ORIGINAL ARTICLE

Minimum required length of orthodontic

microimplant: a numerical simulation
and clinical validation
Jaemin Kum,a Kyung-Ho Park,b Ho-Jin Kim,a Mihee Hong,a Wonjae Yu,a and Hyo-Sang Parka
Daegu, South Korea

Introduction: This study aimed to determine the minimum required length of microimplants (MIs) to prevent
excessive micromotion during MI healing that can lead to MI failure. Methods: Hypothesizing that the implanta-
tion depth of MI in cancellous bone (IDcancel) is the key to the control of micromotion during MI healing, we numer-
ically investigated the minimum IDcancel required to maintain MI micromotion to below the threshold (30 mm) that
would threaten MI survival. Twenty MI and bone models were built using MIs of 4 lengths and bone specimens
with 5 different cortical bone thicknesses to create IDcancel in the 0.5-5.5 mm. Then, applying a horizontal force of
1.5 N on the MI head, we calculated the micromotion (peak and average MI micromotions) and determined the
minimum IDcancel. A clinical test was performed to verify the numerical result by placing 160 MIs in the posterior
maxilla and mandible. Results: A strong correlation (r2 5 0.694) was found to exist between IDcancel and MI mi-
cromotion. A minimum of 2.5 mm of IDcancel was needed to maintain the level of MI micromotion (peak
micromotion) \30 mm threshold. The 6-month survival rate of MI was strongly correlated with IDcancel (r2 5
0.744) and decreased sharply when IDcancel was #2 mm. Conclusions: The minimum lengths of MIs to provide
the minimum IDcancel of 2.5 mm required to promote successful MI healing in the posterior maxilla and mandible
are 5.2 and 6.5 mm, respectively. (Am J Orthod Dentofacial Orthop 2023;163:858-66)

A
lthough orthodontic microimplants (MIs) are
considered to provide absolute anchorage, their
stability in bone is not always reliable. Recent
studies1-5 have shown that 10̶ 40% of MIs placed in
the jaw bone may lose stability and fail depending on
the jaw of insertion,1,2 proximity to adjacent roots,3-5
and patient age.6 Most MI failures occurred within 2-4
months of placement3-5 (ie, during the healing
period).2 These findings suggested that the success or
failure of MIs depends largely on how the bone around
them heals after implantation.
Micromotion, the relative displacement between
implant and bone, is a significant risk factor for compro-
mised bone healing around the implants.7,8 This is
because excessive micromotion can damage the callus
a
Department of Orthodontics, School of Dentistry, Kyungpook National Univer-
sity, Daegu, South Korea.
b
Private practice, Daegu, South Korea.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Mihee Hong, Department of Orthodontics, School of
Dentistry, Kyungpook National University, 2175, Dalgubeoldae-ro, Daegu
41940, South Korea; e-mail, mhhong1208@gmail.com.
Submitted, April 2022; revised and accepted, September 2022.
0889-5406/$36.00
Ó 2023 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2022.09.014
858
and vascular structures forming at the implant-bone
interface as part of bone healing,9 and eventually lead
to fibrous encapsulation of the implants instead of direct
bone contact. Micromotion is a particularly serious
problem for MIs, because, unlike dental implants, MIs
are loaded before the interfacial bone is completely
healed and the secondary stability is established. This
means maintaining micromotion during MI healing
below a certain threshold would be one of the most
important factors to consider to avoid premature MI fail-
ure. Variations in the threshold of implant micromotion
depending on the implant material, surface characteris-
tics, and loading protocols have been documented. For
titanium implants with porous or roughened surfaces,
the minimum allowable threshold was reported at 50-
150 mm, whereas micromotions of ˂30 mm were within
the safe limit and did not interfere with bone heal-
ing.10,11 For the immediately loaded implants, as is the
case with MIs, the threshold was reported to be
30 mm.12,13
Providing MIs with sufficient primary stability is an
important measure to suppress micromotion. Cortical
bone quality, especially the thickness, is a key factor in
achieving MI primary stability.1-3 However, MI primary
stability established during MI implantation does not
last long. Soon it decreases over time, putting MIs at risk
Kum et al
Fig 1. Geometry, loading, and dimensions (in mm) of the microimplants and bone specimens
(IDcancel 5 MI shaft length – 1.5 mm – CBT).
of developing micromotion. This decrease in primary
stability has been attributed to the osteoclastic
remodeling of cortical bone triggered by the damage
that occurred during MI placement.14 Histologic
studies15-17 have shown that the cortical bone within
0.2-0.5 mm from the MI is overcompressed and severely
damaged during MI placement. Although cortical bone
is stronger than cancellous bone, its higher stiffness and
lower fracture strain make it more susceptible to
compression damage. The process of cortical bone
remodeling (ie, removal of damaged tissues and
subsequent new bone formation), which lasts for
months, may account for most of the MI healing period.
In this critical period, in which weakened cortical bone
cannot support the MI, the stability of MIs will be
dependent on the cancellous bone. In other words, the
cancellous bone needs to provide stability to the MI,
allowing it to pass through this critical period until the
cortical bone remodeling is completed.
The above reasoning leads to the hypothesis that the
amount of cancellous bone contact or the implantation
depth of MI into cancellous bone (IDcancel) may be the
key to the success of MI. If this is proven, it could explain
the high failure rate reported for short MIs and those
placed in the mandible. Furthermore, it may allow clini-
cians to select proper MI length considering cortical
American Journal of Orthodontics and Dentofacial Orthopedics
859
bone thickness (CBT) at the placement site so that an
adequate amount of IDcancel is available. Accordingly,
this study aimed to (1) numerically identify the minimum
IDcancel required to suppress MI micromotion below the
threshold value (30 mm) during MI healing and (2) clin-
ically test the relevance of the numerically identified
minimum IDcancel value.
MATERIAL AND METHODS
This study was performed assuming that MIs are
placed in the interradicular space. To simulate the
diverse conditions encountered in clinical settings, 20
MI and bone models were generated using computer-
aided design (Fig 1) by combining MIs of 4 different
shaft lengths (5, 6, 7, and 8 mm) and bone specimens
having 5 different CBTs (1.0, 1.5, 2.0, 2.5 and 3.0
mm). The MIs (Absoanchor SH1413-5, 6, 7, and 8; Den-
tos Inc, Daegu, South Korea) had a slightly tapered shaft
with a diameter of 1.4 mm at the cervix and 1.3 mm at
the apex. Despite the differences in CBT, the 5 bone
specimens had the same height and diameter (7.5 and
3.0 mm). Note that IDcancel created by the 20 MI and
bone models was 0.5-5.5 mm.
The cortical bone layers were composed of 2 parts (in-
ner and outer). The inner part represented the interfacial
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Table I. The material properties used in this study
Material Elastic modulus (GPa) Poisson’s ratio
Ti6Al4V 114 0.31
Cortical bone 13.7 0.3
Cancellous bone 0.9 0.3
Fig 2. Elastoplastic stress-strain relationships of the human cortical and cancellous bones as reported
in the literature.21,22
bone located within a 0.2-mm distance from the surface of
the MI. This part was assumed to undergo substantial re-
modeling (as a result, it loses its structural integrity) during
MI healing because of compression damage it received
during MI placement. In contrast, the outer part was
assumed to remain undamaged during MI placement
and thus retain the structural integrity throughout the
MI healing period. Based on the literature, the entire
cancellous bone was assumed to retain its structural integ-
rity throughout the MI healing period.18-20 A recent finite
element model (FEM) study showed that compression
damage sustained by cancellous bone during MI
placement is minimal as compared with that by cortical
bone.18 Other histologic studies showed that cancellous
bone, even when damaged, can recover much faster
than cortical bone.19,20
Each of the 20 MI and bone models was imported
into the FEM software (version 11.0, DEFORM; Scientific
Forming Technologies, Columbus, Ohio) and meshed
using 3-dimensional tetrahedron elements with 4 corner
nodes. Care was taken to maintain mesh consistency and
ensure that the MIs and bones maintained their shapes
without noticeable distortion, especially at the interface
between them. The material properties used in the FEM
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Kum et al
Yield strain Plastic modulus (GPa) Fracture strain
– – –
0.012 0.76 0.026
0.05 0.03 0.185
analysis are summarized in Table I and Figure 2.21,22
However, although the elastoplastic properties of intact
cortical and cancellous bones were assigned to the outer
part of cortical bone and the entire cancellous bone, the
inner part of cortical bone was assumed to lose its struc-
tural integrity entirely during MI healing. Based on pre-
vious studies, the friction coefficient between MI and
cortical and cancellous bones was set at 0.3.23 A stick
boundary condition was applied between the inner and
outer cortical bones and between cortical and cancellous
bones. All nodes on the periphery of both cortical and
cancellous bones were clamped.
Assuming that the orthodontic forces applied to the
MIs during their healing period are the principal cause
of MI micromotion, a typical loading condition was simu-
lated by applying a horizontal force of 1.5 N to the MI
head, mimicking en-masse retraction of the anterior
teeth. Based on previous studies,7,9 the relative displace-
ment (ie, the gap opening) between the MI and the inner
part of cortical bone was defined as MI micromotion (Fig
3), and data at the following 3 locations were recorded:
(1) the top surface, (2) the midplane, and (3) bottom sur-
face of the inner part of cortical bone (Fig 3). The value
obtained at the top surface, which was the largest of
Kum et al
Fig 3. The relative displacement of MI against cortical
bone (or the gap opening between two) was defined as
MI micromotion. The micromotion value recorded at the
top surface of cortical bone was regarded as the peak mi-
cromotion. The average micromotion was obtained by
averaging the three micromotion values recorded at the
top, middle, and bottom surfaces of the cortical bone.
the 3 (as the MI undergoes tipping under horizontal
force), was defined as the peak micromotion, and the
average of the data obtained at the 3 locations was
defined as the average micromotion.
After obtaining the FEM simulation results, a correla-
tion analysis was performed using the linear regression
model (P\0.05) to examine whether and to what extent
IDcancel (Fig 1) correlates to MI micromotion using SPSS
(version 21; IBM, Armonk, NY). Then, the minimum
IDcancel required to maintain the peak and/or the average
micromotion below the threshold of 30 mm was
determined.
As will be discussed later, the FEM simulation revealed
that MI micromotions (the peak micromotions) of .30
mm can occur when IDcancel is \2.5 mm (Figs 4 and 5),
which suggested that IDcancel should be .2.5 mm. This
indicated that MIs that cannot guarantee
IDcancel of 2.5 mm (eg, when MIs \6 mm are placed in
the posterior mandible in which CBT is .2.5 mm24) would
be at high risk of failure. Because the upper 1.5 mm of the
MI shaft is exposed outside the bone in usual clinical sit-
uations (Fig 1), IDcancel was calculated by the formula:
IDcancel 5 MI shaft length 1.5 mm  CBT.
American Journal of Orthodontics and Dentofacial Orthopedics
861
To check the validity of the above numerical results, a
clinical test was performed under the approval of the Insti-
tutional Review Board of Kyungpook National University
Dental Hospital (IRB no. KNUDH-2021-11-01-00).
Sixty-five adolescent and young female patients (mean
age, 17.9 years; range, 14.6-23.5 years) participated in
the test and received a total of 160 MIs with a length of
5, 6, and 7 mm. Eighty MIs (40 each of 6 and 7 mm
MIs) were inserted in the right and left side of the maxilla
between nos. 5 and 6 in a random split-mouth design. In
the mandible, 80 MIs (40 each of 5 and 6 mm MIs) were
tested similarly, except that MIs were placed between
nos. 6 and 7. All the MIs were inserted by 1 orthodontist
(K.-H.P.) in the attached gingiva near the mucogingival
junction. Note that a wider range of IDcancel was achieved
by inserting relatively long MIs in the maxilla with thin
cortical bone and shorter MIs in the mandible with the
thicker cortical bone. The tested IDcancel values are sum-
marized in Table II: 3.3 mm and 4.3 mm in the maxilla
and 1 mm and 2 mm in the mandible, estimated using
the published CBT data in the literature. CBT between
maxillary nos. 5 and 6 and mandible nos. 6 and 7 have
been reported at 1.2 and 2.5 mm.25,26
RESULTS
The results of the FEM simulations showed that the
amount of MI micromotion varies as a function of
both MI length and CBT (Fig 4). The shorter the MI
length and the thicker the CBT, the greater the micromo-
tion. The MI micromotion (peak and average) did not
reach the threshold value of 30 mm for 8 mm MI regard-
less of CBT (Fig 4, D). In contrast, MIs of 5-7 mm in
length produced micromotions greater than the
threshold depending on CBT. For example, when 7
mm MI was placed in bone with 2.5 mm CBT (Fig 4,
C), the peak micromotion recorded at the top surface
of cortical bone (d1) was 21 mm, whereas the average mi-
cromotion was 12 mm. Because these values were well
below the threshold, the interfacial cortical bone was ex-
pected to heal without significant complications and
recover its elastic properties in time. Conversely, 5-6
mm long MIs produced micromotions (the peak micro-
motion) greater than the threshold when CBT is thicker
than 1.5 mm or 2.5 mm, respectively (Figs 4, A and B).
Figure 5 shows the peak and average micromotions
plotted as a function IDcancel. Strong negative correla-
tions are observed between IDcancel and the peak and
average micromotions with r2 5 0.694 and 0.67, respec-
tively. Note that an IDcancel of at least 2.5 mm is needed
to suppress the peak micromotion below 30 mm, and 1.5
mm is needed to suppress the average micromotion
\30 mm.
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Fig 4. The numerically calculated peak and average micromotions, which vary as a function of MI
length and cortical bone thickness.
In Table II (ie, the summary of clinical test results),
IDcancel values were determined on the basis of the CBT
data (between nos. 5 and 6 in the maxilla and between
nos. 6 and 7 in the mandible) taken from literature.24-26
The relationship between IDcancel and the 6-month suc-
cess rate of the MI is plotted in Figure 6, which showed a
strong correlation between them (r2 5 0.744), confirm-
ing the critical role of IDcancel in MI success. The MI suc-
cess rate dropped sharply when IDcancel was\2 mm. This
result also indicated that the peak micromotion rather
than the average is directly related to the clinical success
or failure of MI.
DISCUSSION
The combined effect of MI length and CBT (ie, the 2
determining factors of IDcancel) on the micromotion of
the MI occurring during its healing period was evaluated
using FEM simulation. As expected, the results showed
that the longer the MI length and the thinner the CBT,
the smaller the amount of MI micromotion (Fig 4). A
strong correlation was evident between the amount of
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Kum et al
MI micromotion and IDcancel (r2 5 0.694; Fig 5, A). The
critical IDcancel needed to suppress the level of the peak
MI micromotion to below the threshold (30 mm), which
is necessary for successful MI healing, was found to be
2.5 mm. The numerical results were supported and vali-
dated by the clinical data. As shown in Figure 6, the sharp
drop in the 6-month survival rate of MI in IDcancel \2 mm
region suggested that a high priority should be given to
securing IDcancel of at least 2.0-2.5 mm when selecting
the length of MI. In contrast, the critical IDcancel observed
in the clinical test was slightly shorter than that obtained
by FEM (2.0 vs 2.5 mm). This discrepancy may be because
hypothetical CBT values were used to calculate IDcancel
in the clinical test. The young female patients who partic-
ipated in this study might have slightly thinner CBT than
that reported in the literature.25,26 It is also a possibility
that the threshold of micromotion for young patients
may be slightly greater than 30 mm. Further studies are
needed to clarify this issue.
Whether the FEM simulation can accurately predict
the complex biomechanical phenomena associated
with MI length and CBT during MI healing may be
Kum et al 863

Fig 5. Correlation between the implantation depth of MI into cancellous bone (IDcancel) and (A) peak
micromotion and (B) average micromotion.

Table II. The 6-mo success rate of the MIs placed in the posterior maxilla and mandible
Jaw of insertion MI shaft length n IDcancel y 6-mo success rate (%)
Maxillaz (between nos. 5 and 6) 6 mm 40 3.3 mm 75.0
7 mm 40 4.3 mm 82.5
Mandiblez (between nos. 6 and 7) 5 mm 40 1.0 mm 47.5
6 mm 40 2.0 mm 75.0
y
IDcancel 5 MI shaft length  1.5 mm  CBT; zCBT between nos. 5 and 6 of maxilla 5 1.2 mm and CBT between nos. 6 and 7 of mandible 5
2.5 mm.25,26

questioned. Previous FEM studies on the effects of MI bone.23,27 However, cancellous bone also was found to
length and/or CBT reported contradicting results from be crucial in clinical studies.28 Moreover, although
clinical findings. For example, some FEM studies showed some FEM studies showed that MI length is not a major
that MI stability depends almost entirely on cortical factor determining MI stability,29,30 MI length did

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Fig 6. Correlation between the implantation depth of MI into cancellous bone (IDcancel) and the 6-month
survival rate of MIs.
contribute to MI stability and success in clinical set-
tings.29-32 So, before further discussion, it may be
necessary to examine and address the causes of these
discrepancies.
The above discrepancies between the FEM23,27,33,34
and clinical results28-32 may be caused by improper
cortical bone models used in the FEM analyses. Many
FEM studies have been performed using intact bone
models consisting of sound cortical bone and
cancellous bone, whose elastic moduli were in the
range of 5.57-22.8 MPa and 0.08-7.93 MPa,
respectively.21,23,27,33,34 The ratio (of the moduli be-
tween cortical and cancellous bone) was around 10,
which is typical for intact bones.21-23 These bone
models cause distortions in stress distribution in the
interfacial bone (because of the large difference in the
elastic stiffness, the force transmission between the MI
and bone occurs predominantly through cortical bone
resulting in high-stress concentrations therein, while
leaving negligible stresses in cancellous bone). Such
stress distributions naturally led to an overestimation
of the role of cortical bone. However, intact bone models
do not reflect the actual clinical situation in which the
interfacial cortical bone cannot retain its elastic proper-
ties. As cortical bone undergoes remodeling, being over-
compressed and damaged during MI placement, it can
lose stiffness drastically soon after MI placement, and
thus, more force will be transmitted to cancellous
bone. This change urges cancellous bone to play an
increased role in supporting the MI and resisting the
force. Therefore when interpreting the FEM results,
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Kum et al
care must be taken to check whether the analysis models
accurately reflect the real clinical conditions.
Using intact bone models may have biased the effect
of MI length too. FEM studies33,34 found that almost all
stresses are carried by cortical bone regardless of MI
length, and as such, concluded that MI length has virtu-
ally no effect on the stress distribution in bone. This led
to the belief that MI length does not play an important
role in MI stability. Interestingly, this belief, along with
the overconfidence in the role of cortical bone, encour-
aged several clinical trials of short MIs whose length was
comparable to CBT.30,31 The idea was to minimize the
risk of adjacent tissue injuries without sacrificing the
amount of cortical bone engagement. Unfortunately,
the results were not as expected. The failure rates of
the short MIs (length \5 mm) were significantly higher
than that of standard-length MIs (6-8 mm). Given that
the only meaningful difference between the short and
long MIs was the length of IDcancel, these results evi-
denced the importance of cancellous bone, or specif-
ically IDcancel, in MI success. Then, other evidence
corroborates the importance of IDcancel—the lower suc-
cess rates observed for the MIs placed in the mandible
than in the maxilla.2,35 In that MIs placed in the
mandible are less likely to secure sufficient IDcancel, their
higher failure rates may demonstrate that it is not the
thick cortical bone, but the sufficient IDcancel required
for successful MI treatment.
The bone models used in the present FEM simulation
were carefully designed to mimic the bone conditions
encountered by MI during its healing. The cortical bone
Kum et al
(located within a 0.2 mm distance from the MI surface)
was assumed to lose all its elastic stiffness, whereas the
interfacial cancellous bone retained its full stiffness. It
may be argued that the cancellous bone may also be
damaged during MI placement and thus lose some stiff-
ness. However, a recent FEM-based study showed mini-
mal cancellous bone damage caused by MI placement.18
Although cortical bone damage was widespread across
the MI and bone interface, cancellous bone damage was
limited to small areas near the MI thread tips. Moreover,
bone physiology studies indicated that the healing and re-
modeling of cancellous could be completed in a much
shorter time than cortical bone.19 Therefore, in the prac-
tical sense, it seems reasonable to assume that the cancel-
lous bone retains its stiffness during MI healing.
Our results showed that MI length is an important
factor in controlling micromotion and that it should be
selected considering CBT, especially when placing MIs
with a length of 5 to 7 mm (Figs 4, A-C). For example,
when CBTs are 1.2 mm or 2.5 mm (as seen in the poste-
rior maxilla and mandible interdental spaces; Table II),
MIs .5-6 mm, respectively, should be selected. These
lengths may be the minimum lengths required to achieve
successful bone healing. In contrast, 8 mm MIs did not
create micromotions exceeding the threshold either in
the maxilla or mandible (Fig 4, D). This suggested that,
whenever possible, it is recommended to place MIs
longer than 8 mm as they are free from the micromotion
problem regardless of CBT. Another issue is MI length (ie,
the risk of adjacent root injury). In general, short MIs
have an advantage in that they are easier to insert with
a lower risk of adjacent root injury but have a lower sta-
bility potential, and vice versa is true for long MIs. So the
optimal length would be short enough to avoid adjacent
root injury but long enough to satisfy the minimum
IDcancel criterion.
Not many studies have been done to determine the
MI length safe from adjacent root injury. Recently, De-
guchi et al,36 through computed tomography analysis,
suggested that MIs \6 mm in length are safe from adja-
cent root contact. Costa et al37 reported similar results
that 4-6 mm long MIs are safe in most oral regions.
From these findings, it may be assumed that 6 mm is
the maximum MI length to avoid adjacent root injury.
Thus, MI length that simultaneously satisfies this crite-
rion and the minimum IDcancel criterion discussed above
may be viewed as optimal. When CBT\2.0 mm, as in the
maxilla, MI lengths of 5-6 mm satisfy both criteria and
thus can be considered optimal. If CBT is 2 mm, as often
observed in the posterior mandible, only 6 mm long MI
satisfies them. However, when CBT .3 mm, no MI
length can satisfy both criteria simultaneously.
American Journal of Orthodontics and Dentofacial Orthopedics
865
A practical approach in such cases may be to place MIs
longer than 7 mm with extra caution to prevent adjacent
root injury, whereas when MIs are placed in safe areas
away from tooth roots, such as infrazygomatic crest
and mandibular buccal shelf, the use of robust MIs
may be a suitable choice.
With regard to MI length and cortical bone, clinicians
commonly perceive that long MIs should be placed in the
maxilla, in which cortical bone is thin, and short MIs in
the mandible, in which the cortical bone is relatively
thick and dense. However, the results of this study sug-
gested that it should be done and vice versa. Because this
study was performed on 1 type of MI and 1 loading con-
dition, and because MI micromotion can be affected by
many factors, such as MI diameter, head/shaft/thread
design, loading conditions, placement angulation, and
cancellous bone properties, care should be taken when
extrapolating our results to other settings.
CONCLUSIONS
This study investigated the effect of IDcancel on the
MI micromotion during the healing period through FEM
simulations. The primary focus was identifying the min-
imum IDcancel to control the MI micromotion below the
threshold (30 mm). Clinical tests were performed to verify
the reliability of FEM results. Within the limitations of
this study, the following conclusions were drawn:
1. FEM simulation showed that IDcancel should be at
least 2.5 mm to suppress the peak micromotion of
MI to below the threshold value of 30 mm.
2. A strong correlation was observed between IDcancel
and the peak MI micromotion (r2 5 0.694) and
between IDcancel and clinical MI success rate (r2 5
0.744).
3. The minimum required lengths of MI for use in the
maxilla (assuming CBT of 1.2 mm) and mandible
(assuming CBT of 2.5 mm) was estimated to be
5.2 mm and 6.5 mm, respectively.
AUTHOR CREDIT STATEMENT
Jaemin Kum contributed to conceptualization, data
curation, and formal analysis; Kyung-Ho Park contrib-
uted to data curation and a formal analysis. Ho-Jin
Kim contributed to validation, visualization, and manu-
script review and editing; Mihee Hong contributed to
methodology, supervision, visualization, and original
draft preparation; Wonjae Yu contributed to conceptu-
alization, software, and original draft preparation; and
Hyo-Sang Park contributed to validation and manu-
script review and editing.
June 2023
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Issue 6
866
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