Original Article

Root proximity of miniscrews at a variety of maxillary and mandibular

buccal sites:
Reliability of panoramic radiography
Jae-Hwa Ana; Yong-Il Kimb; Seong-Sik Kimc; Soo-Byung Parkc; Woo-Sung Sonc; Sung-Hun Kimd

ABSTRACT
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Objectives: To assess the root proximity and the insertion angles of miniscrews after miniscrew
placement at a variety of maxillary and mandibular buccal sites using cone-beam computed
tomography (CBCT) and to determine the differences in root proximity between CBCT and
panoramic radiography (PR).
Materials and Methods: This retrospective study included 50 patients (mean age, 22.0 6 4.5
years) who underwent postoperative CBCT and PR after miniscrew placements for intermaxillary
fixation in orthognathic surgery. Twelve miniscrews were placed in the buccal bone of each patient:
at sites between the central incisor and lateral incisor (SII), sites between the canine and first
premolar (SCP), and sites between the second premolar and first molar (SPM) on the right and left
sides of the mandible and maxilla. The insertion angles were measured on CBCT, and the root
proximity was assessed on CBCT and PR.
The Angle Orthodontist

Results: The mean vertical placement angles ranged from 84.278 to 95.128, and the mean
horizontal placement angles ranged from 90.938 to 101.18. The rates of no contact between the root
and the miniscrew were 68.0% in the SII, 50.5% in the SCP, and 57.8% in the SPM, which were
significantly different (P ¼ .000). The total concordance rate between PR and CBCT was 41.3%.
Conclusions: Clinicians should use extreme caution during placement of miniscrews in the SCP.
There are limitations on the use of PR for evaluating the root proximity of miniscrews. (Angle
Orthod. 0000;00:000–000.)
KEY WORDS: Root proximity; Panoramic radiography; Orthodontic miniscrew

INTRODUCTION eration and orthodontic tooth movement without side

Orthodontic miniscrews have been widely used for a
variety of orthodontic and orthopedic treatments.1 They
are used to enhance anchorage without patient coop-
a
Resident, Department of Orthodontics, Pusan National
University Dental Hospital, Yangsan, South Korea.
b
Associate Professor, Department of Orthodontics, Pusan
National University Dental Hospital, Yangsan, South Korea.
c
Professor, Department of Orthodontics, Pusan National
University Dental Hospital, Yangsan, South Korea.
d
Research Fellow, Department of Orthodontics, Pusan
National University Dental Hospital, Yangsan, South Korea.
Corresponding author: Dr Sung-Hun Kim, Department of
Orthodontics, Pusan National University Dental Hospital, Geu-
moro 20, Mulgeumeup, Yangsan, Kyeongsangnamdo 50612,
South Korea
(e-mail: kmule@hanmail.net)
Accepted: January 2019. Submitted: October 2018.
Published Online: March 11, 2019
Ó 0000 by The EH Angle Education and Research Foundation,
Inc.
effects.2 Recently, the use of miniscrews for intermax-
illary fixation (IMF) in orthognathic surgery has become
popular because of its extensive benefits. It can reduce
the extrusive load to teeth and establish stable
occlusion without relapse after maxillofacial surgery.3
For the orthodontist, common concerns about ortho-
dontic miniscrews are failure rates, risk factors for
failure, and dental root damage after placement. From
their meta-analysis, Schätzle et al.4 assessed that the
success rate was about 83.6%. Shinohara et al.5
concluded that the success rate was about 95% after
the recommended placement technique. Higher suc-
cess rates prevent treatment delays and obtain im-
proved outcomes. To improve success rates, several
studies have analyzed factors affecting miniscrew
failure, such as overloading,6 cortical bone thickness,7
and proximity of the miniscrew to the adjacent teeth.8
Since miniscrews are placed into small spaces between
the roots of adjacent teeth, root proximity is often
considered the major factor affecting miniscrew failure.9

DOI: 10.2319/100318-713.1 1 Angle Orthodontist, Vol 00, No 00, 0000

 2 AN, KIM, KIM, PARK, SON, KIM
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Figure 1. Miniscrew placement sites on the PR.
Cone-beam computed tomography (CBCT) provides
many advantages with respect to orthodontic treat-
ment. CBCT can be used to assess the root proximity
of miniscrews after placement. However, the relatively
The Angle Orthodontist
high radiation dose and high cost have restricted its
use for clinicians. Most clinicians use only panoramic
radiographs (PRs) or periapical films to estimate the
gap between roots of adjacent teeth and assess root
proximity of miniscrews after placement. PRs often
provide distorted and overlapping images of minis-
crews and dental roots affected by several factors,
including the distance between the patient and the
film10 and the position of the object measured.11
Therefore, the actual position of miniscrews placed
by a clinician using PRs needs to be evaluated by
three-dimensional images such as CBCT.
Most research has reported the root proximity after
miniscrew placement only between the second pre-
molar and the first molar.12–14 Recently, other buccal
sites have been commonly used for various orthodontic
tooth movements.15 There has been no previous study
on the root proximity after miniscrew placement at a
variety of maxillary and mandibular buccal sites.
The aim of this study was to assess the root proximity
and the insertion angles of miniscrews after miniscrew
placements at a variety of maxillary and mandibular
buccal sites and to determine the differences in
detection of root proximity between CBCT and PR.
MATERIALS AND METHODS
Samples
This retrospective study included 50 patients who
underwent presurgical orthodontic treatment and who
had postoperative CBCT and PRs taken after minis-
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crew placement for IMF in orthognathic surgery from
August 2017 to May 2018 in Pusan National University
Dental Hospital. The CBCT and PR were not originally
taken for this study but for postoperative assessment
after orthognathic surgery. The average age of the
patients was 22.0 6 4.5 years (range, 18.2–33.0
years), and the sample included 26 female and 24
male patients. There were 6 patients with skeletal
Class I malocclusion and 44 with skeletal Class III
malocclusion, based on ANB values. The exclusion
criteria were impacted or missing tooth, severe
crowding, or developmental syndrome such as cleft
lip and palate. Patients with low-resolution CBCT
images were also excluded. This study was reviewed
and approved by the Institutional Review Board of
Pusan National University Dental Hospital (PNUDH-
2018020).
Data Acquisition
All miniscrews (diameter, 2.0 mm; length, 8 mm;
Dual Top Anchor System, Jeil Medical, Seoul, Korea)
were placed directly with a hand driver by one of three
oral and maxillofacial surgeons, each of whom more
than 10 years of clinical experience, using the self-
drilling method under general anesthesia. PRs were
used to estimate the gap between the roots of the
adjacent teeth before placement. Twelve miniscrews
were placed in the buccal alveolar bone of each
patient: at sites between the central incisor and lateral
incisor (SII), sites between the canine and first
premolar (SCP), and sites between the second
premolar and the first molar (SPM) on the right and
left sides of the mandible and maxilla (Figure 1). All
patients had postoperative CBCT and PRs taken 3
 ROOT PROXIMITY OF MINISCREWS 3

Figure 2. Classification of CBCT images from category I to V: (A) category I, no contact between the root and the miniscrew; (B) category II,
contact between the root and the miniscrew apex; (C) category III, contact between the root and the miniscrew body; (D) category IV, contact
between the root and both the miniscrew body and apex; (E) category V, miniscrew penetration into the root.
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days after orthognathic surgery. The CBCT (DCT pro,
Vatech Co, Seoul, Korea) settings were as follows:
voxel size, 0.3 mm; field of view, 200 3 190 mm. CBCT
data were converted and saved as DICOM files, and
Ez3D pro (Vatech Co) was used for analyzing the
DICOM data. The multiplanar reformation images of
Ez3D pro were viewed using a window width of 3000
HU and a window level of 1000 HU. The root proximity
was categorized into five groups using a modification
of the method of Watanabe and Shigeeda13,14 (Figure
2). The horizontal and vertical inclinations of the
The Angle Orthodontist
interval of 3 weeks. Intraexaminer agreement was
evaluated using the Cohen kappa statistic for the root
proximity and intraclass correlation coefficient (ICC) for
the placement inclination. Intraexaminer agreement
was high, with kappa values of .814 and an average
ICC value of .911. Horizontal placement angle and
vertical placement angle were compared using analy-
sis of variance tests. The Scheffé method was used for
post hoc analysis. The correlation between the root
proximity and the placement sites was examined using
the chi-square test and Fisher exact test. A P value of

miniscrews were measured using Shinohara’s meth-
od.5 A tomographic view was fixed parallel to the
occlusal plane. The angle of the distal side between
the bone surface and the long axis of each miniscrew
was measured as the horizontal placement angle in the
transverse view. The angle between the long axis of
the miniscrew and the long axis of the neighborhood
teeth was measured as the vertical placement angle in
the coronal view. For comparison of CBCT and PR,
paired PRs (Planmeca, Helsinki, Finland) were also
categorized into five groups (Figure 3). All images were
acquired by the same radiologist.
Statistical Analysis
All measurements were performed by one investi-
gator. To evaluate intraexaminer reliability, the data for
15 randomly selected cases were reobtained after an
,.05 was considered significant. SPSS software
(version 23.0; IBM, Armonk, NY) was used for the
statistical analysis.
RESULTS
Insertion Angle
There was a statistically significant difference in the
vertical placement angles (P ¼ .000; Table 1) and the
horizontal placement angles (P ¼ .000; Table 2) among
the 12 placement sites. The mean vertical placement
angles were 88.578 6 9.678 in the maxilla and 93.858
6 8.518 in the mandible, which was significantly
different (P ¼ .000); 91.598 6 9.658 for the right side
and 90.838 6 9.308 for the left side, which was not
statistically significant (P ¼ .325); and 90.508 6 10.288
in the SII, 92.948 6 8.528 in the SCP, and 90.208 6

Figure 3. Classification of PR from category I to V: (A) category I, no contact between the root and the miniscrew; (B) category II, contact between
the root and the miniscrew apex; (C) category III, contact between the root and the miniscrew body; (D) category IV, contact between the root and
both the miniscrew body and apex; (E) category V, overlapping between the root and the miniscrew.

Angle Orthodontist, Vol 00, No 0, 0000

 4 AN, KIM, KIM, PARK, SON, KIM

Table 1. Vertical Placement Anglea

UR UL LR LL
SII SCP SPM SII SCP SPM SII SCP SPM SII SCP SPM
Mean, 8 88.78 ABC 93.67 BC 86.53 AB 84.27 A 91.24 ABC 86.92 AB 93.81 BC 92.98 BC 93.78 BC 95.12 C 93.86 BC 93.57 BC
SD 9.98 9.75 8.81 9.78 7.89 8.97 9.44 8.33 9.30 8.30 7.99 7.80
P value .000*
a
The same superscripts indicate no statistical difference, *P , .05. SD indicates standard deviation; UR, upper right; UL, upper left; LR, lower
right; LL, lower left; SII, sites between central incisor and lateral incisor; SCP, sites between canine and the first premolar; SPM, sites between the
second premolar and the first molar.

9.358 in the SPM, which were significantly different (P ¼ DISCUSSION

.006). The mean horizontal placement angles were
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Orthodontic miniscrew use is one of the milestones

96.938 6 8.168 in the maxilla and 93.758 6 7.488 in the
mandible, which were significantly different (P ¼ .000);
94.848 6 8.058 for the right side and 95.838 6 7.898 for
the left side, which were not statistically significantly
different (P ¼ .131); and 92.788 6 5.158 in the SII,
94.518 6 8.828 in the SCP, and 98.728 6 8.288 in the
SPM, which were significantly different (P ¼ .000).
Root Proximity
The percentages of category I, II, III, IV, and V for
The Angle Orthodontist
in orthodontics. As miniscrews are more widely used,
clinicians become more concerned about complica-
tions, including miniscrew loosening and tooth dam-
age. To reduce the risk of miniscrew complications,
information about positioning and the inclination of the
placed miniscrew is potentially useful.
IMF had been achieved with arch bars or interdental
wiring. Because these methods have some disadvan-
tages such as periodontal problems, decalcification,
and extrusion of the supporting teeth, another method
has been developed.3 Miniscrews can be used to

CBCT images were 58.6%, 8.7%, 20.7%, 11.8%, and
0.2%, respectively (Table 3). The rates of no contact
were 51.7% in the maxilla and 65.6% in the mandible,
which were statistically significant (P ¼ .000); 56.3% in
the right side and 61.0% in the left side, which were not
statistically significant (P ¼ .062); and 68.0% in the SII,
50.5% in the SCP, and 57.8% in the SPM, which were
statistically significant (P ¼ .000). The lowest rate of no
contact was observed in the SCP on the right side of
the maxilla, and the highest rate was observed in the
SII on the left side of the mandible. The percentages of
category I, II, III, IV, and V for PRs were 24.3%, 11.8%,
14.7%, 33.3%, and 15.8%, respectively (Table 4).
Comparison With Panoramic Films
The total concordance rate between PR and CBCT
was 41.3% (Table 5). The concordance rates in the SII,
SCP, and SPM were 34.0%, 33.5%, and 56.5%,
respectively.
achieve IMF in orthognathic surgery. The damage to
tooth roots is the most important problem with this
method.
The mean vertical placement angles of 12 sites
ranged from 84.278 to 95.128, which were different from
those recommended in a previous study. Lim et al.16
suggested that placing miniscrews at 308 or 458 would
increase the contact with cortical bone and minimize
the chance of contacting the adjacent root. Miniscrews
of this study were used to hold orthodontic elastics for
IMF and were accordingly placed perpendicular to the
bone surface.
The mean horizontal placement angles of each site
ranged from 90.938 to 101.18, which was similar to
angles used in previous studies.17 This angle range
resulted from the miniscrews’ being relatively far from
the adjacent roots. The miniscrews in the SII were
placed approximately perpendicular to the bone
surface, whereas the miniscrews in the SPM were
inclined more mesially. This is related to the viewpoint

Table 2. Horizontal Placement Anglea

UR UL LR LL
SII SCP SPM SII SCP SPM SII SCP SPM SII SCP SPM
Mean, 8 94.63 ABC 93.47 AB 100.66 D 92.97 A 98.72 CD 101.10 D 91.72 A 90.93 A 97.67 BCD 91.82 A 94.92 ABC 95.45 ABC
SD 5.26 9.98 7.94 5.88 6.89 8.04 4.42 7.73 7.44 4.52 8.75 8.59
P value .000*
a
The same superscripts indicate no statistical difference, *P , .05. SD indicates standard deviation; UR, upper right; UL, upper left; LR, lower
right; LL, lower left; SII, sites between central incisor and lateral incisor; SCP, sites between canine and the first premolar; SPM, sites between the
second premolar and the first molar.

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 ROOT PROXIMITY OF MINISCREWS 5

Table 3. Classification of Root Proximity on the CBCTa

UR UL LR LL
SII SCP SPM SII SCP SPM SII SCP SPM SII SCP SPM
I 29 17 23 28 25 33 39 29 29 40 30 30
II 0 3 9 3 9 4 3 5 2 1 7 6
III 17 12 12 16 7 7 4 14 15 6 8 6
IV 4 17 6 3 9 6 4 2 4 3 5 8
V 0 1 0 0 0 0 0 0 0 0 0 0
Chi-square (P value) 99.790* (0.000)
a
UR indicates upper right; UL, upper left; LR, lower right; LL, lower left; SII, sites between central incisor and lateral incisor; SCP, sites between
canine and the first premolar; SPM, sites between the second premolar and the first molar.
* P , .05.
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of the practitioner. The drilling direction in the anterior
sites could be identified more easily than that in the
posterior sites. In addition, there was no significant
difference between the right and left sides.
This study showed that, on the CBCT, the rate of no
contact between the root and the miniscrew was
58.6%, which was lower than that reported in previous
studies. Shigeeda14 reported that about 80% showed
no root contact on the CBCT. This is possibly because
placing a miniscrew perpendicular to the long axis of
the teeth and using larger diameter miniscrews would
The Angle Orthodontist
the total concordance rate between CBCT and PR was
41.3%. Therefore, there are limitations for the use of
PRs for evaluating the root proximity of miniscrews,
and PRs for this purpose need to be used with caution.
This study had some limitations. First, the vertical
placement angle of the miniscrews in this study was
larger than that of commonly placed miniscrews.
Second, there were metal artifacts caused by the
miniscrews. These artifacts contributed to image
blurring and might have caused inaccurate assess-
ments of root proximity. Finally, the relationship

increase the chance of contacting the adjacent roots. A
significantly higher rate of no root contact was
observed in the mandible than in the maxilla, possibly
because most patients in this study had skeletal Class
III malocclusion and so the protrusive mandible
provided easy accessibility for placing miniscrews.
The lower rates of no root contact occurred for the
miniscrews placed in the SCP. This may be attributable
to a property of PR that results in greater distortion in
the canine/premolar regions.18 This is also due to the
smaller spaces between the adjacent roots in the
SCP.19
In the PRs, the rate of no contact was 24.3%. Many
miniscrews were not actually in contact with the root,
even though contact of the miniscrew with the root was
observed on the PRs. For example, among 95
overlapping cases between the root and the miniscrew
(category V) in the PRs, only one miniscrew penetrated
into the root (category V) on the CBCT images. Also,
between miniscrew success and root proximity was
not determined because miniscrews for IMF were
removed after 1 or 2 months of placement. Further
research is required.
CONCLUSIONS
 Clinicians should be extremely careful during place-
ment of miniscrews in the SCP.
 Many miniscrews were not in actual contact with the
root, even though contact of the miniscrew with the
root was observed on the PRs.
 There are limitations to the use of PRs for evaluating
the root proximity of miniscrews.
ACKNOWLEDGMENT
This study was supported by a 2018 grant from Busan
Gyeongnam Ulsan Branch of the Korean Association of
Orthodontists.

Table 4. Classification of Root Proximity on the PRa

UR UL LR LL
SII SCP SPM SII SCP SPM SII SCP SPM SII SCP SPM
I 6 2 10 6 5 19 18 12 15 20 15 18
II 8 3 3 6 0 3 15 4 7 12 6 4
III 4 5 23 2 2 9 3 10 15 0 5 10
IV 22 26 10 32 24 15 9 10 12 14 11 15
V 10 14 4 4 19 4 5 14 1 4 13 3
Chi-square (P value) 215.931* (.000)
a
UR indicates upper right; UL, upper left; LR, lower right; LL, lower left; SII, sites between central incisor and lateral incisor; SCP, sites between
canine and the first premolar; SPM, sites between the second premolar and the first molar.
* P , .05.

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 6 AN, KIM, KIM, PARK, SON, KIM

Table 5. Root Proximity Classification on the CBCT and PR 9. Min KI, Kim SC, Kang KH, et al. Root proximity and cortical
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