ORIGINAL ARTICLE

Safe sites for orthodontic miniscrew

insertion in the infrazygomatic crest area
in different facial types: A tomographic
study

Rino Neto,
Almir Lima, Jr Rafael Golghetto Domingos, Annelise Nazareth Cunha Ribeiro, Jose
and Joa ~o Batista de Paiva
S~ao Paulo, Brazil

Introduction: Temporary skeletal anchorage devices (TSADs) are used to obtain skeletal anchorage for ortho-
dontic treatment. Their insertion in the infrazygomatic crest (IZC) allows efficient orthodontic mechanics.
Different facial types have different bone configurations. We aimed to evaluate the differences in bone thick-
nesses in the IZC area among patients of each facial type to determine a safe zone for TSAD insertion.
Methods: For this retrospective study, 86 cone-beam computed tomography (CBCT) scans were divided into
3 groups according to the facial type: group I, 24 CBCT scans of hyperdivergent patients; group II, 30 scans
of neutral patients; and group III, 32 scans of hypodivergent patients. The buccal alveolar bone thickness
was measured in 6 zones between the second premolar and distal root of the second molar, 5, 7, 9, and
11 mm apical to the alveolar crest. Results: The IZC areas with minimum thickness for TSAD insertion follows:
group I, between first and second molars at 11 mm from the alveolar crest, mesial root of the second molar at
9 mm from the crest, and distal root of the second molar at 11 mm from the crest; groups II and III, between first
and second molars at 11 mm from the crest and mesial root of the second molar at 11 mm from the crest.
Conclusions: The safe zones for IZC miniscrew insertion are located 11 mm from the alveolar crest between
the maxillary first and second molars and on the mesial root of the second molar for all the 3 facial types. (Am
J Orthod Dentofacial Orthop 2021;-:---)

T
emporary skeletal anchorage devices (TSADs) have
been used widely to provide absolute anchorage
during orthodontic treatment because they render
tooth movement more predictable and efficient, allow
more efficient orthodontic mechanics, and require less
patient cooperation.1-3 Among the types of devices
available for this purpose are orthodontic miniscrews,
which are available in a variety of diameters and
lengths, are easy to insert and remove, and can be
inserted at several locations.4-8
Orthodontic miniscrews were initially used in the in-
terradicular regions4,9,10; however, their insertion in
From the Department of Orthodontics, School of Dentistry, University of S~ao
Paulo, S~ao Paulo, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Rafael Golghetto Domingos, Av Prof Lineu Prestes,
2227, Cidade Universit
aria, S~ao Paulo 05508-900, SP, Brazil; e-mail,
rafaelgd@alumni.usp.br.
Submitted, November 2019; revised and accepted, June 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.06.044
these regions may be difficult if the distance between
the roots of teeth is reduced, which may increase the
risk of injury to the adjacent teeth.7,8,11,12 Proximity to
the roots is one of the main factors for failure of the in-
terradicular miniscrews.13,14
To minimize eventual failures due to proximity to the
roots and use orthodontic mechanics to obtain adequate
tooth movements, orthodontists sought to insert these
devices in extraalveolar regions such as the infrazygo-
matic crest (IZC).4,7,8,12,15 In this technique, the miniscrew
is inserted parallel to the axial inclination of the maxillary
first molars, allowing the use of larger diameter
screws.15,16 The point of insertion should be as posterior
as possible, using the second molars as a reference, as
they offer increased alveolar bone thickness for miniscrew
insertion, which facilitates the procedure, increases the
chances of primary stability,4,6 and allows orthodontic
mechanics to move teeth with lower risk of contact of
the miniscrews with the roots of the posterior teeth.12
The individual structures of bones vary widely de-
pending on the patient's facial profile. Cortical bone
thickness and mineralization characteristics differ in

1
2 Lima et al
different facial types.17-20 Studies using cone-beam
computed tomography (CBCT) to evaluate the alveolar
cortical plate show that hyperdivergent patients have
lower dentoalveolar cortical thickness than hypodiver-
gent patients.6,21,22 The thickness of available bone in
the IZC may vary widely among patients, which can in-
fluence the insertion of the TSAD.
This study was performed using CBCT to analyze and
determine the region of the IZC—in the 3 facial types (hy-
perdivergent, neutral, and hypodivergent)—that has a
safe alveolar bone thickness for potential TSAD inser-
tion, which would render this procedure safer, easier,
predictable, and most likely to succeed.
MATERIAL AND METHODS
This retrospective study was performed by evaluating
86 CBCT scans of adult patients of both sexes, aged be-
tween 18 and 40 years, and randomly selected from the
database of the Orthodontics and Odontopediatrics
Department, University of S~ao Paulo, S~ao Paulo, Brazil.
Patients with all erupted permanent maxillary teeth
(except for the third molars), no history of orthodontic
treatment, good dental and periodontal health, and no
clinical signs and symptoms of temporomandibular joint
dysfunction were included in the study. Before the study
was initiated, it was approved by the research ethics
committee of the University of S~ao Paulo School of
Dentistry (project no. 2.523.021).
The images were obtained using a cone-beam
computed tomography (I-CAT Cone Beam 3D Dental
Imaging System; Imaging Sciences International, Hat-
field, Pa), were imported in the digital imaging and com-
munications in medicine format and analyzed in a
software (Dolphin Imaging & Management Solutions
and Management Solutions, Chatsworth, Calif) with
0.4-mm voxel resolution. These tomographic images
were reoriented such that the natural head position
coincided with the true horizontal plane,23 aiming to
minimize possible errors in head positioning during im-
age acquisition. Thus, there was no change in the posi-
tion of the head whenever this file was accessed. Next, a
2-dimensional lateral image of the head was obtained
for cephalometric tracing.
The facial type of each patient was established by
cephalometric analysis using the Jarabak index (the ratio
of S-Go and N-Me)24,25; thus, all the scans in the sample
were divided as follows: group 1—hyperdivergent facial
type with 24 scans—had a predominance of a vertical
vector of facial growth, group 2—neutral facial type
with 30 scans—had a balance of vertical and horizontal
facial growth vectors, and group 3—hypodivergent facial
type with 32 scans—had a predominance of a horizontal
vector of facial growth.
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Vestibular bone plate thicknesses were measured bilat-
erally in buccolingual axial slices at distances of 5, 7, 9,
and 11-mm apically from a reference line passing through
the mesial and distal alveolar bone crest of the maxillary
first molars, parallel to the occlusal plane in the sagittal
view8 (Figs 1, A and B). In an axial slice, the thickness
was measured at each of these distances from the most
vestibular point of the root to the most vestibular point
of the adjacent alveolar cortical bone (Fig 2, A). To mea-
sure the thickness on the sites located between the teeth—
between the second premolar and first molar and between
first and second molars—a tangent was drawn to the most
vestibular points of these roots, and the thickness was
measured from a midpoint of this line to the most vestib-
ular point of the adjacent alveolar cortical bone (Fig 2, B).
To analyze its entire tooth extension, the IZC was evalu-
ated at the points from its anterior border—located in
the region between the second premolar and first
molar4—to the distal root of the second molars.
Statistical analysis
Statistical calculations were performed using SPSS
software (IBM SPSS Statistics for Windows version 20;
IBM Corp, Armonk, NY), adopting a significance level of
5%. A preliminary evaluation was performed on 10
CBCT images of each facial type to determine the number
of subjects required for this study. It was determined that
a sample size of 21 subjects in each group was deemed
necessary to consider a power of 80% and a 5 0.05.
Age and specific dental measurements were described us-
ing means and standard deviations and compared with
facial types using the analysis of variance followed by
Bonferroni's multiple comparisons if the results were sig-
nificant.26 The patients' genders were described using ab-
solute and relative frequencies, and the association
between facial types was determined using the chi-
square test.27 The bone thicknesses measured at the 4 dis-
tances for each facial type were described using means
and standard deviations with 95% normal intervals for
all parameters. The differences between the thicknesses
at the 4 measurement sites in all the facial types were
compared using repeated-measures analysis of variance
followed by Bonferroni's multiple comparisons.26 The
interclass correlation coefficients were calculated with
the respective 95% confidence intervals to evaluate
method error.28 This was determined for a part of the
sample, and the differences between measurements
were calculated using Dahlberg's formula.
RESULTS
The results showed no statistically significant differ-
ences between the mean ages of the patients (P 5 0.340)
Lima et al
Fig 1. Sagittal tomographic image with markings at 5, 7, 9, and 11-mm apical from the alveolar crest
(A); axial slice at the respective markings (B).
and gender of the patients (P 5 0.670) in the 3 evaluated
groups—hyperdivergent, neutral, and hypodivergent.
When the buccal bone thickness was measured, all the
thicknesses measured at 5, 7, 9, and 11 mm presented sta-
tistically different means (P \0.05) (Tables I–III), except
for the buccal bone thickness measured between the left
second premolar and first molar in the hyperdivergent
group.
American Journal of Orthodontics and Dentofacial Orthopedics
3
Table I refers to the results of group I—hyperdiver-
gent—and shows that buccal bone thicknesses measured
between first and second molars 11 mm from the alve-
olar crest, at the mesial root of second molar 9 mm
from the alveolar crest, and at the distal root of
second molar 11 mm from the alveolar crest presented
mean values .3 mm, and hence, can be considered
safe sites for miniscrew insertion,11 bilaterally.
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Fig 2. Axial CBCT scan shows the sites of buccal bone thickness measurements on roots of teeth (A)
and between roots of teeth (B).

Table I. Mean alveolar thicknesses in patients in the hyperdivergent group compared with various sites
Sites

Variable 5 mm 7 mm 9 mm 11 mm P
Between second premolar and first molar, right side 0.048
Mean 6 SD 1.33 6 0.66 1.03 6 0.95 0.84 6 0.94 1.18 6 1.22
NI (95%) 0.03-2.63 0-2.9 0-2.68 0-3.56
First molar mesial root, right side 0.008
Mean 6 SD 0.68 6 0.78 0.55 6 0.83 0.39 6 1.03 1.39 6 1.98
NI (95%) 0-2.2 0-2.18 0-2.41 0-5.27
First molar distal root, right side 0.006
Mean 6 SD 1.32 6 0.97 0.94 6 1.06 1 6 1.35 2.18 6 2.32
NI (95%) 0-3.23 0-3.01 0-3.64 0-6.73
Between first and second molar, right side 0.002
Mean 6 SD 2.08 6 0.94 2.13 6 0.91 2.45 6 1.26 3.27 6 1.99*
NI (95%) 0.25-3.92 0.34-3.92 0-4.91 0-7.17*
Second molar mesial root, right side \0.001
Mean 6 SD 2.26 6 0.78 2.59 6 0.91 3.11 6 1.09* 3.69 6 1.8*
NI (95%) 0.73-3.79 0.81-4.36 0.97-5.25* 0.16-7.23*
Second molar distal root, right side 0.028
Mean 6 SD 2.4 6 0.86 2.56 6 1.14 2.85 6 1.29 3.08 6 1.55*
NI (95%) 0.72-4.08 0.33-4.78 0.33-5.37 0.04-6.11*
Between second premolar and first molar, left side 0.138
Mean 6 SD 1.12 6 0.88 0.94 6 0.94 1.09 6 1.03 1.35 6 0.93
NI (95%) 0-2.84 0-2.79 0-3.1 0-3.17
First molar mesial root, left side 0.001
Mean 6 SD 0.52 6 0.81 0.46 6 0.74 0.71 6 1.29 1.58 6 1.98
NI (95%) 0-2.11 0-1.91 0-3.24 0-5.46
First molar distal root, left side \0.001
Mean 6 SD 1.23 6 1.09 1.06 6 1.3 1.32 6 1.95 2.66 6 2.45
NI (95%) 0-3.36 0-3.61 0-5.13 0-7.46
Between first and second molar, left side \0.001
Mean 6 SD 1.89 6 1.25 2.1 6 1.58 2.71 6 1.91 3.71 6 2.1*
NI (95%) 0-4.33 0-5.19 0-6.45 0-7.83*
Second molar mesial root, left side \0.001
Mean 6 SD 2.1 6 1.58 2.36 6 1.67 3.02 6 1.97* 3.87 6 2.08*
NI (95%) 0-5.21 0-5.63 0-6.89* 0-7.95*
Second molar distal root, left side 0.002
Mean 6 SD 2.32 6 1.1 2.57 6 1.5 2.73 6 1.76 3.35 6 1.95*
NI (95%) 0.17-4.47 0-5.5 0-6.17 0-7.17*
Note. Data were analyzed using repeated-measures analysis of variance.
SD, standard deviation; NI, normality interval.
*Sites with mean thicknesses .3 mm.

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Lima et al 5

Table II. Mean alveolar thicknesses in patients in the neutral group compared with various sites
Sites

Variable 5 mm 7 mm 9 mm 11 mm P
Between second premolar and first molar, right side 0.003
Mean 6 SD 0.95 6 0.59 0.68 6 0.58 0.81 6 0.8 1.38 6 1.2
NI (95%) 0-2.1 0-1.82 0-2.38 0-3.74
First molar mesial root, right side \0.001
Mean 6 SD 0.37 6 0.45 0.19 6 0.36 0.38 6 0.69 1.34 6 1.45
NI (95%) (0-1.25) (0-0.9) (0-1.74) (0-4.19)
First molar distal root, right side 0.001
Mean 6 SD 1.42 6 0.91 1.17 6 0.89 1.3 6 1.21 2.37 6 1.86
NI (95%) 0-3.2 0-2.92 0-3.67 0-6.02
Between first and second molar, right side \0.001
Mean 6 SD 1.83 6 0.59 1.74 6 0.67 2.06 6 0.88 3.12 6 1.45*
NI (95%) 0.67-2.98 0.44-3.05 0.33-3.79 0.28-5.96*
Second molar mesial root, right side \0.001
Mean 6 SD 2.07 6 0.84 2.32 6 1.15 2.64 6 1.3 3.64 6 2.01*
NI (95%) 0.43-3.71 0.07-4.57 0.1-5.18 0-7.58*
Second molar distal root, right side \0.001
Mean 6 SD 2 6 0.65 1.91 6 1.03 2.13 6 1.25 2.83 6 1.7
NI (95%) 0.73-3.28 0-3.93 0-4.59 0-6.16
Between second premolar and first molar, left side 0.001
Mean 6 SD 0.93 6 0.75 0.73 6 0.69 0.85 6 0.93 1.34 6 1.13
NI (95%) 0-2.39 0-2.08 0-2.67 0-3.56
First molar mesial root, left side \0.001
Mean 6 SD 0.35 6 0.52 0.08 6 0.27 0.31 6 0.64 0.97 6 1.21
NI (95%) 0-1.36 0-0.61 0-1.57 0-3.34
First molar distal root, left side 0.020
Mean 6 SD 1.33 6 1.06 1.14 6 1.04 1.01 6 1.28 1.88 6 2.06
NI (95%) 0-3.42 0-3.18 0-3.52 0-5.91
Between first and second molar, left side \0.001
Mean 6 SD 1.86 6 0.9 1.8 6 0.85 2.1 6 1.1 2.91 6 1.53
NI (95%) 0.09-363 0.12-3.47 0-4.25 0-5.91
Second molar mesial root, left side \0.001
Mean 6 SD 1.75 6 0.77 1.93 6 0.98 2.47 6 1.23 3.01 6 1.63*
NI (95%) 0.24-3.26 0.01-3.85 0.05-4.89 0-6.21
Second molar distal root, left side 0.014
Mean 6 SD 1.99 6 0.87 1.96 6 1.16 2.23 6 1.41 2.6 6 1.7
NI (95%) 0.28-3.71 0-4.24 0-4.99 0-5.94
Note. Data were analyzed using repeated-measures analysis of variance.
SD, standard deviation; NI, normality interval.
*Sites with mean thicknesses .3 mm.

Table II describes the values of subjects of group II— DISCUSSION

neutral—and shows that buccal bone thicknesses
measured between right first and second molars
11 mm from the alveolar crest and mesial root of the
second molar of both sides 11 mm from the alveolar
crest presented mean values .3 mm.
The values for subjects in group III—hypodiver-
gent—are expressed in Table III, which shows that
buccal bone thicknesses measured between first and
second molars 11 mm from the alveolar crest and
mesial root of the second molar 11 mm from the alve-
olar crest presented mean values larger than 3 mm,
bilaterally.
The use of TSADs as auxiliary anchorage in ortho-
dontics has been increasingly incorporated into routine
clinical practice, and research pertaining to these devices
has been increasing. The insertion site may vary accord-
ing to the orthodontic mechanics planned and the
anatomy of the chosen area, which can individually
vary according to the patient's facial type.4,6,8,9,12,13 A
patient who presents a balanced face in the vertical
dimension is classified as neutral; who presents an
increased anterior facial height is classified as hyperdi-
vergent; who presents a decreased anterior facial height
is called hypodivergent.25

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6 Lima et al

Table III. Mean alveolar thicknesses in patients in the hypodivergent group compared with various sites
Sites

Variable 5 mm 7 mm 9 mm 11 mm P
Between second premolar and first molar, right side 0.001
Mean 6 SD 1.07 6 0.58 0.93 6 0.74 0.96 6 1.01 1.62 6 1.19
NI (95%) 0-2.21 0-2.37 0-2.94 0-3.94
First molar mesial root, right side \0.001
Mean 6 SD 0.68 6 0.86 0.57 6 1.05 0.88 6 1.29 1.53 6 1.7
NI (95%) 0-2.35 0-2.62 0-3.41 0-4.86
First molar distal root, right side 0.002
Mean 6 SD 1.61 6 1.02 1.47 6 1.57 1.69 6 2.13 2.7 6 2.65
NI (95%) 0-3.61 0-4.54 0-5.87 0-7.89
Between first and second molar, right side \0.001
Mean 6 SD 1.99 6 1 2.1 6 1.11 2.45 6 1.61 3.25 6 1.94*
NI (95%) 0.04-3.95 0-4.28 0-5.61 0-7.05*
Second molar mesial root, right side \0.001
Mean 6 SD 2.16 6 0.99 2.57 6 1.49 2.94 6 2.05 3.76 6 2.04*
NI (95%) 0.21-4.1 0-5.48 0-6.96 0-7.75*
Second molar distal root, right side 0.008
Mean 6 SD 2.16 6 0.96 2.04 6 1.23 2.38 6 1.72 2.95 6 2.25
NI (95%) 0.28-4.04 0-4.45 0-5.76 0-7.36
Between second premolar and first molar, left side 0.007
Mean 6 SD 1.32 6 0.75 0.97 6 0.73 0.92 6 0.84 1.53 6 1.22
NI (95%) 0-2.79 0-2.4 0-2.57 0-3.93
First molar mesial root, left side 0.002
Mean 6 SD 0.72 6 0.88 0.49 6 0.71 0.67 6 0.9 1.47 6 1.55
NI (95%) 0-2.45 0-1.88 0-2.44 0-4.5
First molar distal root, left side 0.001
Mean 6 SD 1.4 6 0.76 1.23 6 0.91 1.24 6 1.18 2.21 6 1.69
NI (95%) 0-2.9 0-3.01 0-3.56 0-5.52
Between first and second molar, left side \0.001
Mean 6 SD 2.04 6 0.57 2.07 6 0.68 2.33 6 1.05 3.15 6 1.54*
NI (95%) 0.93-3.16 0.75-3.4 0.27-4.4 0.14-6.16*
Second molar mesial root, left side \0.001
Mean 6 SD 2.05 6 0.75 2.3 6 0.88 2.68 6 1.24 3.56 6 1.68*
NI (95%) 0.58-3.51 0.58-4.02 0.24-5.11 0.27-6.84*
Second molar distal root, left side 0.001
Mean 6 SD 2 6 0.79 1.96 6 1.01 2.22 6 1.42 2.75 6 1.73
NI (95%) 0.44-3.56 0-3.94 0-5 0-6.14
Note. Data were analyzed using repeated-measures analysis of variance.
SD, standard deviation; NI, normality interval.
*Sites with mean thicknesses .3 mm.

Previous studies have concluded that the average
thickness of the buccal alveolar bone plate is greater in
hypodivergent patients,29 which is true for the thickness
of the cortical bone in both the mandible and the
maxilla.6,30 In this study, the highest average buccal
bone thickness was found at the mesial root of the
second molar 11 mm from the alveolar crest in the hy-
perdivergent group with a mean thickness of 3.87 mm,
whereas in the hypodivergent group, the same site
showed a mean of 3.56 mm (Tables I and III). Although
it is a clinical difference of 0.31 mm, this result differs
from the results reported in previous studies.5,8 In all
the evaluated groups, there was an increase in average
bone thickness in the distal and apical direction, similar
to previous studies.5,8
During the insertion of the miniscrew in the alveolar
crest, the initial insertion of the miniscrew perpendicular
to the tooth in the region of the mucogingival line is
recommended. After the perforation of the cortical bone,
angulation from 50 to 70 should be used to continue
the screw insertion and avoid contact with the adjacent
roots by searching for a thicker area on the alveolar buccal
bone surface.12,16 Any contact with adjacent roots,
whether during insertion or during orthodontic mechanics,
can cause damage to the tooth roots, failure in mechanics,
or compromised stability of the miniscrew.5,7,12

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Lima et al
Fig 3. Safe sites for infrazygomatic miniscrew insertion. Hyperdivergent patients (A); neutral patients
(B); hypodivergent patients (C).
The miniscrews inserted in the IZC area allow the use
of more complex mechanics.4,7 These are steel devices
with 2 mm diameters and are wider than the diameters
of the conventional ones. During the selection of a site
for the insertion of an orthodontic miniscrew, a safe dis-
tance of at least 0.5 mm from the tooth roots is recom-
mended.11 Hence, to insert a screw of 2 mm diameter in
the IZC area, at least a bone thickness of 3 mm should be
available for safe and effective insertion—0.5 mm dis-
tance from the root, 2 mm of the screw, and 0.5 mm dis-
tance from the most vestibular point of the adjacent
alveolar cortical bone—which guarantees a minimum
safe distance from the root of the adjacent tooth and
also the bone-implant contact ratio to the screw, which
is very important for TSADs primary stability.
In the hyperdivergent group (Table I), the sites deter-
mined to be safe with at least 3 mm of minimum bone
thickness for insertion are located in the area between
the first and second molars 11 mm from the alveolar
crest, the mesial root of the second molar 9 mm and
11 mm from the alveolar crest and distal root of the
second molar 11 mm from the alveolar crest on both
sides (Fig 3, A). The site between the first and
second molars revealed the highest means of 3.69 mm
on the right side and 3.87 mm on the left side. In the
neutral group (Table II), the sites determined to be safe
are located between the first and second molars
11 mm from the alveolar crest and mesial root of the
second molar 11 mm from the alveolar crest on both
sides (Fig 3, B). In this group, the greatest mean of
3.64 mm was found on the mesial root of the right
second molar. Although the site between the left first
and second molars 11 mm from the alveolar crest pre-
sented an average bone thickness of 2.91 mm, it can
be considered a safe site for the miniscrew insertion
because this difference is not clinically significant as
the same site on the right side presented a mean of
3.12 mm. In the hypodivergent group (Table III) the sites
determined to be safe are between the first and
second molars 11 mm from the alveolar crest and the
American Journal of Orthodontics and Dentofacial Orthopedics
7
mesial root of the second molar 11 mm from the alveolar
crest on both sides (Fig 3, C). This latter site presented
the highest mean for this group, showing a mean of
3.76 mm on the right and 3.56 mm on the left side.
Considering the horizontal measurements taken
11 mm from the alveolar crest on all 3 facial types, an
ascending tendency of the mean buccal bone thickness
in a distal direction is noticeable up to the
second molar mesial root. The same ascending tendency
can also be noticed in the apical direction when the sites
between the first and second molar and on the
second molar mesial root are vertically assessed. These
data may show that safer sites for installing a TSAD in
the IZC region are apically and distally located. Future
studies comparing the facial type influence on buccal
bone thickness regarding IZC screws insertion should
be done.
Similar studies have revealed that the appropriate site
for miniscrew insertion in the IZC is between the first and
second maxillary molars.4,5,8 Our study adds that this site
should generally be located 11 mm apical from the alve-
olar crest and that the mesial root of the maxillary
second molar can serve as a site of choice for insertion
in patients of all 3 facial types. It is necessary to
remember that in the site 11 mm apical from the alveolar
crest, the chance of reaching the mucogingival junction
or invading the movable mucosa is great.7,15 Previous
studies found no statistical differences in the success
rate between extraalveolar TSADs inserted in movable
mucosa or attached gingiva.7,15 In the case of reaching
the movable mucosa, the orthodontist should consider
choosing longer-length screws to maintain the screw
head out of the mucosa intending the screw viability
all over the treatment.
The previous studies6,31 evaluated only the thickness
of cortical bone at the insertion sites of these devices,
which is an important factor for attaining primary stabil-
ity in the miniscrews due to the insertion torque, which
may further influence the success rates of the
miniscrews. However, they did not measure the total
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8 Lima et al
bone thickness in this area. Miniscrews of 2 mm diame-
ters inserted in the IZC area with adequate cortical bone
thickness but a total buccal bone thickness of less than
3 mm may show compromised primary stability and
increase the chances of damage during insertion because
of the proximity to the adjacent roots. In our study, we
measured the total thickness of the buccal alveolar
bone to determine the sites most suitable for miniscrew
insertion.
As the measurement of alveolar bone thickness is a
delicate evaluation, a reduced field of view tomography
should be used to reduce the voxel size and increase the
image quality. This study was conducted using existing
tomographic images from a database, which were per-
formed in a larger field of view and obtained a voxel
size of 0.4 mm. Previous studies32,33 have also used
0.4 mm voxels and deemed them appropriate for such
measurements.
This study analyzed the total buccal bone thickness
in the IZC area to determine a safe area for the insertion
of TSAD to be used as skeletal anchorage in orthodontic
treatments. However, other factors do influence the sta-
bility of these devices. A secure insertion area does not
imply guaranteed stability; it is the first step for success-
ful insertion and stability of the device.
CONCLUSIONS
According to the results obtained in this study, the
sites that can be considered safe by the orthodontist
for the insertion of infrazygomatic miniscrews are
located bilaterally 11 mm from the maxillary alveolar
crest between the first and second molars and on the
mesial root of the second molar, for the 3 facial types.
For patients with hyperdivergent facial types, the site
9 mm from the maxillary alveolar crest at the mesial
root of the second molar and the site 11 mm from the
maxillary alveolar crest at the distal root of the
second molar were added.
AUTHOR CREDIT STATEMENT
Almir Lima J
unior contributed to conceptualization,
methodology, formal analysis, investigation, original
draft preparation, and visualization; Rafael Golghetto
Domingos contributed to original draft preparation,
review and editing of the manuscript, and visualization;
Annelise Nazareth Cunha Ribeiro contributed to the
methodology and investigation; Jos
e Rino Neto
contributed to validation and supervision; Jo~ao Batista
de Paiva contributed to conceptualization, methodol-
ogy, resources, and supervision.
- 2021  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics
ACKNOWLEDGMENTS
The authors would like to acknowledge CAPES for
providing a scholarship for the MSc degree of Almir
Lima Jr., DDS.
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