Bone and Cortical Bone Thickness of Mandibular Buccal Shelf
Bone and Cortical Bone Thickness of Mandibular Buccal Shelf
Bone and Cortical Bone Thickness of Mandibular Buccal Shelf
ABSTRACT
Objective: To analyze the buccal bone thickness, bone depth, and cortical bone depth of the
mandibular buccal shelf (MBS) to determine the most suitable sites of the MBS for mini-screw
insertion.
Materials and Methods: The sample included cone-beam computed tomographic (CBCT) records
of 30 adult subjects (mean age 30.9 6 7.0 years) evaluated retrospectively. All CBCT examinations
were performed with the i-CAT CBCT scanner. Each exam was converted into DICOM format and
processed with OsiriX Medical Imaging software. Proper view sections of the MBS were obtained
for quantitative and qualitative evaluation of bone characteristics.
Results: Mesial and distal second molar root scan sections showed enough buccal bone for mini-
screw insertion. The evaluation of bone depth was performed at 4 and 6 mm buccally to the
cementoenamel junction. The mesial root of the mandibular second molar at 4 and 6 mm showed
average bone depths of 18.51 mm and 14.14 mm, respectively. The distal root of the mandibular
second molar showed average bone depths of 19.91 mm and 16.5 mm, respectively. All sites
showed cortical bone depth thickness greater than 2 mm.
Conclusions: Specific sites of the MBS offer enough bone quantity and adequate bone quality for
mini-screw insertion. The insertion site with the optimal anatomic characteristics is the buccal bone
corresponding to the distal root of second molar, with screw insertion 4 mm buccal to the
cementoenamel junction. Considering the cortical bone thickness of optimal insertion sites, pre-
drilling is always recommended in order to avoid high insertion torque. (Angle Orthod.
2017;87:745751.)
KEY WORDS: Mandibular buccal shelf; Mini-screw; Mini-implants; Skeletal anchorage; Extra-
alveolar orthodontic anchorage; Temporary anchorage devices
INTRODUCTION
a
Assistant Professor, Department of Biomedical and Dental
Sciences and Morphofunctional Imaging, Section of Orthodon- Orthodontic mini-screws have attained widespread
tics, School of Dentistry, University of Messina, Messina, Italy. use recently, providing skeletal anchorage to improve
b
Research Assistant, Department of Biomedical and Dental orthodontic mechanics.13 Mini-screws have demon-
Sciences and Morphofunctional Imaging, Section of Orthodon-
tics, School of Dentistry, University of Messina, Messina, Italy. strated good patient acceptance4 and relatively low
c
Associate Professor, Head of Orthodontic Unit and Chair of failure rates, reported at around 13.5%.5,6 Primary
the Orthodontic Postgraduate Program, Department of Surgical stability is a key factor for successful mini-screw
and Morphological Sciences, Section of Orthodontics, School of
Medicine, University of Insubria, Varese, Italy. placement.7 Anatomical factors affecting the stability
d
Associate Professor, Head of Orthodontic Unit and Chair of of mini-screws are bone characteristics (bone density,
the Orthodontic Postgraduate Program, Multidisciplinary Depart-
ment of Medical-Surgical and Dental Specialties, Second
Corresponding author: Dr Riccardo Nucera, c/o AOU Policli-
University of Naples, Naples, Italy.
nico G. Martino, UOC di Odontoiatria e Odontostomatologia,
e
Associate Professor, Department of Biomedical and Dental
Via Consolare Valeria 1, 98125 Messina, Italy
Sciences and Morphofunctional Imaging, Section of Orthodon-
(e-mail: [email protected])
tics, School of Dentistry, University of Messina, Messina, Italy.
f
Full Professor and Chair, Department of Biomedical and Accepted: April 2017. Submitted: January 2017.
Dental Sciences and Morphofunctional Imaging, Section of Published Online: June 09, 2017
Orthodontics, School of Dentistry, University of Messina, 2017 by The EH Angle Education and Research Foundation,
Messina, Italy. Inc.
bone depth, cortical bone thickness), soft tissue ization based on patients sex was applied to select the
characteristics (mucosa vs attached gingiva, tissue included CBCT exams. The protocol of this study was
thickness, mobility and proximity to the frenum), and approved by the human research ethical committee
the proximity of specific anatomical structures (roots, (Approval No. 102/16). All CBCT examinations were
nerves, vessels, sinus/nasal cavities). performed with the i-CAT CBCT scanner (Imaging
Different sites have been used for mini-screw Sciences International, Hatfield, Pa) after setting the
insertion: palatal bone,7,8 the palatal side of the acquisition parameters as follows: 120 kV, 5 mA, and
maxillary alveolar process,9 the mandibular retromolar 4- to 6-second exposure time. Each exam was
area,10 the infrazygomatic crest,11 the maxillary and converted to digital imaging and communications in
mandibular bucco alveolar cortical plate,12 and the medicine (DICOM) format. DICOM files were pro-
posterior palatal alveolar process.7 Recently, the cessed using the OsiriX Medical Imaging 32-bit
mandibular buccal shelf (MBS) has been proposed13 software (Pixmeo, Geneva, Switzerland; www.
as a suitable extra-alveolar mini-screw insertion site. osirix-viewer.com).
The MBS is located bilaterally in the posterior part of The following procedure was used to obtain proper
the mandibular body, buccal to the roots of the first and view sections of the MBS for quantitative and
second molars and anterior to the oblique line of the qualitative evaluation of bone characteristics. Three
mandibular ramus. preliminary reference lines were considered, as shown
To date, no quantitative and qualitative bone by the software interface, corresponding to the three
assessment of the MBS has been performed for mini- conventional scan planes (sagittal: yellow line; axial:
screw insertion. The aim of this study was to analyze violet line; and coronal: blue line). These view scan
the buccal bone thickness, bone depth, and cortical planes were reoriented according to the following
bone depth of the MBS to determine the most suitable method: the furcation point of the right and left first
sites of the MBS for mini-screw insertion. molar and the furcation point of the right second molar
were identified and the axial view scan plane was
MATERIALS AND METHODS reoriented in order to pass through these three
furcation points. In this reoriented axial scan plane,
The sample of this retrospective study included two points were identified at the center of the dento-
cone-beam computed tomographic (CBCT) records of alveolar process at the level of the mesial root of the
30 subjects (mean age 30.9 6 7.0 years), including 15 mandibular first molar and the distal root of the second
males (mean age 31.2 6 7.7 years) and 15 females molar. These points were used as references to
(30.7 6 5.2 years) selected from the digital archive of a reorientate the sagittal view scan plane section in
private practice. The CBCT exams were performed order to identify the mesio-distal direction of the
between June 2012 to November 2015 and were pre- mandibular alveolar process in the molar segment.
selected if the examined subjects fulfilled the following Finally, the coronal view scan plane was reoriented in
selection criteria: Caucasian subjects, aged between order to best fit the direction of the two-thirds coronal
20 and 41 years, with an absence of periodontal long axes of these four roots (Figure 1): mesial and
disease, no metallic restorations in the first or second distal first molar roots, mesial and distal second molar
permanent mandibular premolars and molars, no roots. This procedure identified four coronal view
missing teeth except for third molars, no genetic sections used to investigate the MBS bone character-
syndromes or craniofacial dysmorphism, no history of istics. It was repeated for both the right and left sides.
facial trauma, and no previous orthognathic surgery A modified version of the method reported in
treatment. previous publications14,15 was performed to identify
Seventy-six patients fulfilled the selection criteria (35 specific parameters evaluating bone quantity and
male and 41 female). The patients were divided quality on each coronal view section.
according to sex, and each of the two samples was This methodology included the following steps:
ordered by age from the youngest to the oldest patient.
These two lists of patients were used to assign a Identification of the vestibular cementoenamel junc-
number to each patient from 1 to 35 for the male list tion (CEJ) on each scan view root section;
and from 1 to 41 for the female list. A random Evaluation of the buccal total bone thickness on two
sequence generator (http://www.randomizer.org) was horizontal reference lines located apically at 6 mm
used to generate two lists of randomized numbers of (TotThick-at-6) and 11 mm (TotTick-at-11) from the
35 and 41 numbers, respectively. The first 15 numbers CEJ (Figure 2); and
of both random lists were selected and the corre- Apico-coronal total bone depth (cortical medullary
sponding CBCT exams were included in the study. bone) and cortical coronal bone depth were mea-
According to this method, a balanced block random- sured on two vertical reference lines buccally located
Figure 1. Software interface; reoriented reference scan lines (sagittal: yellow line; axial: violet line; and coronal: blue line) in order to best fit the
direction of the long axes of the mesial root of the second left mandibular molar.
Statistics
A preliminary analysis was run on 10 subjects to
obtain data for power analysis evaluation. The MBS
bone thicknesses measured on a horizontal reference
line apically located at 6 mm from CEJ (TotThick-at-6)
of the mesial and distal roots of the right second molar
were compared, and the difference in means of 1.81
Figure 2. The bucco-lingual thicknesses of total bone (cortical
mm and the standard deviation (SD) of 2.47 mm were medullary bone) and cortical bone were measured on two horizontal
used as outcomes to perform the power analysis reference lines apically located at 6 mm (TotThick-at-6) and 11 mm
calculation. The results of the power analysis indicated from the CEJ (TotTick-at-11).
a
First column abbreviations: R1M-m indicates right first molar
Figure 3. The apico-coronal bone depth thicknesses of total bone mesial root; L1M-m, left first molar mesial root; R1M-d, right first
(cortical medullary bone) and coronal cortical bone were measured molar distal root; L1M-d, left first molar distal root; R2M-m, right
second molar mesial root; L2M-m, left second molar mesial root;
on two vertical reference lines buccally located at 4 mm (TotaDepth-
R2M-d, right second molar distal root; and L2M-d, left second molar
at4 and CortDepth-at-4) and 6 mm (TotaDepth-at6 and CortDepth-at- distal root.
6) from the CEJ.
Table 3. Descriptive Statistics of Cortical Coronal Thickness Values of Different Root Sites Measured on Two Vertical Reference Lines at 4
(CortDepth-at-4) and 6 mm (CortDepth-at-6) buccal to the Cementoenamel Junction. The Abbreviations in the First Column Are Explained in the
Table 1 Footnotea
CortDepth-at-4 CortDepth-at-6
Evaluated Root Sites Mean SD a
Min b
Max c
Mean SDa Minb Maxc
R1M-m 7.20 6.94 0 20.75 2.38 5.21 0 16.27
L1M-m 7.66 5.53 0 19.85 4.63 5.27 0 14.73
R1M-d 7.45 5.57 0 17.15 4.34 5.76 0 19.19
L1M-d 5.19 2.38 0 13.2 7.58 6.14 0 21.28
R2M-m 6.63 4.86 2.24 19.62 7.45 6.60 0 21.87
L2M-m 5.45 3.77 0 18.58 7.45 6.68 0 21.93
R2M-d 6.07 5.32 1.24 21.9 10.46 8.08 0 23.23
L2M-d 4.94 3.35 1.9 17.78 6.99 6.31 0 20.48
a
SD indicates standard deviation; bMin, minimum; and cMax, maximum. Vs indicates versus.
values considered suitable for mini-screw insertion ciated with mandibular interradicular mini-screw inser-
are labeled with the light gray color, and data tion. In order to properly insert a mini-screw in the
considered nonsuitable are labeled with the dark MBS, an understanding of the anatomical bone
gray color. Table 4 reports the results of the inferential characteristics of this insertion site is essential.
statistics. Upon preliminary evaluation, a minimum cutoff value
of the buccal extension of the MBS for safe mini-screw
DISCUSSION insertion was considered to be 5 mm of buccal bone
To the best of our knowledge, this is the first study in thickness (1.7 mm of root safety distance, 1.6 mm of
the literature that investigates the anatomic skeletal screw diameter, 1.7 mm of cortical buccal bone safety
characteristics of the MBS for mini-screw insertion. distance). Descriptive statistical data showed that the
The MBS potentially offers some clinical advantages total buccal bone thickness increases in the distal and
compared to dento-alveolar interradicular mini-screw in the apical portions of the MBS.
insertion sites. The MBS extends buccally with a The amount of buccal bone thickness was evaluated
considerable amount of bone, and this extension at two different vertical levels: 6 and 11 mm apical to
allows clinicians to insert mini-screws in an orientation the CEJ. Distal root of the second molar scan sections,
parallel to the long axes of the molar roots.13 This on both the right and left sides, were the only sections
insertion modality could offer clinical advantages by that showed an average of more than 5 mm of total
avoiding possible screw-to-root contact during anterior- buccal bone thickness 6 mm apical to the CEJ (Table
posterior dental movements along the dento-alveolar 1). Both the mesial and distal second molar root scan
process. Another advantage could be a reduced risk of sections on both sides (right and left) showed enough
screw-to-root contact during insertion, considering that buccal bone for mini-screw insertion at 11 mm apical to
screw-to-root contact is one of the most frequent the CEJ. Significant differences (P , .05) in buccal
causes of failure.16 This characteristic could help to bone thickness were found between measurements at
explain the observations by Chang et al.,13 who 6 and 11 mm (Table 4). Inferential statistics also
reported lower failure rates compared to those asso- revealed that the distal root of the second molar site
Table 4. Inferential Statistics of Buccal Bone Thickness Data of Right and Left Second Molar. The Abbreviations in the First Column Are
Explained in the Table 1 Footnotea
Right Second Molar Left Second Molar
Evaluated Root Sites R2M-m R2M-d L2M-m L2M-d
TotThick-at-6 3.76 (62.53) Vs** 5.57 (62.42) 4.25 (62.38) Vs** 5.63 (62.44)
Vs* Vs* Vs* Vs*
TotThick-at-11 6.86 (62.02) Vs** 7.88 (61.71) 7.04 (61.65) Vs** 7.71 (61.69)
TotDepth-at-4 9.46 (63.64) Vs (NS) 8.81 (64.41) 8.44 (63.47) Vs (NS) 8.19 (62.8)
Vs (NS) Vs (NS) Vs (NS) Vs (NS)
TotDepth-at-6 8.69 (66.33) Vs (NS) 11.41 (67.44) 9.44 (65.96) Vs (NS) 9.34 (65.63)
TotCort-at-4 6.63 (64.86) Vs (NS) 6.07 (65.32) 5.45 (63.77) Vs (NS) 4.94 (63.35)
Vs (NS) Vs (*) Vs (NS) Vs (NS)
TotCort-at-6 7.45 (66.6) Vs (NS) 10.46 (68.08) 7.45 (66.68) Vs (NS) 6.99 (66.31)
a
NS indicates not significant.
** Significant difference with P , .05 (unpaired t-test); * Significant difference with P , .05 (paired t-test).
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