statistically insignificant (P = .54). Cortical BMD in the mandible was
higher in the failure group. It was statistically insignificant (P = .36) (Figure 3B).
In this review, two articles studied cancellous bone density effects on the success of screws.
The effect size was 1.15 in the maxilla, indicating a very strong effect of the cancellous bone
density on the miniscrew success. This result may suggest the possibility that the cancellous
BMD may compensate for the thin CBT in the maxilla. On the other hand, the effect size was
-.65 in the mandible, a moderate negative effect of the bone density on screw success. The
mandible is known to have higher CBT and BMD with less variation than the maxilla.
Excessively high cancellous BMD over a certain point may work negatively on the success
rate of screws in the mandible with thick cortical bone. One possible explanation for this is
overheating during insertion. Thermally-induced bone necrosis may be far more detrimental
to the stability of screws than thin CBT or low BMD. However, cancellous bone-related
results in this review should be taken with extra caution because only two studies were
available in the review. Meta-analysis was not available due to the small number of available
studies.
CBT and BMD effects on the success rate of screws may be far more complicated than
previously studied. It is recommended that future studies present separate data from the
maxilla and mandible as well as overall data. Also, BMD related studies need to include
cancellous BMD effects on the success rate since cancellous BMD may be more important
than cortical BMD for the screw success.

CONCLUSION
The overall weighted mean success rate for miniscrews was 87.21% (89.87% in the
maxilla and 79.24% in the mandible). The miniscrews placed in the maxilla had a
significantly higher success rate (P < .05). The CBT did not significantly affect the success of
the screws (P = .07). The cortical bone density did not affect the success of the screws in both

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 maxilla and mandible (P = .54, .36 respectively). The cancellous BMD demonstrated a very
Accepted Article
strong effect on the success of miniscrews in the maxilla, whereas, in the mandible, it showed
a moderate negative effect. Due to the small number and clinical heterogeneity of the
included studies, the results should be interpreted with caution. Further randomized clinical
studies with a large sample size are recommended.

ACKNOWLEDGMENT

This paper was supported by Wonkwang University in 2021.

Conflict of interest

The authors have no conflicts of interest to declare.

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FIGURE LEGENDS
FIGURE 1 Flow chart of the study selection
FIGURE 2 Forest plot of the success rate of miniscrews (maxilla vs mandible)
FIGURE 3 A, Forest plot of cortical bone thickness; B, Forest plot of cortical bone density
in the maxilla; C, Forest plot of cortical bone density in the mandible

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Accepted Article
TABLE 1 Articles reviewed
Miniscrew Diameter Length Placement Force Loading
Authors Title Journal Design
type (mm) (mm) method applied type
Effect of cortical bone ISA orthodontic
Motoyoshi et al thickness and implant Int J Oral Maxillofac implants
PCS 1.6 8 Self-tapping 2N Immediate
(2007)11 placement torque on stability Implants (Biodent, Tokyo,
of orthodontic mini-implants Japan)
The effect of cortical bone
ISA orthodontic
thickness on the stability of Int J Oral Maxillofac
Motoyoshi et al implants
12
orthodontic mini-implants and Surg PCS 1.6 8 Self-tapping 2N 1 month
(2009) (Biodent, Tokyo,
on the stress distribution in
Japan)
surrounding bone
Root proximity and cortical
bone thickness effects on the AbsoAnchor
Min et al 50-
success rate of orthodontic Angle Orthod PCS (Dentos, Daegu, 1.2~1.3 8 Self-drilling Immediate
(2012)13 200g
micro-implants using cone Korea)
beam computed tomography
Bone density and miniscrew AbsoAnchor
Samrit et al
stability in orthodontic Aust Orthod J PCS (Dentos, Daegu, 1.5 7~8 Self-drilling 2N 1 week
(2012)14
patients Korea)
Evaluation of optimal length AbsoAnchor
Suzuki et al Am J Orthod 50-
15
and insertion torque for PCS (Dentos, Daegu, 1.3 5~8 Self-tapping Immediate
(2013) Dentofacial Orthop 100g
miniscrews Korea)
Watanabe et al Orthodontic miniscrew failure AbsoAnchor 50-
16
Orthod Craniofac Res PCS 1.4 5~8 Self-tapping Varies
(2013) rate and root proximity, (Dentos, Daegu, 100g

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Accepted Article
insertion angle, bone contact Korea)
length, and bone density
Bone density effects on the
success rate of orthodontic AbsoAnchor
Lee et al Am J Orthod 50-
17
microimplants evaluated with PCS (Dentos, Daegu, 1.2~1.3 8 Self-drilling Immediate
(2016) Dentofacial Orthop 200g
cone-beam computed Korea)
tomography

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TABLE 2 The Newcastle-Ottawa Scale (NOS) for non-randomized clinical tests
Study selection Comparability Outcome

Outcome of Adequacy
Representative- Selection of interest not of Adequacy of
Ascertainment Comparability Assessment Total Overall
Study ness of exposed non-exposed present at the duration completeness
of exposure of the cohort of outcome score assessment
cohort cohort start of the of of follow-up
study follow-up

Motoyoshi et al
1 0 1 1 0 0 1 1 5 Medium
(2007)11

Motoyoshi et al
1 1 1 1 0 1 1 1 7 High
(2009)12

Min et al13 1 0 1 1 0 0 1 1 5 Medium

Samrit et al14 1 0 1 0 0 0 1 1 4 Medium

Suzuki et al15 1 0 1 0 0 1 1 1 5 Medium

Watanabe et al16 1 0 0 0 0 0 1 1 3 Low

Lee et al17 1 0 0 1 0 0 1 1 4 Medium

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TABLE 3 A, Success rates of the miniscrews; B, Cortical bone thickness of the insertion site (mm); C, Cortical bone thickness in the maxilla
and mandible (mm); D, Cortical bone density of the insertion site (HU; absolute and relative); E, Cancellous bone density of the insertion site
(HU; absolute and relative)

TABLE 3A Success rates of the miniscrews

Maxilla Mandible Overall

Authors Screws (n) Success rate (%) Screws (n) Success rate (%) Screws (n) Success rate (%)

Motoyoshi et al11 56 87.5 31 87.1 87 87.4

12
Motoyoshi et al 115 88.7 94 88.3 209 88.5
13
Min et al 172 90.7 0 NA 172 90.7
14
Samrit et al 20 100.0 18 77.8 38 89.5
15
Suzuki et al 122 93.4 64 70.3 186 85.5
16
Watanabe et al 132 90.7 58 70.7 190 85.3
17
Lee et al 127 85.0 0 NA 127 85.0

Total 744 89.9 ± 4.5 265 79.2 ± 7.7 1009 87.2 ± 2.1
(Weighted mean) (Weighted mean) (Weighted mean)

TABLE 3B Cortical bone thickness of the insertion site (mm)

Success group Failure group

Authors n Mean SD n Mean SD Effect size

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Motoyoshi et al11 (76) 1.42 0.59 (11) 0.97 0.31 Combined 0.7974

Min et al13 (156) 1.23 0.43 (16) 1.06 0.31 Maxilla 0.4040

(114) 1.60 0.30 (8) 1.60 0.30 Maxilla 0.0000

Suzuki et al15
(45) 1.90 0.40 (19) 2.00 0.50 Mandible -0.2318

(112) 1.63 0.26 (10) 1.53 0.20 Maxilla 0.3906

Watanabe et al16
(38) 2.34 0.57 (14) 2.19 0.47 Mandible 0.2748

Total 0.2725

TABLE 3C Cortical bone thickness in the maxilla and mandible (mm)

Maxilla Mandible

Success group Failure group Success group Failure group

Authors n Mean SD n Mean SD Effect size n Mean SD n Mean SD Effect size

Min et al13 (156) 1.23 0.43 (16) 1.06 0.31 0.404 (0) NA NA (0) NA NA NA

Suzuki et al15 (114) 1.60 0.30 (8) 1.60 0.30 0.0000 (45) 1.90 0.40 (19) 2.00 0.50 -0.2318

Watanabe et al16 (112) 1.63 0.26 (10) 1.53 0.20 0.3906 (38) 2.34 0.57 (14) 2.19 0.47 0.2748

Total 0.264 0.0215

TABLE 3D Cortical bone density of the insertion site (HU; absolute and relative)
Success group Failure group

Authors n Mean SD n Mean SD Effect size

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Samrit et al14 (34) 1004.77 288.38 (4) 1161.23 366.31 Combined -0.5292

Suzuki et al15 (114) 993.3 218.8 (8) 1006 346.1 Maxilla -0.0557

(45) 902.8 236.3 (19) 946.7 151.5 Mandible -0.2040

Watanabe et al16
(24) 15.51 1.32 (5) 14.43 3.04 Maxilla 0.6394

(21) 14.68 1.65 (13) 14.92 1.43 Mandible -0.1528

Lee et al17
(108) 951.17 190.35 (19) 948.65 200.88 Maxilla 0.0131

Total -0.0482

TABLE 3E Cancellous bone density of the insertion site (HU; absolute and relative)
Success group Failure group

Authors n Mean SD n Mean SD Effect size

Samrit et al14 (14) 539.69 152.97 (4) 636.9 140.40 Mandible -0.6451

Lee et al17 (108) 590.21 148.83 (19) 419.59 142.85 Maxilla 1.1530

Total 0.2540

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