Original Article

An evaluation of insertion sites for mini-implants

A micro-CT study of human autopsy material
Morten G. Laursena; Birte Melsenb; Paolo M. Cattaneoc

ABSTRACT
Objective: (1) To report the thickness of the cortical bone in insertion sites commonly used for
orthodontic mini-implants, (2) to assess the impact of a change in insertion angle on primary
cortical bone-to-implant contact, and (3) to evaluate the risk of maxillary sinus perforation.
Materials and Methods: At autopsy, 27 human samples containing three to five adjacent teeth
were excised and scanned using a table-top micro-computed tomography system. Bone thickness
measurements were taken at 45u and 90u to the long the axis of the adjacent teeth, simulating a
mini-implant insertion at the mid-root level.
Results: In the maxilla, the overall mean cortical thickness at 90u was 0.7 mm buccally in the
lateral region, 1.0 mm buccally in the anterior region, and 1.3 mm palatally. In the mandible, the
mean cortical thickness was 0.7 mm buccally and 1.8 mm lingually in the anterior region; 1.9 mm
buccally and 2.6 mm lingually in the lateral region. Changing the insertion angle from 90u to 45u
increased the cortical bone-to-implant contact by an average of 47%. Perpendicular insertion at the
mid-root level only rarely interfered with the sinus, whereas apically inclined insertion increased the
risk of sinus perforation.
Conclusions: Buccally and palatally in the maxilla and buccally in the anterior mandible, the
thickness of the alveolar cortical bone is often less than 1 mm. In contrast, the alveolar cortical
bone is frequently thicker than 2 mm laterally in the mandible. Changing the insertion angle to 45u
will generally enhance implant stability but increase the risk of perforation to the maxillary sinus.
(Angle Orthod. 2013;83:222–229.)
KEY WORDS: Mini-implant; Micro-CT; Temporary anchorage; Orthodontics; Alveolar bone

INTRODUCTION and easily accessible insertion sites are the buccal

Primary stability of skeletal anchorage is dependent
on the quantity and quality of bone in the insertion site.
It has been reported that the cortical bone should have
a thickness of more than 1 mm in order to obtain good
stability of orthodontic mini-implants.1–3 The most used
a
Clinical Assistant Professor, Department of Orthodontics,
School of Dentistry, Health, Aarhus University, Denmark. Private
practice, Aarhus, Denmark.
b
Professor and Department Chair, Department of Orthodon-
tics, School of Dentistry, Health, Aarhus University, Denmark.
c
Associate Professor, Department of Orthodontics, School of
Dentistry, Health, Aarhus University, Denmark.
Corresponding author: Dr Morten G. Laursen, Clinical
Assistant Professor, Department of Orthodontics, School of
Dentistry, Health, Aarhus University, Vennelyst Boulevard 9, DK-
8000 Aarhus, Denmark
(e-mail: mortengl@yahoo.com)
Accepted: July 2012. Submitted: April 2012.
Published Online: August 27, 2012
G 2013 by The EH Angle Education and Research Foundation,
Inc.
aspect of the alveolar process in both the maxilla and
mandible as well as the palatal side of the maxillary
alveolar process in the premolar and molar region.4
The thickness of human cortical bone in these areas
has been assessed by conventional computed tomog-
raphy (CT)5–8 and cone-beam computed tomography
(CBCT).9–13 More detailed information can be achieved
using micro-computed tomography (micro-CT). Indeed,
compared to CBCT and CT, micro-CT scanning offers
an enhancement of voxel quality and a reduction in
voxel size, providing higher precision imaging.14 A
detailed description of the alveolar process might
provide the clinician with fundamental knowledge,
increasing the success of orthodontic treatment with
mini-implant anchorage. To the knowledge of the
authors, the entire human dentoalveolar bone complex
has not been studied previously by means of micro-CT.
The general recommendation is to place mini-
implants in attached gingiva,4,15,16 yet as apical as
possible since the interradicular distance increases in
the apical direction, reducing the risk of root damage.13,16

Angle Orthodontist, Vol 83, No 2, 2013 222 DOI: 10.2319/042512-344.1

MINI-IMPLANTS AND MICRO-CT
A solution is to insert the mini-implants at an angle
directing the mini-implant apically, which will also lead
to an increased primary bone-to-implant contact.5,17
On the other hand, this solution might increase the
risk of sinus perforation. In particular, the risk of sinus
perforation with interradicular mini-implants placed
from the buccal aspects with an apical insertion
direction so far has not been addressed systemati-
cally. The risk of perforation of the maxillary sinus
during mini-implant insertion has merely been report-
ed in relation to insertion at the apical level of the
molars, including the infrazygomatic crest and distally
to the second molar.9,10,17–20 Long mini-implants of 8 to
10 mm have been reported to be associated with a
higher risk of sinus membrane perforation than the
shorter mini-implants of 6 mm.21
The purpose of this study was to: (1) provide
detailed information of the cortical thickness in the
most commonly used insertion sites, (2) assess how a
change in the insertion angle influences the primary
cortical bone-to-implant contact, and (3) evaluate the
risk of sinus perforation during mini-implant insertion.
MATERIALS AND METHODS
Permission from the National Committee on Health
Research Ethics was granted to collect tissue samples
containing teeth and surrounding alveolar bone at
human autopsy of 27 adult donors (18 male, 9 female).
The age of the donors ranged from 20 to 50 years, with
a mean age of 34 years. None of the donors had report
of disease or medication, which could influence the
bone turnover. A dentoalveolar bone-block containing
three to five adjacent teeth was excised from each
individual. All teeth were in occlusion, and except from
third molars, all teeth were represented in at least four
samples. No differentiation between the right and left
side was made. The samples were fixed in 70%
alcohol before micro-CT scanning was performed with
a table-top micro-CT system (mCT40, Scanco Medical,
Bassersdorf, Switzerland) at an energy of 70 kVp and
a current of 113 mA. A standard-medium resolution
mode (1024 pixels, 500 projections) with an integration
time of 200 ms was chosen, resulting in an isotropic
voxel of 37 mm and an in-plane dimension of 1024 3
1024 pixels. To improve the validity and quality of the
reconstructed images, an oversampling factor of 3 was
adopted during the scanning (Figure 1). After scan-
ning, the single-slice images were exported as stacks
of TIFF files.
The TIFF file datasets were imported into Mimics
(Materialise, Leuven, Belgium), where all of the
measurements were performed. The datasets were
aligned in the three planes of space along the tooth
axis of the adjacent teeth. Before every set of
223
measurements, the root length of each tooth, defined
as the distance from the cementoenamel junction to
the apex, was measured. One hundred fifty-one
possible insertion sites were examined. The thickness
of the cortical bone was measured buccally as well as
palatally/lingually, corresponding to the approximal
spaces between all teeth. To simulate an insertion in
the attached gingiva close to the mucogingival
junction, the measurements were performed at 45u
and 90u in relation to the long axis of the teeth at the
mid-root level (Figure 2). At the same level, the risk of
perforating to the maxillary sinus (Figure 3a) was
assessed by measuring the distance from the outer
aspect of the palatal and buccal cortical bone plate to
the maxillary sinus cavity at 45u and 90u (Figure 3b). It
was noted whether the simulated insertion path
caused a sinus perforation or not.
The three-dimensional (3D) rendering of the sam-
ples was performed after importing the datasets into
VGStudio MAX (Volume Graphics GmbH, Heidelberg,
Germany).
Statistical Analyses
The data were grouped according to localization
in either the upper or lower jaw. Each group was
subdivided with respect to buccal and palatal/lingual
aspect and according to the insertion angle. Mean
values were calculated for each group and presented
along with the minimum and maximum value. The error
of the method for determination of cortical thickness
was calculated by double measurements of 10
randomly selected sites from 10 randomly selected
samples using the Dahlberg formula (s 5 !Sd2 / 2n,
where d 5 difference between the first and second
measurements).22 The error of the method for the
distance to the sinus from the outer (ie, buccal and
palatal) cortical bone was calculated on double
measurements of 10 randomly selected sites in the
four samples available.
RESULTS
Error of the Method
The method error for the measurement of the
cortical bone thickness was 0.15 mm at 90u and
0.27 mm at 45u. The method error for the distance to
the maxillary sinus from the outer cortical bone was
0.63 mm at 45u, while at 90u it was not calculated
because only one interdental site presented with risk
of sinus perforation at this insertion angulation.
Thickness of Cortical Bone at 906
The mean thickness of the buccal cortical bone
posterior to the lateral incisor in the maxilla and
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224 LAURSEN, MELSEN, CATTANEO

Figure 1. Micro-CT scanning of a mandibular posterior segment. A clear differentiation between trabecular and cortical bone is provided by the
detailed visualization.

anterior to the first premolar in the mandible was less
than 1 mm measured perpendicularly to the long axis
of the teeth (Table 1A,B). Between the maxillary
incisors the mean buccal cortical thickness was
1.1 mm. Palatally, the cortical bone was on average
slightly thicker with an overall mean value of 1.3 mm.
The cortical bone was found laterally in the mandible
where the cortex was thicker both lingually and
buccally than in any other region. The average cortical
bone thickness laterally in the mandible ranged from
1.45 mm to 2.99 mm, at an angle of 90u. Lingually in
the anterior mandible, the mean cortical bone was
1.81 mm thick. In both jaws, the cortical bone was
generally thicker on the lingual/palatal side than on the
corresponding buccal side. A large interindividual
variation was noted.
Impact of a Change in Insertion Angle to 456
A change in measurement angle from 90u to 45u to
the tooth long axis resulted in an increase of the
measured cortical bone thickness (Table 1A,B). The
overall average increase in the primary alveolar bone-
to-implant contact was 47%.
Risk of Sinus Perforation
The maxillary sinus floor extended further into the
alveolar process in relation to the molars than to the
premolars, but rarely reached the mid-root level
(Table 2). Therefore, when insertion was simulated
perpendicular to the long axis of the teeth, only one
interdental space involved a risk of sinus perforation. A
change in the angle to 45u, on the other hand, did

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MINI-IMPLANTS AND MICRO-CT
Figure 2. The thickness of the buccal and lingual cortical bone was measured at mid-root level (red dotted line). Mini-implant insertion was
simulated with angulations of 45u and 90u to the long axis of the teeth.
increase the risk of perforation considerably. Examin-
ing the interdental spaces from second premolar to
second molar, all interdental spaces presented with
risk of perforation at a 45u insertion angle. At 45u, the
distance from the outer-buccal or outer-palatal cortical
bone plate to the sinus was ranging from 2.1 to 8.8 mm.
A thin layer of cortical bone lining the maxillary sinus
was found in all four samples.
DISCUSSION
The aim of this study was to analyze the anatomy of
the human alveolar bone by means of high-precision
225
3D micro-CT scanning of human autopsy material. In
particular, the thickness of the cortical bone was
assessed in the most common insertion sites of mini-
implants, as the primary stability of mini-implant
systems is first and foremost dependent on the bone
quantity and quality of the insertion site.1,3 Because the
samples derived from autopsy material, alveolar bone
blocks could be harvested, and a high-resolution
micro-CT scanning could be applied. This resulted in
an isotropic voxel size of 0.037 mm with a minimized
partial volume effect compared to CT and CBCT (in the
most recent CBCT study10 on cortical thickness the
Angle Orthodontist, Vol 83, No 2, 2013
226 LAURSEN, MELSEN, CATTANEO

Figure 3a. Sinus perforation can occur during mini-implant insertion. The simulated mini-implant insertions are performed with angulations of 45u
and 90u to the long axis of the teeth.
Figure 3b. The distances from the outer cortical bone to the maxillary sinus cavity were measured at mid-root level simulating mini-implant
insertion angles of 45u and 90u to the long axis of the teeth.

voxel size was 0.28 mm). The voxel size has a critical
influence on the measured thickness of the cortical
bone: Tsutsumi et al.23 demonstrated in an in vitro
CBCT study that the measured structure must have a
thickness of at least 3 to 4 voxel size to maintain high
accuracy of the measurements. The thickness of the
alveolar cortical bone was found to be often less than
1 mm buccally in the entire maxilla and anteriorly in the
mandible, corroborating earlier reports.5,7,10–12 Thus,
the accuracy of the micro-CT measurements was high

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MINI-IMPLANTS AND MICRO-CT 227

Table 1A. Mean, Minimum, and Maximum Cortical Bone Thickness (in mm) in the Maxillaa
Maxilla 7-6 Maxilla 6-5 Maxilla 5-4
Mean Min Max Mean Min Max Mean Min Max
Buccal 90u 0.54 0.26 0.70 0.92 0.54 1.33 0.44 0.26 0.61
Buccal 45u 0.83 0.44 1.06 1.33 1.07 1.88 0.89 0.44 1.22
Palatal 90u 0.84 0.20 1.46 1.39 0.74 2.17 1.16 1.02 1.29
Palatal 45u 1.10 0.83 1.66 1.72 1.35 2.07 1.43 0.80 1.96
a
The 90u and 45u indicate the degrees at which measurements were performed in relation to the long axis of the teeth at the mid-root level.

Table 1B. Mean, Minimum, and Maximum Cortical Bone Thickness (in mm) in the Mandiblea
Mand 7-6 Mand 6-5 Mand 5-4
Mean Min Max Mean Min Max Mean Min Max
Buccal 90u 2.56 1.64 3.83 1.80 1.02 2.66 1.95 0.91 2.87
Buccal 45u 3.46 2.37 5.47 2.55 1.33 4.10 2.76 1.74 3.39
Lingual 90u 2.31 1.39 3.90 2.45 1.37 3.64 2.59 1.10 4.70
Lingual 45u 3.55 2.27 5.53 3.54 1.70 5.87 3.55 1.74 7.72
a
The 90u and 45u indicate the degrees at which measurements were performed in relation to the long axis of the teeth at the mid-root level.

compared to earlier studies. On the other hand, the
limited sample size of the present study was a
limitation, especially considering the large interindivid-
ual variation.
Different references have been used for measuring
the thickness of the cortical bone, eg, the palatal
plane,12 the Frankfort horizontal plane,13 the occlusal
plane,7 the mandibular plane,8 the perpendicular to the
bone surface,10,11 of the local insertion site and the long
axis of adjacent teeth.5,6 We opted for the latter method
because it seems to be clinically applicable. However,
the direction of the measurements has an influence on
the measurement of the cortical thickness, as the
surface is generally slightly angulated in relation to the
long axis of the teeth. The use of different measure-
ment and scanning methods might explain some of the
variation of the measured cortical bone thickness
found in the literature.5–8,10–13 Additionally, the intrain-
dividual irregular thickness of the cortical bone seen in
Figure 2 increases the variation of the measured
thickness.
The marked range between minimum and maximum
values of the cortical bone thickness found between
same sites in different samples could be ascribed to a
large interindividual variation also noted by Baumgaertel10
and Baumgaertel and Hans.11 Taking into account the
mean values and the large variation, it can be deducted
that the thickness of the cortical bone in the individual
patient often will be less than 1 mm at the midroot level
both buccally and palatally in the entire maxillary alveolar
process, as well as buccally in the anterior mandibular
alveolar process. Therefore, the stability of the mini-
implants eventually has to rely on the trabecular bone
structure in these areas1; consequently, a long mini-
implant with an intraosseous length of 8 mm might be the
right choice.1 Moreover, an apical directed insertion will
increase the primary cortical bone-to-implant contact. On
the other hand, the alveolar cortical bone buccally and
lingually in the posterior mandible would frequently be
thicker than 2 mm, regardless of the insertion angle. In
this region, a mini-implant of 6 mm should be sufficient,1
and the consequent higher insertion torque moment
could even call for predrilling in order to decrease the risk
of implant fracture or secondary implant failure.24,25
The relatively short distance to the maxillary sinus
from the outer alveolar cortical bone found in the
present study implies a risk of perforation of the
maxillary sinus if mini-implants are planned for
insertion with an apical inclination. A recent study10
measured the bone depth perpendicular to the bone

Table 2. Distance (in mm) to the Maxillary Sinus From the Outer Aspect of the Buccal and Palatal Alveolar Processa
Region 7-6 Region 6-5 Region 5-4
Buccal 90u 5.46 – – – – – – – – – – –
Buccal 45u 4.35 3.25 4.84 5.81 8.76 6.63 7.22 5.15 – – – –
Palatal 90u 3.82 – – – – – – – – – – –
Palatal 45u 2.82 6.26 5.20 4.63 2.92 5.21 7.31 2.05 – – – –
a
The 90u and 45u indicate the degrees at which measurements were performed in relation to the long axis of the teeth at the mid-root
level. The en dash denotes no risk of sinus perforation at any distance, as the insertion path is passing inferiorly or anteriorly to the maxillary
sinus.

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228 LAURSEN, MELSEN, CATTANEO

Table 1A. Extended

Maxilla 4-3 Maxilla 3-2 Maxilla 2-1 Maxilla 1-1
Mean Min Max Mean Min Max Mean Min Max Mean Min Max
0.77 0.55 0.97 0.72 0.47 1.03 1.10 0.16 1.95 1.11 0.16 1.78
1.61 1.07 2.09 1.74 1.09 2.84 1.95 0.33 3.78 1.55 0.21 2.77
1.83 1.25 2.99 1.29 0.85 1.58 1.29 0.48 1.86 1.44 0.30 2.00
1.94 1.35 2.27 1.50 0.91 2.10 1.62 0.62 2.20 2.10 0.54 3.64

Table 1B. Extended

Mand 4-3 Mand 3-2 Mand 2-1 Mand 1-1
Mean Min Max Mean Min Max Mean Min Max Mean Min Max
1.45 0.50 2.50 0.84 0.44 1.24 0.64 0.25 1.12 0.46 0.49 0.57
2.97 1.15 4.24 1.56 0.77 2.25 1.18 0.73 1.54 0.71 0.59 0.91
2.99 2.15 4.18 2.49 0.84 3.18 1.24 0.36 2.21 1.71 0.97 2.60
3.60 3.24 3.84 3.18 1.41 3.79 1.57 0.51 2.37 2.02 1.14 3.10

surface and found a minimum distance from the palatal CONCLUSIONS

aspect, slightly apical to the mid-root level, to the sinus
as low as 1.90 mm distally and 0.80 mm mesially to
the first maxillary molar. Having in mind that these
specific interradicular sites are recommended as safe
sites for insertion of mini-implants,5,13,17 sinus perfora-
tions are expected to be a relatively common side
effect. Nevertheless, not much attention has been
given to this side effect, presumably because a small
perforation rarely gives rise to complications and
heals without intervention.26–28 The use of long mini-
implants (8 mm) is recommended1 in order to increase
primary stability when thin cortical bone (less than
1 mm) can be expected.1,2 In the maxillary molar
region, insertion of 8-mm long mini-implants at 45u to
the long axis of the teeth will increase the cortical
bone-to-implant contact (compared to perpendicular
insertion) and the trabecular bone-to-implant contact
in cases with a sufficient distance to the sinus.
Furthermore, the use of an 8-mm mini-implant will
increase the chance of obtaining bicortical anchorage,
shown by Brettin et al.29 to be superior to unicortical
anchorage. However, apically angulated insertion in
the maxillary molar region will lead to a higher risk of
sinus perforation. The present study indicates that the
risk of sinus perforation can be reduced without
compromising the primary stability, if the 8-mm mini-
implant is inserted as occlusally/marginally as possi-
ble, still with an apical direction.
A successful mini-implant insertion should lead to a
stable implant without complications or injury to teeth
or surrounding tissues. Hence, the use of skeletal
anchorage should be applied only after careful
diagnosis and planning of biomechanics in relation to
the insertion site and vice versa.30
N The interindividual variation was large with respect to
the cortical bone thickness as well as the distance
from the outer alveolar cortical bone to the maxillary
sinus.
N The thickness of the alveolar cortical bone is often
less than 1 mm buccally and palatally in the entire
maxilla, and buccally in the anterior mandible.
N In the posterior mandible, the alveolar cortical bone
is frequently thicker than 2 mm.
N Changing the insertion angle from 90u to 45u can
enhance primary mini-implant stability but will in-
crease the risk of sinus perforation in the maxillary
molar region.
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