ORIGINAL ARTICLE

Quantitative evaluation of cortical bone

thickness with computed tomographic
scanning for orthodontic implants
Toru Deguchi,a Miho Nasu,b Kaoru Murakami,b Toshinori Yabuuchi,b Hiroshi Kamioka,a
and Teruko Takano-Yamamotoc
Okayama, Japan

Introduction: The purpose of this study was to quantitatively evaluate cortical bone thickness in various
locations in the maxilla and the mandible. In addition, the distances from intercortical bone surface to
root surface, and distances between the roots of premolars and molars were also measured to determine
the acceptable length and diameter of the miniscrew for anchorage during orthodontic treatment.
Methods: Three-dimensional computed tomographic images were reconstructed for 10 patients. Cortical
bone thicknesses were measured in the buccal and lingual regions mesial and distal to the first molar, distal
to the second molar, and in the premaxillary region at 2 different levels. Differences in cortical bone thickness
at 3 angles (30°, 45°, and 90°) were also assessed. Distances of the intercortical bone surface to the root
surface and the root proximity were also measured at the above areas. Results: Significantly less cortical
bone thickness was observed at the buccal region distal to the second molar compared with other areas in
the maxilla. Significantly more cortical bone was observed on the lingual side of the second molar compared
with the buccal side. In the mandible, mesial and distal to the second molar, significantly more cortical bone
was observed compared with the maxilla. Furthermore, significantly more cortical bone was observed at the
anterior nasal spine level than at Point A in the premaxillary region. Cortical bone thickness resulted in
approximately 1.5 times as much at 30° compared with 90° Significantly more distance from the intercortical
bone surface to the root surface was observed at the lingual region than at the buccal region mesial to
the first molar. At the distal of the first mandibular molar, significantly more distance was observed compared
to that in the mesial, and also compared with both distal and mesial in the maxillary first molar. There was
significantly more distance in root proximity in the mesial area than in distal area at the first molar, and
significantly more distance was observed at the occlusal level than at the apical level. Conclusions: These
data show that the safest location for placing miniscrews might be mesial or distal to the first molar, and an
acceptable size of the miniscrew is less than approximately 1.5 mm in diameter and approximately 6 to 8 mm
in length. (Am J Orthod Dentofacial Orthop 2006;129:721.e7-721.e12)

R
ecently, there have been many reports about
implants as orthodontic anchorage.1-3 Mini-
screws especially, have been widely used as
orthodontic anchorage, because they can be placed in
various locations in the alveolar bone.4-7 It is known
From the Department of Orthodontics and Dentofacial Orthopedics, Okayama
University Graduate School of Medicine, Dentistry and Pharmaceutical Sci-
ences, Okayama, Japan.
a
Lecturer.
b
Graduate student.
c
Professor and chair.
Supported by grants-in-aid for scientific research from the Japan Society for the
Promotion of Science.
Reprint requests to: Teruko Takano-Yamamoto, Department of Orthodontics
and Dentofacial Orthopedics, Okayama University Graduate School of Medi-
cine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-Cho, Okayama
700-8525, Japan; e-mail, t_yamamo@md.okayama-u.ac.jp.
Submitted, August 2005; revised and accepted, November 2005.
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.02.026
that the quantity (bone volume) and quality (bone
density) of alveolar bone are important factors for the
stability of implants.8,9 Structurally, the maxilla has
relatively thin cortices that are interconnected by a
network of trabeculae.10 The mandible, however, is
composed of thick cortices and has more radially
oriented trabeculae. Thus, anatomical characteristics
such as the thickness of cortical bone might differ
between the 2 jaws. By angulating the miniscrew, the
thickness of cortical bone contact with the miniscrew
might increase. In addition, we previously suggested
that cortical bone thickness might have some affect on
implant success rate.11
Only a few studies have evaluated the quantity of
bone for implant placement for orthodontic anchor-
age.12-14 Schnelle et al12 evaluated interradicular bone
between the roots using panoramic radiographs. How-
ever, the thickness of the cortical bone could not be
721.e7
721.e8 Deguchi et al
measured on panoramic or periapical radiographs.
Gahleitner et al13 evaluated bone volume using dental
computed tomography (CT), although they focused
only on the hard palate for palatal implants. It is also
important to determine the acceptable length and diam-
eter of miniscrews to avoid damaging the roots. Our
preliminary animal study indicated an approximately
5% to 7% possibility of damaging the roots or nerve
tissue when placing miniscrews. In a recent study, the
depths of the hard and soft tissues of the oral cavity
were measured by using volumetric CT.14 However,
the locations measured were different from the loca-
tions used for miniscrews in clinics, and the measure-
ments were mainly performed bicortically instead of
monocortically.
In this study, we quantitatively analyzed the differ-
ence in cortical bone thickness in the maxilla and the
mandible using three-dimensional (3D) CT to deter-
mine optimal locations and angulations for miniscrews
used as anchorage in orthodontic treatment.
MATERIAL AND METHODS
Our sample consisted of CT (Aquilion multi,
4DAS, Toshiba, Tokyo, Japan) images from 5 women
and 5 men. The average age of the subjects was 22.3
years, with Skeletal Class I (ANB angle ⫽ 2° ⫾ 2°);
Angle Class I (n ⫽ 4), Class II (n ⫽ 4), or Class III (n
⫽ 2) malocclusions; average mandibular plane angles
(35.6° ⫾ 5.6°); and posterior discrepancies less than 3 mm
These patients had impacted teeth (canine) (n ⫽ 4) or
asymmetric occlusions (n ⫽ 4), or were planning to have
genioplasty (n ⫽ 2). They all consented to participate in
the study.
CT images were taken at 200-mm field of view, 120
kV, 300 m, scanning time of 0.5 second/rotation, and
slice thickness of 0.5 mm with a high-resolution mode.
The CT data were saved as Digital Imaging and
Communications in Medicine (DICOM) files, and 3D
reconstructed images of the maxilla and the mandible
were made by using the V-works program (version 3.0,
CyberMed, Seoul, South Korea; http://www.cybermed.
co.kr) (Fig 1).
To measure the thickness of cortical bone, the
maxilla and the mandible were divided by the occlusal
plane. Then sagittal images were constructed mesial
and distal to the first molars, and distal to the second
molar by sectioning a line parallel to the long axis of
the adjacent teeth (Fig 1). Differences in cortical bone
thickness in the posterior regions were measured within
3 to 4 mm (occlusal level) of the gingival margin
(alveolar crest) and 6 to 7 mm of the gingival margin
(apex level) at a 45° angle (Fig 2, A) mesial and distal
to the first molar, and distal to the second molar.
American Journal of Orthodontics and Dentofacial Orthopedics
June 2006
Fig 1. 3D constructed V-works image in lateral view.
Maxilla and mandible were bisected from occlusal plane
(Occ.Pl.). Sagittal images were taken from line parallel
to long axis of teeth (dotted line) between molars and
premolar (solid line).
Because miniscrews for intrusion of molars are gener-
ally placed distal to the first molar or between the
molars, measurements at the apex level were taken only
in those 2 areas. On the other hand, differences in
cortical bone thickness between implant angulation
were measured by 3 angulations (30°, 45°, and 90°)
from the long axis of each tooth (Fig 2, A) mesial and
distal to the first molar and distal to the second molar.
Data of the differences in angulation are the total
average in the 3 locations. Furthermore, cortical bone
thickness at the premaxillary region was measured
because miniscrews are placed at this area for intrusion
of the incisors. Two areas were measured: at A-point
and near the anterior nasal spine (Fig 2, B).
The total distance from intercortical bone surface to
root surface was measured at these angles (Fig 2, A).
Both cortical bone thickness and length from the root
surface to the cortical bone should be measured to
determine the acceptable length of the miniscrew.
For the measurement of root proximity, cross-
sectional images at the occlusal plane level were made;
then horizontal images were constructed that were
sectioned by a line that passed the mesiodistal central
groove of each tooth (Fig 3, A). Then, the distance
between the roots of the second premolar to the mesial
root of the first molar, and the distal root of the first
molar to the mesial root of the second molar were
measured at the same level (occlusal and apical) that
the cortical bone thickness was measured where the
miniscrews were placed (Fig 3, B).
One-way analysis of variance models (ANOVA)
and the Fisher protected least significant difference for
American Journal of Orthodontics and Dentofacial Orthopedics Deguchi et al 721.e9
Volume 129, Number 6

Fig 2. A, V-works image on which measurements were analyzed at posterior regions. Measure-
ments of cortical bone thickness (d1) and distance from intercortical bone surface to root surface
(d2) was measured in 3 angles approximately 3 to 4 mm or 6 to 7 mm from gingival margin. Boxed
area shows at higher magnification how measurements were made. R, root; CB, cortical bone;
G, gingiva. B, V-works image on which measurements were analyzed at anterior regions. ANS,
anterior nasal spine; A, Point A; I, incisor.

Fig 3. A, Cross-sectional V-works image showing lines where horizontal image was constructed for
measurement of root proximity. CG, Mesiodistal central groove. B, Horizontal sectional V-works
image representing where root proximity was measured (distance between arrows).

post hoc comparison were used at the level of P ⬍.05
to compare the following parameters: differences in
cortical bone thickness between locations (posterior
and anterior, buccal and lingual, maxillary and man-
dibular) and angulations (30°, 45°, 90°), differences in
distances from the internal cortical bone surface to the
root surface between the mesial and distal regions of
the first molar, and differences in root proximity be-
tween the first and second molar roots.
The study protocol was reviewed and approved by
the Institutional Board of Okayama University.
RESULTS
There were no significant differences by sex, age,
or side in either cortical bone thickness or root
proximity.
The average cortical bone thicknesses in the maxilla
measured at the occlusal level were 1.8 ⫾ 0.6 (mean ⫾
SD) mm, 1.5 ⫾ 0.5 mm, and 1.3 ⫾ 0.5 mm, mesial and
distal to the first molar and distal to the second molar,
respectively (Table I). Significantly less cortical bone
was observed distal to the second molar than mesial and
distal to the first molar (P ⬍.05). At the apical level,
cortical bone thickness averaged 1.6 ⫾ 0.6 mm mesial
to the first molar and 1.6 ⫾ 0.5 mm distal to the first
molar (Table I). In the mandible, at the occlusal level,
the averages for cortical bone thickness were 1.9 ⫾ 0.6
mm, 2.0 ⫾ 0.6 mm, and 1.9 ⫾ 0.7 mm, mesial and
distal to the first molar, and distal to the second molar,
respectively (Table I). At the apical level, thicknesses
averaged 1.8 ⫾ 0.5 mm mesial to the first molar and
1.8 ⫾ 0.5 mm distal to the first molar (Table I). There
was no significant difference between locations in the
mandible. A significant difference between jaws was
721.e10 Deguchi et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2006

Table I. Difference in cortical bone thickness in posterior regions

5-6 (O) 5-6 (A) 6-7 (O) 6-7 (A) 7 (O)

Mean SD Mean SD Mean SD Mean SD Mean SD

Maxilla
Buccal 1.8 0.6 1.6 0.6 1.5 0.5 1.6 0.5 1.3* 0.5
Lingual 1.7 0.9 — — 1.7 0.7 — — 1.7† 0.6
Mandible
Buccal 1.9 0.6 1.8 0.5 2.0‡ 0.6 1.8 0.5 1.9‡ 0.7

*Significant difference between 5-6, 6-7, and lingual (P ⬍.05).

†
Significant difference between buccal (P ⬍.05).
‡
Significant difference between jaws (P ⬍.05).
5, Second premolar; 6, first molar; 7, second molar; O, occlusal level; A, apical level.

Table II. Difference of cortical bone thickness in ante- Table III.

Difference in cortical bone thickness between
rior regions implant angulations
Anterior nasal 30° 45° 90°
Point A spine
Mean SD Mean SD Mean SD
Mean SD Mean SD
Maxilla
Maxilla Buccal 2.0* 0.8 1.5* 0.6 1.2* 0.5
Buccal 1.4 0.5 3.6* 0.6 Lingual 2.2* 0.4 1.7* 0.5 1.3* 0.3
Mandible
*Significant difference from Point A (P ⬍.05).
Buccal 2.6* 0.8 1.8* 0.6 1.5* 0.5

*Significant difference from other groups (P ⬍.05).

observed mesial to the first molar (P ⬍.05) and distal to
the second molar (P ⬍.01).
Lingual cortical thickness was also measured in the
maxilla. The averages of cortical bone thickness were
1.7 ⫾ 0.9 mm, 1.7 ⫾ 0.7 mm, and 1.7 ⫾0.6 mm, mesial
and distal to the first molar, and distal to the second
molars, respectively (Table I). Significantly more cor-
tical bone thickness was observed on the lingual side
only at the site distal to the second molar region (P
⬍.01).
In the premaxilla region, the averages of cortical
bone thickness were 1.4 ⫾ 0.5 mm at the A-point level
and 3.6 ⫾ 0.6 mm at the anterior nasal spine (Table II).
Significantly more cortical bone thickness was ob-
served at the anterior nasal spine compared with A-
point (P ⬍.0001).
In the buccal region of the maxilla, average cortical
thicknesses were 2.0 ⫾ 0.8 mm, 1.5 ⫾ 0.6 mm, and
1.2 ⫾ 0.5 mm at 30°, 45°, and 90°, respectively (Table
III). Significantly more cortical thickness was observed
at 30° than at 45° (P ⬍.0001) and 90° (P ⬍.0001).
There was also a significant difference between the
measurements at 45° and 90° (P ⬍ .01). In the lingual
region of the maxilla, average cortical bone thicknesses
were 2.2 ⫾ 0.4 mm, 1.7 ⫾ 0.5 mm, and 1.3 ⫾ 0.3 mm
at 30°, 45°, and 90°, respectively (Table III). Signifi-
cantly greater cortical thickness was observed at 30°
than at 45° (P ⬍.0001) and 90° (P ⬍.0001). There was
also a significant difference between measurements at
45° and 90° (P ⬍.001). In the mandible, average
cortical thicknesses were 2.6 ⫾ 0.8 mm, 1.8 ⫾ 0.6 mm,
and 1.5 ⫾ 0.5 mm at 30°, 45°, and 90°, respectively
(Table III). Significantly greater cortical thickness was
observed at 30° than at 45° (P ⬍.0001) and 90° (P
⬍.0001). There was also a significant difference be-
tween the measurements at 45° and 90° (P ⬍.001).
In the maxilla, average distances between intercor-
tical bone and root surface were 2.2 ⫾ 0.8 mm, 2.4 ⫾
0.7 mm, 4.0 ⫾ 1.1 mm, and 2.1 ⫾ 1.0 mm on the
buccal side, mesial and distal to the first molar, and on
the lingual side, mesial and distal to the first molar,
respectively (Table IV). Significantly more distance
was observed at the lingual side mesial to the first molar
compared with all other areas in the maxilla (P
⬍.0001). In the mandible, the average distances were
2.5 ⫾ 1.0 mm at the mesial side of the first molar and
3.6 ⫾ 1.0 mm at the distal side of the first molar (Table
IV). Significantly more distance was observed at the
distal region than at the mesial (P ⬍.0001), and at the
maxillary distobuccal (P ⬍.0001) and lingual molar
regions (P ⬍.0001).
In the maxilla, root proximities between the second
premolar and the mesial root of the first molar were
2.1 ⫾ 0.7 mm at the occlusal region and 6.1 ⫾ 1.1 mm
American Journal of Orthodontics and Dentofacial Orthopedics Deguchi et al 721.e11
Volume 129, Number 6

Table IV. Distance from intercortical bone surface to immediately, because implant stability might be achieved
root surface by mechanical interdigitation rather than by osseointegra-
tion at the early stage of implant healing. Therefore,
5-6 6-7
bone quantity seems to be the major factor in the
Mean SD Mean SD stability of miniscrews.4,11
Maxilla Based on these results, there was significantly less
Buccal 2.2 0.8 2.4 0.7 cortical bone distal to the maxillary second molar region
Lingual 4.0* 1.1 2.1 1.0 compared with the mesial and distal areas of the first
Mandible molars in the buccal region This is consistent with the
Buccal 2.5 1.0 3.6†‡ 1.0 study by Schnelle et al,12 who concluded that adequate
*Significant difference between buccal and 6-7 (P ⬍.05). bone existed mesial to the maxillary molar. Moreover,
†
Significant difference between 5-6 (P ⬍.05). from our results, compared with the lingual side, the
‡
Significant difference between the jaw (P ⬍.05). buccal region distal to the second molar also showed
5, Second premolar; 6, first molar; 7, second molar.
significantly less cortical bone. Previous studies indicated
that the posterior region in both jaws tends to have a
Table V. Difference in root proximity between locations thinner, more porous cortex and finer trabeculae.10,15
5-6 (O) 5-6 (A) 6-7 (O) 6-7 (A) Therefore, at the maxillary buccal region, miniscrews
should be placed mesial or distal to the first molar rather
Mean SD Mean SD Mean SD Mean SD
than posterior to the second molar because an adequate
Maxilla 2.1* 0.7 6.1* 1.1 1.5* 0.5 3.8* 1.6 amount of the cortical bone is available at the former sites.
Mandible 1.5 0.8 5.4 1.2 1.7 0.7 4.6 1.5 We also analyzed cortical bone thickness in 2 different
*Significant difference between 5-6 and 6-7, and between O and A locations by the distances from the alveolar crest at the
(P ⬍.05). occlusal and apical levels. However, there were no signif-
5, Second premolar; 6, first molar; 7, second molar; O, occlusal level; icant differences in any locations measured at these sites.
A, apical level. This is inconsistent with another study of panoramic
radiographs in which it was concluded that there is more
adequate bone near the movable mucosa than at the
at the apical region (Table V). However, root proximi- attached gingiva.12 It is known that significant magnifica-
ties between the distal root of the first molar and the tion errors and distortions can occur with panoramic
mesial root of the second molar were 1.5 ⫾ 0.5 mm at radiographs.16,17 Furthermore, those authors evaluated
the occlusal region and 3.8 ⫾ 1.6 mm at the apical only bone in a mesiodistal direction without considering
region (Table V). In the mandible, average root prox- the buccolingual direction. In addition, our recent clinical
imities between the second premolar and the mesial study showed a high success rate of approximately 90%
root of the first molar were 1.5 ⫾ 0.8 mm at the for miniscrews implanted at the attached gingiva level.18
occlusal level and 5.4 ⫾ 1.2 mm at the apical region Placing implants in movable mucosa is known to cause
(Table V). Root proximities between the distal root of tissue irritation and inflammation of gingival tissue, re-
the first molar and the mesial root of the second molar sulting in loss of the implant. Thus, we suggest that
were 1.7 ⫾ 0.7 mm at the occlusal level and 4.6 ⫾ 1.5 sufficient cortical bone exists at the attached gingival level
mm at the apical region in the mandible (Table V). and that miniscrews placed there will remain stable.
Significant differences were observed between the There was also a significant difference between max-
maxilla and the mandible in all groups, and between the illary and mandibular cortical bone thickness at the occlu-
occlusal and apical levels in all groups (P ⬍.0001). sal level distal to the second molar and at the apical level
distal to the first molar region. Significantly more cortical
DISCUSSION bone was present in the mandibular molar region than in
Clinically, there are 2 types of loading patterns for the maxillary molar region. However, miniscrews fail in
implants as orthodontic anchorage. One is to allow the both the mandibular and maxillary posterior regions.11,19
implant to heal before the application of orthodontic The reason for their failure remains unclear, but it might
force and to achieve osseointegration at the bone- be associated with factors other than the amount of
implant interface. After osseointegration, bone quality cortical bone surrounding the implant. For example, we
as much as bone quantity are important factors, because usually place the miniscrew at the attached gingiva, which
of the necessity for long-term maintenance of the stability is a narrow site in the posterior region in the mandible, and
of the bone-implant interface.8,9 With the second type of poor oral hygiene might cause infection at these sites.11,19
loading pattern, for miniscrews, the force can be loaded In the use of miniscrews as anchorage devices, it is
721.e12 Deguchi et al
speculated that there might be an increase of cortical bone
contact by changing the angulation of the miniscrew. In
our study, there was a significant difference in the thick-
ness of cortical bone at 3 angulations. The smaller the
angle, the more cortical bone contact to the miniscrew in
both jaws. Compared with placing implants perpendicular
to the long axis of the teeth, angling the implant at
approximately 30° would increase contact with as much
as 1.5 times more cortical bone. Thus, we recommend an
angle of approximately 30° to the long axis of the tooth to
increase the interdigitation of these miniscrews.
A limitation to the use of miniscrews might be the risk
of damage to the roots of adjacent teeth. From our
findings, there was at least 1.5 mm of distance between the
roots in both the maxilla and the mandible. Thus, we
believe that we can avoid damaging the roots in most
cases by using miniscrews with a diameter of less than 1.5
mm in both jaws. However, from the findings of distance
from the intercortical bone surface to the root surface,
there was at least 2 mm on average in all examined
locations. Thus, the safest length for miniscrews would be
the thickness of the soft tissue (2-3 mm)14 and the cortical
bone (2 mm), and the distance from the intercortical bone
to root surface (2 mm)—ie, 6 mm. Thus, 6 mm would be
the safest length to avoid damaging the roots in most
cases. The miniscrews mainly used recently in our clinic
were 1.3 mm in diameter and 6, 8, or 10 mm in length.18
Furthermore, in lingual orthodontic treatment, because the
palatal mucosa is much thicker than other areas,20 a longer
miniscrew (8-10 mm) is recommended. In addition, the
best choice for miniscrew placement would be between
the first and second molars for lingual orthodontics be-
cause there is more distance from the intercortical bone
surface to the root surface in that area than in the area
distal to the second molar.
CONCLUSIONS
From the cortical bone thickness, the best available
location for a miniscrew is mesial or distal to the first
molar, and the best angulation is 30° from the long axis of
the tooth. From findings of the distance from the intercor-
tical bone surface to the root surface and the root prox-
imity, the safest length is 6 mm with a diameter of 1.3
mm. In addition, for lingual orthodontics, the recom-
mended location is mesial to the first molar at 30°, and 8
to 10 mm in length.
However, a limitation of this study is that only bone
quantity was assessed. The quality of bone surrounding
the implant might also have an impact on implant stabil-
ity. Further clinical studies are necessary to evaluate the
quality of bone surrounding miniscrews.
American Journal of Orthodontics and Dentofacial Orthopedics
June 2006
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