Hindawi Publishing Corporation

Journal of Oral Implants

Volume 2014, Article ID 870193, 9 pages
http://dx.doi.org/10.1155/2014/870193

Research Article
Inferior Level of Maxillary Sinus and Cortical Bone
Thickness at Maxillary Posterior Quadrant, in Three Different
Growth Patterns: 3D-Computed Tomographic Study

Pavankumar Janardan Vibhute1,2 and Pushkar A. Patil3

1
Department of Orthodontics, Yogita Dental College and Hospital, Khed, District Ratnagiri, Maharashtra 415709, India
2
“Braces & Implant Clinic”, 202-203, 4th Floor, Vishal Ventila, Near Noble Hospital, Hadapsar, Pune 411028, India
3
Department of Orthodontics, Sharad Pawar Dental College, Datta Meghe Institute of Medical Sciences,
Wardha, Maharashtra 442004, India

Correspondence should be addressed to Pavankumar Janardan Vibhute; [email protected]

Received 5 September 2014; Accepted 20 November 2014; Published 15 December 2014

Academic Editor: Athanassios Kyrgidis

Copyright © 2014 P. J. Vibhute and P. A. Patil. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Objective of this retrospective study was to measure cortical bone thickness and lowest level of maxillary sinus at maxillary posterior
quadrant in different growth pattern (hypodivergent, average, and hyperdivergent) at prospective microimplant placement sites in
order to understand both safety and stability aspects of microimplant placement by using cone-beam 3-dimensional computed
tomographic images. In posterior quadrant, vertical distance from cementoenamel junction to lowest level of maxillary sinus at
interradicular region was measured. Buccal cortical bone thickness was measured at 3 different vertical levels at interradicular space.
The cortical bone thickness was found more at sinus floor level and above it than below the sinus floor. In perspective of miniscrew
placement, study shows that maxillary sinus floor is safer with average and hyperdivergent growth pattern than hypodivergent
growth pattern. In the proximity of maxillary sinus floor, 1 mm or more cortical bone can be expected in maxillary posterior region
in average and hyperdivergent growth patterns. However, it was thicker in hypodivergent than hyperdivergent growth patterns.
Hypodivergent patients require either more horizontal insertion (more parallel to occlusal plane) or shorter length of miniscrew
to avoid damage to maxillary sinus.

1. Introduction Schneiderian membrane and penetrating the antrum of the

maxillary sinus [7]. There is also no consensus on use of sinus
Mini-implants have become the popular source of orthodon- wall cortex for miniscrew stability.
tic anchorage, because they can be placed in various locations It is known that the quantity (bone volume) and quality
in the alveolar bone [1–4]. Several investigators have recom- (bone density) of alveolar bone are important factors for
mended, in posterior maxilla, the zygomatic crest specifically, the stability of miniscrew [8]. Structurally, the maxilla has
the buccal surface of the malar process for skeletal anchorage relatively thin cortices that are interconnected by a network
during retraction of maxillary anterior teeth, intrusion of of trabeculae [9]. Cortical bone morphology is influenced
posterior teeth, and other orthodontic movements. This by force application and also influenced by the stresses and
site is preferable to miniscrew insertion because of its two strain produced by functional loads of associated muscle
cortical layers (buccal and sinus floor) which ensure primary of mastication. Thus, anatomical characteristics such as the
stability if a screw of appropriate length is fixed bicortically thickness of cortical bone might differ between the different
[5, 6]. The primary challenge to safe insertion of miniscrews skeletal patterns. By angulating the miniscrew, the thickness
in the zygomatic crest is the possibility of perforating the of cortical bone contact with the miniscrew might increase
2 Journal of Oral Implants

but might result in maxillary sinus damage [8, 10]. In Procedure to measure CBT is as follows. Buccal CBT
addition, we previously suggested that cortical bone thickness measurement was done at the interradicular space between
might have some effect on implant success rate. 2nd premolar-1st molar and 1st molar-2nd molar at 3 different
Few studies have evaluated the quantity of cortical bone in levels, that is, at LLMS, 2 mm above LLMS, and 2 mm below
maxilla and mandible for implant placement for orthodontic LLMS. Each measurement was taken from the buccal alveolar
anchorage [11–13], but none of these studies shows the cortical plate. For this measurement, a reference horizontal line was
bone thickness in the proximity of maxillary sinus. It is also drawn at the lowest level of sinus floor parallel to CEJ and
important to determine the lower level of maxillary sinus three horizontal measurements were taken parallel to this line
in different growth pattern, to avoid complication of sinus at 3 different vertical levels (Figures 4(a) and 4(b)).
damage during miniscrew placement. Studies have warned
of possible presence of the sinus in these areas often selected 3. Results
for screw placement in relation to tooth roots [10, 14]. Poggio
et al. [10] reported that the insertion of miniscrews in the In hyperdivergent and average growth pattern LLMS ranged
maxillary molar region above 8 mm from the alveolar crest from 11.11 to 20.86 mm (SD, 3.02–5.06) and 10.04 to 16.21 mm
must be avoided because of the presence of the sinus but also (SD, 1.98–2.49), respectively; in both groups the LLMS tend
these studies lack the difference in the level of maxillary sinus to get decreased from premolar segment to molar segment
in different skeletal growth pattern individuals. and LLMS was found least between 1st and 2nd molar and
Thus, the purpose of this computed tomographic (CT) greatest between 1st and 2nd premolar. In hypodivergent
image study was to determine the lower level of maxillary growth pattern, average LLMS ranged from 6.3 to 11.22 mm
sinus and buccal cortical bone thickness in maxillary pos- (SD, 0.99–2.05). LLMS was least between 2nd premolar
terior quadrant in different growth pattern individual, from and 1st molar, whereas between 1st and 2nd premolar it
perspective of safe placement and increased primary stability. was greatest. In general, LLMS was least in hypodivergent
compared to hyperdivergent and average growth pattern
(Figure 5, Table 1).
2. Materials and Methods Mean CBT in hypodivergent growth pattern ranged from
1.51 to 2.97 mm (SD 0.18–0.74). The CBT was found more
30 untreated adult patients with bimaxillary protrusion and
between 2nd premolar and 1st molar at the LLMS and least
fairly aligned arches of age ranges between 18 and 25 years
between 2nd premolar and 1st molar below LLMS (Table 2).
(mean age 22.4 years) with no craniofacial anomalies or
In average growth pattern CBT ranged from 1.03 to 1.57 mm
systemic disease were selected. Patients with severe crowding, (SD 0.11–0.43); CBT was found more between 1st and 2nd
missing teeth, or radiographic signs of periodontal disease molar above LLMS and least between 2nd premolar and
were excluded. They were divided into three groups based 1st molar below LLMS (Table 3). In hyperdivergent growth
on Frankfurt mandibular plane angle (FMPA) [15], 10 hypo- pattern, average CBT was ranged from 0.9 to 2 mm (SD
divergent (FMPA less than 16∘ ), 10 hyperdivergent (FMPA 0.12–0.36). More CBT was found between 1st and 2nd molar
above 34∘ ), and 10 average growth pattern (FMPA between at LLMS and least between 2nd premolar and 1st molar
22∘ and 27∘ ) cases. Each patient was scanned on KODAK below LLMS (Table 4). In general, the CBT was more in
9000C 3D machine (Trophy, France) which is in compliance hypodivergent growth pattern and least in hyperdivergent
with the requirements of the EEC (European Economic growth pattern and it was more at and above the LLMS than
Community) and International Medical standards at 70 Kv below LLMS in all 3 groups.
and 10 mA for 10.8 seconds for each quadrant of the jaw. The
added power of a 50 mm × 38 mm focused field of view helps
4. Discussion
the operator to visualize specific regions of interest with true
anatomic accuracy. Miniscrew placement technique is an artistic performance
The CT images were formatted into standard DICOM aided at most by conventional 2-dimensional X-ray images.
and reconstructed into continuous slices at 0.76 𝜇m thickness Most miniscrews are currently placed high in the interradic-
each. (Figures 1(a) and 1(b)) The CT image analysis for ular spaces between 2nd premolar and 1st permanent molar
each image was conducted by Kodak 3D viewer, 2.2 version or between 1st and 2nd permanent molar in order to avoid
software, and curved slicing images with sections of 76 𝜇m root damage without 3-dimensional information of bone
thickness were chosen for measurements (Figure 2). Same thickness and maxillary sinus floor level. This placement
person to minimize human error obtained all measurements. protocol offers little protection against the 2 major problems
Procedure to measure LLMS is as follows. Line was drawn of miniscrew placement, that is, the possibility of maxillary
at superior border of the most inferior point on the floor sinus damage and the danger of premature loosening of the
of the maxillary sinus. Second line was drawn from the implant due to inadequate primary stability [16]. Therefore,
mesial CEJ of one tooth to the distal CEJ of adjacent tooth the aim of this study was to evaluate the variation in
and perpendicular distance between these two lines was cortical bone thickness and level of maxillary sinus and their
taken as the lower level of maxillary sinus from CEJ. First correlation with different growth patterns in the maxillary
LLMS measurement was done on buccal side between the 1st posterior regions by using 3D CT.
premolar and 2nd molar region in the interradicular space, Safe placement zone and initial stability are the keys to
from CEJ on both sides of the maxilla (Figures 3(a) and 3(b)). the overall success of miniscrew anchorage. Without initial
Journal of Oral Implants 3

(a)

(a) (b)

Figure 1: (a) 3D reconstruction of maxilla. (b) Orientation of maxilla in 3 planes.

The point at which permanent deformation occurs on a

stress-strain curve is known as the yield point. The fracture
point is the point beyond the yield point at which the bone
breaks. The region of the stress-strain curve that pertains to
the present project is between the yield point and the ultimate
tensile strength point. Bone modeling and remodeling occurs
based on the applied stresses and strains.
With respect to the muscles of mastication, the weaker
the musculature is, the weaker the bite forces are. Weak bite
forces lead to smaller functional effects on the maxilla and
mandible.
Miyajima et al. [17] and Dalstra et al. [18] showed
Figure 2: One quadrant oriented to measure LLMS from CEJ and maximum stress at the cortical bone level when an implant
CBT between 1st and 2nd molar interdentally. is loaded. In a finite element study, Dalstra et al. [18] demon-
strated that increasing cortical bone thickness drastically
reduced the peak strain development in the peri-implant
bone tissue. In particular with 1 mm or more of cortical
stability, there will not be a late stability. Initial stability thickness, the peak strain in the bone was confined to the
is derived from good mechanical interlocking between the adapted window of Frost’s Mechanostat theory [19–22]. This
implant and the bone. inverse relationship between cortical bone thickness and peak
Initial stability is influenced by 3 factors, bone quality strain development suggests that cortical bone thickness is
(host factor), implant design (material factor), and placement the key determinant of initial stability.
technique (operator factor). For bone quality, cortical bone Miyamoto et al. [23] used resonance frequency analysis to
thickness is the most important determinant of initial stabil- measure the initial placement torque of restorative implants.
ity [16]. They quantified initial stability by units of implant stability
As demonstrated by numerous studies, cortical bone quotient (ISQ) derived from resonance frequency analysis
thickness of the maxilla and mandible varies. The pattern value. Using linear regression analysis, they also showed a
of cortical bone thickness appears to be somewhat consis- high correlation between cortical bone thickness and the
tent from one individual to another. In general, the cortex ISQ value (r 5 0.84). This close relationship between initial
increases in thickness from molar segment to premolar stability and cortical bone thickness was similar to the
segment and is thicker on the palatal side of the maxilla than findings of Wilmes et al. [24]. Miyamoto et al. concluded that
the buccal side, and in the mandible, it is thicker on the buccal implant stability at placement largely depends on local bone
aspect as compared to the lingual aspect. If the patterns are conditions [23].
generally consistent, then what is the cause for this variation? The importance of cortical bone thickness was again
To understand these patterns, a discussion of the function demonstrated by a study of Wilmes et al. [25]. They found
of bone is necessary. One of the functions of bone is to sup- placing microimplants at an angle between 60∘ and 70∘
port the structures around it. Bone must be stiff and strong resulted in the highest placement torque values. At an oblique
enough to resist the stress and strain developed. Additionally, angle, the microimplant can obtain a longer distance through
it must be able to adapt to the changes due to growth and cortical bone and achieve higher initial stability.
the environment. The stress and strain experienced by bone Results of our study showed significant differences in
include axial compression, bending, twisting, and shearing. cortical bone thickness in the proximity of maxillary sinus
Bone is able to withstand the stress and strain up to a point. of the hypodivergent individuals, when compared to normal
4 Journal of Oral Implants

Sinus

1st molar
(a) (b)

Figure 3: (a) Schematic diagram showing LLMS measurement. (b) Actual measurement of LLMS.

2 mm

0 mm

2 mm

(a) (b)

Figure 4: (a) Schematic CBT measurement. (b) Actual measurement of CBT.

and hyperdivergent growth pattern individuals. Present study placing it in at least 1 mm thickness of cortical bone [28].
shows, cortical bone thickness in hypodivergent growth This raises question about miniscrew implant placement in
pattern individuals is thicker than that of hyperdivergent individuals with hyperdivergent growth pattern.
and normal growth pattern individuals. Similar results were Park and Cho [16] state that cortical bone thickness was
found in 1998 by Tsunori et al. [26] and in 2001 by Masumoto site dependent and it increased as the distance from the
et al. [27]. They found that the cortical bone thickness of the alveolar ridge increased. In the present study, similar findings
first and second molar section was thicker in short face sub- were found. The thickness of buccal cortical bone was more at
jects by 0.1–2.5 mm than the normal and long face subjects. the level of and 2 mm above the LLMS (i.e., coronal to sinus),
From the present study, similar finding was obtained for the as compared to 2 mm below the LLMS (i.e., apical to sinus).
cortical bone thickness at 2nd premolar and 1st permanent This difference may be because of presence of two cortical
molar section was thicker in hypodivergent subject by 0.1 to layers (buccal and sinus floor) at and coronal to LLMS.
2 mm and at 1st and 2nd permanent molar section by 0.4 In the present study, sex differences were not studied since
to 1.7 mm than hyperdivergent and normal growth pattern prior studies have shown no sex differences in cortical bone
individuals. The differences of cortical bone thickness may be thickness of either the maxilla or mandible [8]. Since males
explained by masticatory function and its corelation with the and females eat essentially the same types of food, the strain
facial type. produced during mastication might be expected to be similar,
In the present study it was found that the cortical bone as would cortical bone thickness.
thickness in the proximity to maxillary sinus in hypodi- While it is generally accepted that some degree of ana-
vergent individuals was more than 1.5 mm irrespective of tomic asymmetry is widely displayed in the normal human
interradicular site while the cortical bone thickness at some craniofacial complex, this study failed to find a generalized
sites of hyperdivergent subjects was less than 0.8-0.9 mm. significant difference (𝑃 > 0.05) between the right and left
It has been suggested that miniscrew success depends on sites measured.
Journal of Oral Implants 5

11-12 mm 15 mm 20-21 mm
7-8 mm 6-7 mm 11 mm 15-16 mm
9 mm 11-12 mm

Hypodivergent growth pattern Average growth pattern Hyperdivergent growth pattern

Figure 5: LLMS comparison between hypodivergent growth pattern, average growth pattern, and hyperdivergent growth pattern.

4.1. Safe Zone for Miniscrew Placement in Posterior Maxilla In the present study it was found that in hyperdivergent
with respect to Maxillary Sinus. Previously, interradicular and normal growth pattern individuals the maxillary sinus
sites were analyzed for the safe placement of miniscrew in level drops gradually from 1st premolar to 2nd permanent
posterior maxilla to avoid root damage [10, 12, 16]. The molar and most inferior level was found between 1st and 2nd
general recommendation is to place miniscrews in attached permanent molar. Similar findings were observed by Kim et
gingiva [12, 29, 30], but apical placement is favored since the al. [35], who studied the maxillary sinus thickness with the
interradicular distance increases in the apical direction which help of CT scan. They concluded that the maxillary sinus
reduces the risk of root damage [12, 16]. Inserting miniscrew floor was located most inferiorly between the 1st molar and
at an angle directed apically will lead to an increased primary 2nd molar and most superiorly between the 1st premolar and
bone-to-implant contact [8, 10]. On the other hand, this 2nd premolar. But the finding for hypodivergent individuals
might increase the risk of sinus perforation. In particular, is contradictory to their finding. In this group the maxillary
the risk of sinus perforation with interradicular miniscrews floor was located more inferiorly between 2nd premolar and
placed from the buccal aspects with an insertion directed 1st permanent molar region.
apically has not been addressed systematically, so far. Results of this study showed significant differences in the
The risk of perforation of the maxillary sinus during level of maxillary sinus in hypodivergent individuals, when
miniscrew insertion has merely been reported in relation compared to normal and hyperdivergent individuals. These
to insertion at the apical level of the molars, including the differences in the level might be because of the difference
infrazygomatic crest, and distally to the second molar [10, 31– in muscular pattern, which has an influence on anatomical
33]. development of face.
Long miniscrews of 8 to 10 mm have been reported to be Previous studies recommended that the interradicular
associated with a higher risk of sinus membrane perforation sites mesial to maxillary 1st molar slight apical to the midroot
than the shorter miniscrews of 6 mm [34]. level are safe sites for insertion of miniscrews [8, 10, 16], and
Thus, from the previous studies it has been concluded that sinus perforations are expected to be a relatively common
the length of miniscrew as well as more apical or angulated side effect. Nevertheless, not much attention has been given
placement of miniscrews results in perforations of maxillary to this side effect, presumably because a small perforation
sinus. rarely creates complications and heals without intervention
Previous studies showed the differences in the level of [36–38].
maxillary sinus and gave different limit for placement of In the present study, relative short distance of maxillary
miniscrews in the individuals [10, 14] but failed to specify the sinus from CEJ in hypodivergent groups implies a risk of
reason for this variability. perforation of the maxillary sinus if miniscrews are planned
As the musculature influences the anatomical develop- for insertion with an apical inclination. The normal dis-
ment of face, maxilla, and mandible, there might be an tance of maxillary sinus floor at interradicular site between
anatomical variation associated with development of para- 2nd premolar and 1st permanent molar was 6.30 mm and
nasal sinuses as muscle function varies. To see this anatomical 6.90 mm on right and left side, respectively, suggesting that
variation, the lower level of maxillary sinus was analyzed in maxillary floor extended up to midroot level in this group,
different growth pattern individuals for safe placement of so miniscrew above this level should be inserted cautiously.
miniscrew. Similar limit was suggested by Ishii et al. [14] in their study.
Thus, in order to characterize the relationship of the max- They recommended miniscrew placement is not higher than
illary sinus and the CEJ of teeth in posterior maxilla as well 6–8 mm from the alveolar crest due to presence of maxillary
as clarifying any morphological differences between various sinus.
interradicular sites and different growth patterns individuals, Poggio et al. [10] provide an anatomical map to assist the
analysis was carried out with 3D CT of posterior maxilla in clinician in miniscrew placement in a safe location between
hypodivergent, hyperdivergent, and normal growth pattern. dental roots. They advocate insertion of the miniscrews in the
6 Journal of Oral Implants

Table 1: Distance of LLMS from CEJ (mean value, in millimeters).

R 4-5 R 5-6 R 6-7 L 4-5 L 5-6 L 6-7

Mean 11.03 6.3 7.77 11.22 6.9 7.45
Hypodivergent growth pattern
SD 1.46 1.48 1.66 2.05 1.75 0.99
Mean 16.21 12.35 10.04 15.47 11.94 10.82
Average growth pattern
SD 1.98 2.36 2.34 2.49 2.37 2.48
Mean 20.0 14.92 11.11 20.86 15.11 11.34
Hyperdivergent growth pattern
SD 3.68 3.17 3.29 5.06 3.26 3.02

Table 2: Buccal CBT in hypodivergent (mean value, in millimeters).

R 5-6 R 6-7 L 5-6 L 6-7

Mean 2.19 2.53 2.36 2.61
CBT 2 mm above LLMS
SD 0.53 0.70 0.29 0.52
Mean 2.46 2.11 2.97 2.17
CBT at LLMS
SD 0.22 0.53 0.74 0.36
Mean 1.51 1.68 1.66 1.61
CBT 2 mm below LLMS
SD 0.29 0.18 0.30 0.26

Table 3: Buccal CBT average growth pattern (mean value, in millimeters).

R 5-6 R 6-7 L 5-6 L 6-7

Mean 1.36 1.57 1.46 1.50
CBT 2 mm above LLMS
SD 0.22 0.43 0.15 0.22
Mean 1.21 1.33 1.28 1.34
CBT at LLMS
SD 0.23 0.15 0.17 0.22
Mean 1.03 1.14 1.2 1.21
CBT 2 mm below LLMS
SD 0.17 0.15 0.15 0.11

maxillary molar region above 8–11 mm from the bone crest The use of long miniscrews (8 mm) is recommended
to be avoided because of the presence of the sinus. In present in order to increase primary stability when thin cortical
study similar limit was observed for individuals with normal bone (less than 1 mm) is expected [18, 28]. In the maxillary
growth pattern but this limit contradicts that observed for molar region, insertion of 8 mm long miniscrew at 45∘ to
hypodivergent individuals. the long axis of the teeth will increase the cortical bone-
In hyperdivergent individuals, high placement of minis- to-implant contact (compared to perpendicular insertion)
crew is required for vertical control and for intrusion of and the trabecular bone-to-implant contact in cases with a
posteriors. Lower level of maxillary sinus was found farthest sufficient distance from the sinus. Furthermore, the use of
in this group at each interradicular space, compared to the an 8 mm miniscrew will increase the chance of obtaining
rest of 2 groups of this study. Between 2nd premolar and bicortical (buccal and sinus floor) anchorage, shown by
1st permanent molar the maxillary sinus was at 15.5 mm and Brettin et al. [39], which is superior to unicortical anchorage.
15.11 mm on right and left side, respectively, and between 1st However, apically angulated insertion in the maxillary molar
and 2nd permanent molar it was at 11.11 mm and 11.34 mm on region will lead to a higher risk of sinus perforation.
right and left side, respectively. The present study indicates that the risk of sinus perfo-
From these findings upper limit for placement of minis- ration can be reduced without compromising the primary
crew in hyperdivergent individuals was found to be 14- stability in hypodivergent individuals, if the 8 mm miniscrew
15 mm and 10-11 mm, at interradicular space between 2nd is inserted 6-7 mm from CEJ, where sufficient cortical bone
premolar-1st permanent molar and 1st-2nd permanent molar, was observed, similarly in hyperdivergent individuals when
respectively. high placement is required apically and angulated miniscrew
Similarly, in normal growth pattern individuals the upper insertion (for attaining more contact of cortical bone) is
limit for miniscrew insertion was found to be 11-12 mm and found safe at 10–12 mm from CEJ.
9-10 mm at interradicular space between 2nd premolar-1st This study failed to find a generalized significant dif-
permanent molar and 1st-2nd permanent molar, respectively, ference (𝑃 = 0.05) between the left and right side. This
which is similar to the limit given by Poggio et al. [10]. would support the findings of Fernandes [40] who found no
Journal of Oral Implants 7

Table 4: Buccal CBT in hyperdivergent (mean value, in millimeters).

R 5-6 R 6-7 L 5-6 L 6-7

Mean 0.87 0.98 0.91 0.95
CBT 2 mm above LLMS
SD 0.18 0.27 0.15 0.36
Mean 0.87 1.20 1.02 1.13
CBT at LLMS
SD 0.18 0.27 0.15 0.36
Mean 0.84 0.95 0.96 0.88
CBT 2 mm below LLMS
SD 0.12 0.20 0.21 0.15

significant difference between left and right maxillary sinus 4.1.3. Scope for Future Studies. In future research, it is
volume and linear measurements in his sample of 53 dried recommended to evaluate bone mineral density of cortical
skulls. In light of this finding, left and right measurements bone although 2 cortical bones can have the same thickness,
were combined in an effort to bolster the sample size for all and they might have completely different bone mineral
further analyses. densities and hence different initial stability values. In the
Previous studies suggest that the palatal site provide more present method of evaluation, bone mineral density was not
clearance from possible interference with maxillary sinus, considered because it was not possible to calibrate the mineral
and Ishii et al. [14] and Poggio et al. [10] also specifically density with the same software. In addition, more studies are
recommend this site as the safest in the posterior maxillary needed to evaluate the anatomy of maxillary sinus among
alveolus. Therefore, in our study consideration was given only different ethnic groups, different dentoskeletal patterns, and
dentofacial anomalies which is poorly documented in the
to the buccal placement site and relation of maxillary sinus
literature.
was measured with CEJ at buccal side of posterior maxilla.

5. Conclusion
4.1.1. Clinical Implications. This study provides valuable
information to the clinician with regard to preferable sites From perspective of miniscrew placement, maxillary sinus
for miniscrew placement in order to avoid maxillary sinus floor is safer with average and hyperdivergent growth pattern
damage and for primary stability amongst different growing than hypodivergent growth pattern. In the proximity of
pattern individuals by utilizing high resolution CT scanning. maxillary sinus floor, 1 mm or more cortical bone can be
In hypodivergent growth pattern, miniscrew insertion expected in maxillary posterior region; however, it is thicker
6-7 mm above the CEJ should be avoided and when high in hypodivergent than hyperdivergent growth patterns.
placement is required, the miniscrew should be placed less Hypodivergent patients require more horizontal insertion or
angulated and more parallel to occlusal plane. length of miniscrew should be reduced.
For vertical control and for intrusion of posterior teeth,
high placement at 10–12 mm from CEJ is found to be safe Conflict of Interests
in hyperdivergent individuals, but soft tissue and cortical
bone thickness should be considered. In this group angulated The authors declare that there is no conflict of interests
insertion of miniscrew in order to achieve more cortical bone regarding the publication of this paper.
in this group might be helpful.
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