SYSTEMATIC REVIEW

Interradicular sites and cortical bone

thickness for miniscrew insertion: A
systematic review with meta-analysis
Michele Tepedino,a Paolo M. Cattaneo,b,c Xiaowen Niu,b and Marie A. Cornelisb,c
L'Aquila, Italy, and Aarhus, Denmark

Introduction: Safe zone maps are useful for the clinician to plan miniscrew insertion and possibly reduce radi-
ation exposure. This study aimed to investigate the available evidence regarding the presence of sufficient
interradicular space and adequate cortical bone thickness in patients with a complete permanent dentition, in
the vestibular and palatal or lingual interradicular sites, mesial to the second molar. Methods: PubMed, Scopus,
Web of Science, Cochrane Library, and OpenGrey databases were searched up to January 2019 for observa-
tional studies involving patients with fully erupted second molars that investigated the amount of interradicular
space and/or the cortical thickness of the alveolar processes using 3-dimensional data sets. A custom tool
was prepared and used to assess the risk of bias in individual studies. A meta-analysis was performed when
at least 4 different studies evaluated 1 identical parameter homogeneously. Publication bias was assessed
with the Egger linear regression test. Results: Twenty-seven observational articles were included in the quali-
tative synthesis. Only 11 articles were at low risk of bias. Fifteen articles were included in the meta-analysis. The
results were graphically reported in “safe-zone” maps. Conclusions: In the maxilla, the most suitable insertion
sites are those from mesial to the first molar to distal to the first premolar, and between the canine and the lateral
incisor, all at 6 mm from the cementoenamel junction. In those areas, the cortical bone has adequate thickness,
not requiring predrilling. In the mandible, the preferable vestibular interradicular spaces are those between first
and second molars and between first and second premolars, both at 5 mm from the cementoenamel junction,
and predrilling is suggested in these areas. Trial registration number: PROSPERO CRD42016042081. (Am J
Orthod Dentofacial Orthop 2020;-:---)

A
nchorage management is one of the key factors
in orthodontic treatment planning. The intro-
duction of orthodontic miniscrews for skeletal
anchorage has surely simplified many treatment me-
chanics. Many insertion sites have been proposed, with
the interradicular alveolar bone being the most common
site. Despite the large diffusion of orthodontic minis-
crews, their success rate can still be improved.
a
Department of Biotechnological and Applied Clinical Sciences, University of
L'Aquila, L'Aquila, Italy.
b
Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus
University, Aarhus, Denmark.
c
Dentistry and Health Sciences, Melbourne Dental School, University of
Melbourne, Melbourne, Australia.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Michele Tepedino, Department of Biotechnological
and Applied Clinical Sciences, University of L'Aquila, Viale S. Salvatore, Edificio
Delta 6, 67100 L'Aquila, Italy; e-mail, m.tepedino@hotmail.it.
Submitted, March 2020; revised and accepted, May 2020.
0889-5406/$36.00
Ó 2020.
https://doi.org/10.1016/j.ajodo.2020.05.011
Many factors influence the clinical outcome, such as
miniscrews' length and diameter, design, surface charac-
teristics, surgical technique and clinician's experience,
bone quantity and quality, loading force, primary stabil-
ity, root proximity, presence of attached gingiva sur-
rounding the miniscrew's head, and oral hygiene.1-5
Among the listed factors, root proximity is certainly
one of the most important.6,7 In addition, the proximity
between the miniscrew and the dental root increases the
risk of root resorption8; for these reasons, many authors
suggest a clearance of 1-1.5 mm between the miniscrew
and the dental surface.8-10 Liou et al11 recommended
2 mm of space around the miniscrew because they
observed that miniscrews migrate under orthodontic
loading.
According to these considerations, appropriate “safe
zones” for miniscrew insertion are fundamental to avoid
any damage to the patient and to achieve clinical suc-
cess. Many authors elaborated safe zones maps of the
alveolar bone for miniscrew insertion,12-15 and a
systematic review was also published in 2012.16

1
2 Tepedino et al
However, since then, many new studies based on 3-
dimensional images of the alveolar bone assessed inter-
radicular space and cortical bone thickness. Indeed, it is
not sufficient to have a safe amount of space for minis-
crew insertion, but the available bone should also have
adequate density and cortical bone thickness to provide
a reasonable probability of clinical success of the minis-
crew.17
OBJECTIVES
The present systematic review with meta-analysis
aimed to answer the following PIOS (Population, Inter-
vention, Outcome and Study Design) question: which
are the vestibular and palatal or lingual interradicular
sites mesial to the second molars showing a favorable
amount of space and adequate cortical bone thickness
for miniscrew insertion in patients with permanent
dentition, assessed through computed tomography or
cone-beam computed tomography images on human
material in observational studies.
MATERIAL AND METHODS
Protocol and registration
This systematic review with meta-analysis was con-
ducted following the guidelines of the Cochrane Hand-
book for Systematic Reviews of Interventions and is
reported following the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses statement
guidelines.18,19 The methods of analysis and the inclu-
sion criteria were specified in advance and documented
in a protocol registered in the National Institute of
Health Research database (http://www.crd.york.ac.uk/
prospero/; trial registration number: CRD4201
6042081). No funding was received for the realization
of the present work.
Eligibility criteria
The studies included in the present systematic review
were observational studies on patients with permanent
dentition and fully erupted second molars, which inves-
tigated the amount of interradicular space and/or
cortical thickness of the alveolar processes, buccally
and/or palatally, in the whole arch (from the
second molar to the contralateral second molar) or
complete anterior or posterior segments, using
3-dimensional computed tomography images.
Systematic reviews, narrative reviews, case reports,
and opinion articles were excluded. Studies analyzing
only a few interradicular spaces, measuring cortical
bone thicknesses in areas different than the alveolar pro-
cess, using 2-dimensional radiographs, not reporting
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Table I. Search strategy used for electronic database
search
Database Search syntax
PubMed (“safe zones” OR “insertion site” OR “insertion sites” OR
“interradicular space” OR “interradicular spaces” OR
“interradicular site” OR “interradicular sites” OR
placement OR alveolar OR cortical) AND ((Mini-implant
OR mini-implants OR microimplant OR microimplants
OR miniscrew OR miniscrews OR (Temporary
anchorage device) OR (Temporary anchorage devices)
OR (temporary skeletal anchorage device) OR
(temporary skeletal anchorage devices) OR (skeletal
anchorage))
measurements in millimeter of the interradicular spaces
and/or cortical thickness, and not reporting data from a
general population but rather data stratified for
morphologic or demographic characteristics, were
excluded as well.
Information sources, search strategy, and study
selection
The following databases were searched without
language and initial date restrictions up to January 20,
2019: MEDLINE via PubMed, Scopus, Web of Science,
Cochrane Library, and OpenGrey. The search strategy
for PubMed, which was appropriately modified to
comply with the search syntax of each electronic data-
base, is reported in Table I. In addition, a manual search
of the reference list of the eligible studies was carried out
to retrieve additional articles. Duplicate articles were
removed.
Eligibility was discussed by 2 authors (M.T. and
M.A.C.) by screening the title and abstracts of the
retrieved articles. Whenever in doubt about the inclusion
or exclusion of an abstract, the full text was accessed. If
the full text did not provide the required information, an
attempt was made to contact the corresponding author
by e-mail or by ResearchGate (https://www.
researchgate.net), allowing a 2-week deadline for an
answer. Any disagreement between the authors was
resolved by discussion and consensus or by involving a
third author who was requested to arbitrate (P.M.C.).
Data items and collection
The data that were extracted—using a customized
datasheet—from the included studies are enlisted in
Table II. The main outcomes retrieved from the articles
were the measurements in millimeters of the mesiodistal
interradicular space and the thickness of the cortical
bone. If the required data were not reported in the arti-
cles, an attempt was made to contact the corresponding
Tepedino et al
Table II. Items extracted from the included manu-
scripts during the data collection process
Data collection
Authors; title; year of publication; language; study design; nature of
the sample; method of sample selection; sample size; sample
demographic characteristics; absence or presence of dental
crowding; studied area; main outcome measure, secondary
outcome measure; image method; voxel size; type of image
calibration; measurement levels; reference point for measurement
level; statistics used; method error assessment; number of
observers; blinding of the observer/s; main outcome results;
secondary outcome results
authors by e-mail and by ResearchGate (https://www.
researchgate.net), allowing a 2-week deadline for an
answer.
Risk of bias/quality assessment in individual
studies
To assess the risk of bias in the selected studies, we
designed and applied a customized quality assessment
tool (Supplementary Table I). The tool comprised 2
domains: 1 for the assessment of the quality of the mea-
surement method of interradicular spaces and/or cortical
bone thickness, and 1 for the assessment of the quality
of the diagnostic images. The first domain consisted of
5 questions, whereas the second domain consisted of 3
questions. Each question resulted in a score varying
from 0 to 2. Studies scoring a total from 0 to 5 were
considered at high risk of bias, studies scoring a total
from 6 to 10 were considered at moderate risk of bias,
whereas studies scoring a total from 11 to 15 were
considered at low risk of bias.
Summary measures and approach to synthesis
The data regarding the average mesiodistal interra-
dicular bone and cortical bone thickness were reported
separately. Data were divided into anterior and posterior
areas of the maxillary and mandibular jaws, respectively.
In addition, data were divided into the vestibular and
lingual/palatal sides for measurements of the cortical
bone thickness. The data were reported through a graph-
ical summary and through tables with a color coding, to
allow a quick comparison between the different studies.
A mesiodistal interradicular bone space of 3 mm or more
was flagged in green, as an interradicular distance of at
least 3 mm is reported to be necessary to place a 1.5-mm
diameter miniscrew safely.8-10 A space of 1.5 mm or less
was highlighted in red (because it is not recommended),
whereas an amount of interradicular bone in between
1.5 and 3 mm was highlighted in yellow. When both
left and right sides measurements were reported for
American Journal of Orthodontics and Dentofacial Orthopedics
3
the same space, the mean of the 2 measurements was
used to assign the color. Similar criteria were used for
the cortical bone thickness. In particular, a cortical
bone thickness of 0.5 mm or less was highlighted in
red (because such a thin cortical bone is not
recommended for miniscrew placement),20 a cortical
thickness between 0.5 and 1.5 mm was highlighted in
green (because miniscrews can be safely placed without
predrilling of the insertion site), a cortical thickness be-
tween 1.5 and 2.5 mm was highlighted in yellow
(because predrilling with a 1 mm bur is recommended),
and cortical thickness of .2.5 mm was highlighted in
light blue (as a predrilling with a 1.1-mm bur is recom-
mended for a depth of 4 mm).21
When at least 4 different studies evaluated the same
outcome at the same distance from the same reference
point—regardless of whether a cone-beam computed to-
mography or a computed tomography was used—a
meta-analysis was performed.
The pooled outcomes for this systematic review were
the overall evaluation for the mesiodistal width of the
maxillary vestibular interradicular space, cortical bone
thickness of the vestibular space, cortical bone thickness
of the palatal interradicular space, mesiodistal interra-
dicular space for mandibular vestibular, and cortical
bone thickness for the mandibular vestibular posterior
area. Pooled estimates of effect size in outcomes and
weight were calculated between intervention groups
by using a random-effects model (DerSimonian-Laird
method22) to account for the different patient character-
istics and measurement techniques adequately.
Risk of bias across studies
The Cochran Q test was used to assess heterogeneity
between studies, and the I2 test was used to measure the
proportion of inconsistency in the combined estimates
owing to between-study heterogeneity. I2 values lower
than 30% can be regarded as representing low heteroge-
neity, values of 30%-60% can be regarded as represent-
ing moderate heterogeneity, and values of .60% can be
regarded as representing substantial heterogeneity.18
Publication bias (including small-study effects) was
planned to be assessed with the Egger linear regression
test.
All analyses were performed using Stata CI (version
15; StataCorp, College Station, Tex). A 2-tailed P value
of 0.05 was considered significant for hypothesis testing,
except for the test of heterogeneity and publication bias,
in which a P value of 0.01 was applied because of low
power.
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Fig 1. PRISMA flow diagram showing the study's screening and selection process. PRISMA,
Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS For inclusion in the meta-analysis, the articles were

Study selection and characteristics
A total of 2058 articles were retrieved through an
electronic database search, whereas a manual search of
reference lists provided 1 additional article.23 After
removal of duplicates, 1117 articles were left. Among
them, 1065 articles were excluded because they were
not relevant or not responding to the inclusion criteria.
Fifty-two full text articles were accessed, and after appli-
cation of the selection criteria (articles with only a
limited number of interradicular spaces measured,24-37
inadequate imaging methods,13,38 areas other than the
interradicular alveolar bone studied,39-41 methodology
not responding to the inclusion criteria,23,42-45 and
results reported in an ambiguous way46 were excluded),
27 articles were included in the qualitative synthesis
(Fig 1).12,15,47-71
grouped according to the reference point used for mea-
surements (alveolar crest [AC] or cementoenamel junc-
tion [CEJ]) and the distance from the reference point
where the interradicular space or the cortical bone thick-
ness were measured. When 4 articles or more were
grouped, those were selected for inclusion in the
meta-analysis. Articles reporting only a range of values
instead of mean and standard deviation,57,63,70 or with
measurements taken at midroot65 or a percentage of
the root length15 instead of a fixed distance from a
reference point, were excluded. On the basis of these
criteria, 15 articles were included in the meta-
analysis.12,48-54,56,58,60,61,64,68,71
The included articles and the data extracted are reported
in Table III. Of the 27 included studies, 16 were retrospective
studies,12,15,47-50,52,53,55,58-62,67,69 and 10 were prospective
observational studies.51,54,56,57,63-66,68,70,71 Regarding the

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 American Journal of Orthodontics and Dentofacial Orthopedics

Tepedino et al
Table III. Characteristics of the included studies
Sample Region of Details of the Imaging Voxel Main outcome Measurement Reference Secondary
Study size Age interest studied spaces method size measure levels* point outcome measure
Poggio 25 Range: 20-40 Maxilla and From second molar to CBCT NS Mesiodistal 2/5/8/11 AC NA
et al, 200612 mandible canine interradicular
space
Lim et al, 30 Mean 27.3 Maxilla From mesial of second CT NS Cortical bone 2/4/6/8 AC Soft tissue
200763 (range, 23-35) molar to central thickness thickness
incisor
Hern
andez 21 NA Maxilla and From mesial of second CT NS Mesiodistal 3/6/9 AC NA
et al, 200866 mandible molar to central interradicular
incisor space
Lim et al, 200810 28 Mean 27.3 Maxilla From mesial of second CT NS Cortical bone 2/4/6 AC Mesiodistal
(range, 23-35) molar to central thickness interradicular
incisor space
Baumgaertel 30y Adults Maxilla and From distal of second CBCT NS Cortical bone 2/4/6 AC
and Hans, 200968 mandible molar to central thickness
incisor
Lee et al, 200971 49 Mean 27.8 6 7.3 Maxilla and From mesial of second CT NS Mesiodistal 2/4/6/8 CEJ NA
mandible molar to central interradicular
incisor space
Lim et al, 200970 28 Mean 27.3 Maxilla and From mesial of second CT NS Mesiodistal 2/4/6, at 0 , AC NA
(range, 23-35) mandible molar to central interradicular 15 , 30 ,
incisor space/cortical 45 to root
bone thickness surface
Monnerat 15y Adults, NS Mandible From second molar to CT NS Cortical bone 3/5/7/9/11 AC Interradicular
et al, 200964 canine thickness space
Park and Cho, 60 Mean 27.1 Maxilla and From second molar to CBCT NS Mesiodistal 5/7/9 CEJ Cortical bone
200955 mandible canine interradicular thickness
space
Fayed et al, 201052 66 maxillae, Mean 20 years old Maxilla and From mesial of second CBCT NS Mesiodistal 2/4/6 CEJ Cortical bone
34 mandibles for the total mandible molar to central interradicular thickness
sample incisor space
Baumgaertel, 30y Mean 31.2 6 10.6 Maxilla From second molar to CT 0.28 mm Cortical bone 4/8/12 AC NA
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201147 canine thickness

Bittencourt 12 Range: 20-30 Maxilla and From second molar to CT NS Mesiodistal 2/5/8/11 AC
et al, 201154 mandible canine interradicular
space
Silvestrini Biavati, 25 Range: 18-58 Maxilla and From second molar to CT 0.5 mm Mesiodistal 5/8/11 AC
201158 mandible canine interradicular
space
Laursen 27y Mean 34 Maxilla and From mesial of second Micro-CT 37 micron Cortical bone Midroot Root Distance from
et al, 201365 (range, 20-50) mandible molar to central thickness length sinus
incisor

5
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6
Table III. Continued

Sample Region of Details of the Imaging Voxel Main outcome Measurement Reference Secondary
Study size Age interest studied spaces method size measure levels* point outcome measure
Ozdemir 155 Mean 32.3 6 7.9 Maxilla and From second molar to CBCT 0.093 mm Cortical bone 4 AC Correlation with
et al, 201349 (group 1); mandible canine thickness vertical facial
33.1 6 8.2 type
(group 2);
34.4 6 6.8
(group 3)
Sawada 40y Mean 28.2 Maxilla From mesial of second Micro-CT 140 3 Mesiodistal Custom AC/CEJ
et al, 201350 (range, 15-44) molar to central 140 3 50 interradicular reference
incisor micron space/cortical pointsz
bone thickness
Zhao et al, 201351 32 Mean 30.1 Maxilla and From second molar to CBCT NS Cortical bone 2/4/6/8/10 AC
(range, 21-44) mandible canine thickness
Choi et al, 201456 52 Mean 27.9 Maxilla From second molar to CBCT 0.16 mm Mesiodistal 4/6/8 CEJ Cortical bone
canine interradicular thickness,
space buccal and
palatal
Germec-Cakan 196 Mean 31.8 6 7.8 Maxilla and From second molar to CBCT 0.093 mm Cortical bone 4 AC Correlation with
American Journal of Orthodontics and Dentofacial Orthopedics

et al, 201448 (group 1); mandible canine thickness angle class

34.6 6 7.5
(group 2);
35.8 6 6.3
(group 3)
Veli et al, 201467 75 Mean 15.3 Maxilla and From second molar to CBCT 0.3 mm Cortical bone 5/7/9 CEJ Correlation with
(group 1); mandible canine thickness face pattern
17.7 (group 2)
da Costa Sabec 100 Mean 17.4 6 6.74 Mandible From second molar to CBCT 0.4 mm Mesiodistal 5 mm, at 45 , CEJ NA
et al, 201569 canine interradicular 60 , and 90
space/cortical angulation
bone thickness
Yang et al, 201553 50 Mean 25.7 Maxilla From mesial of second CBCT 0.3 mm Mesiodistal 1.5/3/6/9 CEJ Alveolar bone
(range, 18-39) molar to central interradicular thickness,
incisor space distance of CEJ
from sinus floor,
bone density
Sadek et al, 201661 45 Range: 18-35 Maxilla and From mesial of second CBCT 0.3 mm Cortical bone 4/7 AC
mandible molar to central thickness
incisor

Tepedino et al
Moslemzadeh 40 NS Mandible From second molar to CBCT NS Mesiodistal 2/4/6/8/10 CEJ
et al, 201760 canine interradicular
space
Tepedino et al 7

characteristics of the studied population, 3 studies59,67,69

Bone density in HU

slices from the CEJ to the apex of the shortest root of every interradicular space; yThe sample was composed of autoptic material; z10 equal levels from the alveolar crest to the alveolar base on cross
*Millimeters of depth from the reference point; yThe sample was composed of autoptic material; z10 equal levels from the alveolar crest to the alveolar base on cross slides, and 4 equal levels on occlusal
between sagittal
outcome measure
included a sample of adolescents (aged \18 years), 4

Correlation with
skeletal class
Secondary

studies selected a mixed sample of adults and adoles-

crowding
Difference
cents,50,52 or did not report this information,60,66 whereas
all of the remaining studies were conducted on an adult
population. Only 5 articles reported the ethnicity of their
Measurement Reference

sample,47,50,54,59,62 and 7 articles did not report any kind

point

of information regarding the sex of the included

CEJ

1/3 and 2/3 of CEJ

AC

subjects.12,50,54,62,64,67,68 Fifteen articles12,15,51,52,55-60,63,66,69-71

included information on dental crowding among the
root length

inclusion criteria for the sample selection, 5 studies were

levels*

conducted on human autoptic material,47,50,64,65,68 with 2 of

2/4/6/8

6/8

them using microcomputed tomography for the imaging of

the specimens.50,65 The sample size ranged from 1254 to 196
subjects.48
Main outcome

interradicular
measure
Cortical bone

Cortical bone

Regarding the methodology used, 14 articles

thickness

thickness

Mesiodistal

measured the cortical thickness of the alveolar

space

bone,47-51,59,61-63,65,67-70 8 articles measured the

mesiodistal interradicular distance,12,15,53,54,58,60,66,71
and 5 articles evaluated both variables as research out-
Voxel

0.63 mm

comes.52,55-57,64 Fifteen articles used the AC as a refer-

size

0.3 mm

From mesial of second OPT/CBCT 0.3 mm

slides, and 4 equal levels on occlusal slices from the CEJ to the apex of the shortest root of every interradicular space.

ence for measuring the interradicular space or the

cortical bone thickness; 10 articles used the CEJ; 1
Imaging

article50 used the AC for the measurements of the

method

From second molar to CBCT

cortical thickness and the CEJ for the measurements of

From mesial of second CT

the interradicular space; 1 article65 used the middle of

the root as the reference point. In general, there was
studied spaces

molar to central

molar to central
Details of the

large heterogeneity in the measurement levels—regard-

less of the reference point used—making the data diffi-
cult to compare.
incisor

canine

incisor

Risk of bias within studies

Region of

By applying the custom quality assessment tool, 4 ar-

mandible

mandible
Mean 32.7 (group Maxilla and

Maxilla and
interest

ticles were at a high risk of bias, 11 articles were at a low

Maxilla

risk of bias, and the remaining 12 studies were at a mod-

erate risk of bias (Table IV). Concerning the assessment
19 6 6.1 (CBCT

of quality for the measurement methods, the informa-

(group 2); 34.5

(OPT group);
mean 16 6 5.2

tion regarding the observers who made the measure-

(group 3)
Age
Mean 17.9

1); 29.2

ments and their blinding were generally lacking. Only

group)

12 studies of 27 reported an adequate estimation of

the method error, whereas 7 studies50,51,54,55,60,64,66
did not report any kind of information on method error.
NS, not specified; NA, not available.

Regarding the assessment of image quality, 13

Sample
size

studies12,51,52,54,55,57,60,63,64,66,68,70,71 did not report in-

60

94

80 1 80

formation on the voxel size of the images used—making

Table III. Continued

it difficult to estimate the magnitude of the possible

measuring error. Five studies54,58,60,71,72 did not report
Al-Jaf et al, 201862

information on the procedure for data set reorienting.

et al, 201759

et al, 201815

Of the 10 corresponding authors who were contacted

Ohiomoba

Tepedino

to retrieve the missing information, only 1 author43 pro-

Study

vided information about the voxel size of the images

used.

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8 Tepedino et al

Table IV. Scoring of the included articles according to the custom-developed quality assessment tool
Quality of measurement method Quality of images

Sample Method Reference Data Image Voxel Image

Author size Observer error point reporting type size reorienting Total
Poggio et al, 200612 1 1 2 1 1 1 0 0 7
Lim et al, 200763 1 1 1 1 0 1 0 1 6
Hern
andez et al, 200866 1 0 0 1 1 1 0 1 5
Lim et al, 200857 1 1 1 1 0 1 0 2 7
Baumgaertel and Hans, 200968 1 1 2 1 1 1 0 2 9
Lee et al, 200971 2 1 1 2 1 1 0 0 8
Lim et al, 200970 1 1 1 1 0 1 0 2 7
Monnerat et al, 200964 0 0 0 1 1 1 0 2 5
Park and Cho, 200955 2 1 0 2 1 1 0 2 9
Fayed et al, 201052 2 1 1 2 1 1 0 2 10
Baumgaertel, 201147 1 0 2 1 1 1 2 2 10
Bittencourt et al, 201154 0 0 0 1 1 1 0 0 3
Silvestrini Biavati, 201158 1 1 2 1 1 1 1 0 8
Laursen et al, 201365 1 1 2 1 1 2 2 2 12
Ozdemir et al, 201349 2 1 2 1 1 1 2 2 12
Sawada et al, 201350 1 1 0 2 1 2 2 2 11
Zhao et al, 201351 1 1 0 1 1 1 0 2 7
Choi et al, 201456 2 1 1 2 1 1 2 1 11
Germec-Cakan et al, 201448 2 1 2 1 1 1 2 2 12
Veli et al, 201467 2 1 1 2 1 1 1 2 11
da Costa Sabec et al, 201569 2 1 2 2 1 1 1 2 12
Yang et al, 201553 2 2 1 2 1 1 1 2 12
Sadek et al, 201661 2 1 2 1 1 1 1 2 11
Moslemzadeh et al, 201760 1 0 0 2 1 1 0 0 5
Ohiomoba et al, 201759 2 1 2 1 0 1 1 2 10
Al-Jaf et al, 201862 2 2 2 2 1 1 1 2 13
Tepedino et al, 201815 2 1 2 2 1 1 1 2 12

Results of individual studies and meta-analysis
The data regarding the maxillary mesiodistal interra-
dicular spaces and cortical bone thickness, extracted
from the included studies, are reported in
Supplementary Tables II–VII. The data regarding the
mandibular mesiodistal interradicular spaces and
cortical bone thickness, extracted from the included
studies, are reported in Supplementary Tables VIII–XIII.
Regarding the mesiodistal interradicular space, a
meta-analysis could only be performed for the maxillary
vestibular spaces at 6 mm from the CEJ (Fig 2), and for
the vestibular posterior area in the mandible at 5 mm
from the CEJ (Fig 3). For the maxillary spaces, 4 articles
for the anterior area52,53,56,71 and 4 articles for the pos-
terior area52,53,60,71 were included, whereas only 4 arti-
cles were included for the mandibular spaces.12,54,58,64
All the studies showed a high heterogeneity
(I2 .74%); therefore, a random-effect model was
used. On the basis of these results, the most favorable
site for miniscrew insertion in the anterior maxilla at
6 mm from the CEJ is the site between canine and lateral
incisor, followed by the site between the 2 central
incisors, and then the site between central and lateral in-
cisors (Fig 2). The most favorable sites for miniscrew
insertion in the posterior maxilla at 6 mm from the
CEJ are located between the first and second premolars,
and between the second premolar and first molar, where
at least 3 mm of interradicular space is regularly present
(Fig 2). In the vestibular posterior mandible, the most
favorable interradicular sites for miniscrew insertion, at
5 mm from the CEJ, are located between the first and
second premolars and between the first and
second molars (Fig 3). A safe zone map of the mesiodistal
interradicular spaces was drawn, according to the results
of the present meta-analysis (Fig 4, A).
Regarding the cortical bone thickness, it was possible
to perform a meta-analysis for the vestibular and palatal
cortical bone thickness of the posterior maxilla at 4 mm
from the AC (Figs 5 and 6), and for the vestibular cortical
bone thickness of the posterior mandible at 4 mm from
the AC (Fig 7). Safe zone maps of the cortical bone thick-
ness of the vestibular (Fig 4, B) and palatal (Fig 4, C)
insertion sites were drawn and reported according to
the results of the present meta-analysis, using the color

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Fig 2. Forest plots for the mesiodistal width of the vestibular interradicular sites at 6 mm apical to the
CEJ in the maxilla. ES, effect size; CI, confidence interval.

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Fig 3. Forest plots for the mesiodistal width of the vestibular interradicular sites at 5 mm apical to the
CEJ in the posterior area of the mandible. ES, effect size; CI, confidence interval.

coding previously described to highlight the areas that
allow miniscrew insertion with or without predrilling,
or the areas that are not suitable at all. For the vestibular
cortical bone of the maxillary posterior area, 6 studies
were pooled.48-51,61,68 According to these results, in gen-
eral, the interradicular sites in the posterior maxilla do
not require predrilling because the cortical thickness
did not exceed 1.5 mm.21 Regarding the palatal cortical
bone of the maxillary posterior area, the results (from
pooling 5 articles)47-50,61 revealed that the predrilling
of the insertion site was not necessary, except for the
palatal space between canine and first premolar, where
the cortical bone is thicker than 1.5 mm (Fig 6). Concern-
ing the thickness of the vestibular cortical bone in the
posterior mandible, 5 studies were included in the
meta-analysis.48,49,51,61,68 These studies suggested that
the thickness of the cortical bone was increasing from
mesial to distal, and predrilling of the insertion site
with a 1 mm bur should be recommended. For the area
between the first and second molars, predrilling with a
1.1 mm bur at a depth of 4 mm is advisable, as the cortical
thickness in this area may exceed 2.5 mm (Fig 7).
Risk of bias across studies
The results of the Egger test for publication bias sug-
gested the presence of a statistically significant asymme-
try between effect size and sample size. This finding was
observed for the measurements of the maxillary vestib-
ular interradicular spaces 6 mm apical from the CEJ, be-
tween the canine and the lateral incisor (P 5 0.011) and
between the first and second premolars (P 5 0.028); the
mandibular vestibular interradicular spaces 4 mm apical
from the AC, between the first and second premolars
(P 5 0.004); and the measurements of the palatal
cortical bone thickness 4 mm apical from the AC, be-
tween first and second premolars (P 5 0.006).

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Tepedino et al
Fig 4. Safe zone maps drawn with the data retrieved from
the meta-analysis. A, Safe zone map for the vestibular in-
terradicular spaces in the maxilla and in the posterior
mandible. The values were retrieved from the meta-
analysis of the interradicular measurements at 6 mm
from the CEJ in the maxilla and 5 mm from the CEJ in
the posterior mandible, and colors are assigned
according to the legend reported in the figure. See
Figures 2 and 3 for the 95% confidence intervals;
B, safe zone map for the vestibular cortical bone thick-
ness in the posterior maxilla and mandible. The values
were retrieved from the meta-analysis of the cortical
bone thickness measurements at 4 mm of depth from
the AC, and colors are assigned according to the legend
reported in the figure. See Figures 5 and 7 to see the 95%
confidence intervals; C, safe zone map for the palatal
cortical bone thickness in the maxilla. The values are
retrieved from the meta-analysis of the cortical bone thick-
ness measurements at 4 mm of depth from the AC, and
colors are assigned according to the legend reported in
the figure. See Figure 6 to see the 95% confidence
intervals.
American Journal of Orthodontics and Dentofacial Orthopedics
11
DISCUSSION
Summary of evidence
By combining the data of the mesiodistal interradic-
ular width with the amount of cortical bone thickness, it
is possible to define the interradicular sites that offer the
best conditions for clinical success in miniscrew inser-
tion, at least concerning the quality and quantity of
hard tissues.
In the vestibular anterior maxilla, all of the included
studies reported the presence of cortical bone thickness
between 0.5 and 1.5 mm for all the sites (Supplementary
Table IV), with only 2 exceptions.57,70 Regarding the me-
siodistal interradicular width, the safest sites are the sites
between the 2 central incisors, at 6 mm or more, and the
sites between the lateral incisor and the canine, at 8 mm
or more (Supplementary Table II). In contrast, the space
between the central and the lateral incisors should
seldom be considered as a suitable insertion site.
In the vestibular posterior maxilla, most of the
included studies report the presence of a cortical bone
thickness between 0.5 and 1.5 mm for all the sites
(Supplementary Table V), with only a few excep-
tions.51,57,70 This is a favorable condition that offers
good primary stability without the need to predrill the
insertion site.21 The sites in this area that also offer an
adequate amount (.3 mm) of interradicular bone are
the sites between first and second premolars at 6 mm
of depth (from CEJ or AC, depending on the studies),
where all the authors reported more than 3 mm of space
and the space between the first molar and second pre-
molar at 6 mm of depth. For the latter space, only 1
article60 reported slightly less than 3 mm
(2.95 6 0.95), with a large 95% confidence interval.
This finding was confirmed by the results of the present
meta-analysis (Fig 2). Unfortunately, it is not possible to
combine the data from the meta-analysis of both mesio-
distal space and cortical bone thickness because the
measurements were taken at different levels (6 mm
from the CEJ and 4 mm from the AC, respectively). How-
ever, the clinician should consider that when accounting
for a mean biological width of 2 mm, the 2 distances are
very close to one another. Furthermore, the site between
the first molar and second premolar (8 mm of depth)
could be considered a viable option, because 5 of 7
studies12,50,58,60,71 reported a mesiodistal space greater
than 3 mm. In contrast, the sites between the canine
and the first premolar and the sites between first and
second molars should be considered with caution
because mesiodistal sites are smaller than 3 mm
(Supplementary Table III).
The palatal anterior and posterior maxilla are gener-
ally offering a cortical bone thickness between 0.5 and
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Fig 5. Cortical bone thickness of the vestibular interradicular spaces 4 mm apical to the AC in the
posterior area of the maxilla. ES, effect size; CI, confidence interval.

1.5 mm at all sites (Supplementary Tables VI and VII);
thus it could be reported with confidence that predrilling
is not required for the palatal spaces from the first
premolar to the second molar at 4 mm from the AC
(Figs 4, C and 6).
In the vestibular anterior mandible, despite the pres-
ence of adequate cortical bone thickness (between 0.5
and 1.5 mm) (Supplementary Table X) as reported by
all of the included articles except 1,70 there are no suit-
able sites for miniscrew insertion because of the reduced
amount of mesiodistal bone between the roots
(Supplementary Table VIII). Two studies15,71 reported
less than 1.5 mm interradicular space at almost every
level of the anterior mandible, and according to 1
study,66 an adequate amount of interradicular space
can be found only at 9 mm from the AC, which is prob-
lematic in respect to the soft tissue because it is likely to
be covered by unattached gingiva, which is a risk factor
for miniscrew failure.73
In the vestibular posterior mandible, a thicker cortical
bone should be expected. Thus, except for the site be-
tween the canine and the first premolar, predrilling is
suggested. In addition, predrilling should be even deeper
for the space between the first and second molar
(Supplementary Table XI). These results were confirmed
by the present meta-analysis at a depth of 4 mm from
the AC (Figs 4, B and 7). As in the case of the maxilla,
it is not possible to combine the data from the meta-
analysis of both mesiodistal space and cortical bone
thickness, because the measurements were taken at
different levels (5 mm from the CEJ and 4 mm from
the AC, respectively). However, on the basis of the results
of the present meta-analysis, it can be suggested that
miniscrew insertion—with cortical bone predrilling—is
possible for the site between the first and second premo-
lars and between the first and second molars at 5 mm of
depth from the CEJ (Figs 3 and 4). The space between
the canine and the first premolar is generally presenting
an amount of space between 1.6 and 2.9 mm, which
needs more careful evaluation before miniscrew inser-
tion. Finally, the space between the second premolar
and first molar shows a good amount of space from
6 mm and apically (from either the CEJ or the AC),
because only 2 mesiodistal space sites54,60 are measured
below 3.0 mm (Supplementary Table IX).
Regarding the lingual anterior and posterior
mandible, limited data are available,52,58,64,65 as these
areas are seldom used for miniscrew insertion. The

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Tepedino et al
Fig 6. Cortical bone thickness of the palatal interradicular spaces 4 mm apical to the AC in the posterior
area of the maxilla. ES, effect size; CI, confidence interval.
lingual anterior mandible shows a thicker cortical bone
than the vestibular area, suggesting the need for predril-
ling before miniscrew insertion (Supplementary Table
XII). Regarding the lingual posterior mandible, the areas
between the first and second molars and between the
first molar and the second premolar show a thinner
cortical bone than the corresponding vestibular area,
but still above 1.5 mm, thus requiring predrilling
(Supplementary Table XIII). The area between the first
and second premolars showed a cortical bone thickness
above 2.0 mm, with 2 studies reporting a cortical bone
thickness above 2.5 mm at midroot level65 and at
11 mm from the AC.64 The area between the canine
and the first premolar also has a thick cortical bone
(above 2.5 mm and between 4 mm and 6 mm from the
CEJ); thus, predrilling is suggested.
The results of the present systematic review with
meta-analysis focus on hard tissues, but the properties
of the soft tissues play a fundamental role as well, as
demonstrated by several studies.73-75 Ideally, the
American Journal of Orthodontics and Dentofacial Orthopedics
13
miniscrew should be placed into the attached gingiva,
although in some patients, the adequate amount of
bone can only be found in an area covered by alveolar
mucosa. In such situations, the risks of root damage
surpass the availability of attached gingiva, and a
compromise should be achieved, for example, by tilting
the miniscrew and placing it in the attached gingiva,
close to the mucogingival line. Alternatively, in some
patients, the interradicular space could be increased,
for example, by diverging the roots, but because this
procedure results in extended treatment time and a
jiggling movement, its convenience should be
evaluated carefully.
Limitations
The main limitation of the present systematic review
with meta-analysis was related to the high heterogeneity
of the included studies, both regarding the measurement
method and the reference level used, which limited the
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Fig 7. Cortical bone thickness of the vestibular interradicular spaces 4 mm apical to the AC in the
posterior area of the mandible. ES, effect size; CI, confidence interval.

possibility of conducting an extensive meta-analysis of
the collected data. In addition, many of the included
studies lacked information about the estimation of the
method error, which reduces the precision of the results
that are provided in the present study.
and between the first and second premolars, both at
5 mm from the CEJ. For both interradicular sites, at a
depth of 4 mm from the AC, it is necessary to predrill.
For the lingual anterior and posterior areas of the
mandible, the predrilling of the insertion site is advisable.

CONCLUSIONS
In the maxilla, the most favorable vestibular interra-
dicular sites are the sites mesial and distal to the first
molar, and between the canine and the lateral incisor,
all located at 6 mm from the CEJ. In those areas, the
cortical bone has an adequate thickness that does not
require predrilling. A similar amount of cortical bone
thickness is also present in the palatal area from the
mesial of the second molar to the distal of the first
premolar.
In the mandible, the most favorable vestibular interra-
dicular sites are those between the first and second molars
ACKNOWLEDGMENTS
Michele Tepedino: conceptualization, formal anal-
ysis, writing - original draft, and visualization; Paolo
M. Cattaneo: writing - review & editing, validation, and
supervision; Xiaowen Niu: formal analysis; Marie A. Cor-
nelis: conceptualization, formal analysis, writing - review
& editing, validation, and supervision.
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2020.05.011.

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terradicular sites for orthodontic mini-implant placement. Orthod
Craniofac Res 2009;12:299-304.
71. Lee KJ, Joo E, Kim KD, Lee JS, Park YC, Yu HS. Computed tomo-
graphic analysis of tooth-bearing alveolar bone for orthodontic
miniscrew placement. Am J Orthod Dentofacial Orthop 2009;
135:486-94.
72. Niwlikar KB, Khare V, Nathani R, Bhayade SS, Shewale A. Bone
mapping for mini-implant placement with various facial growth
patterns using three dimensional volumetric tomography. J Clin
Diagn Res 2018;12:13-8.
73. Miyawaki S, Koyama I, Inoue M, Mishima K, Sugahara T, Takano-
Yamamoto T. Factors associated with the stability of titanium
screws placed in the posterior region for orthodontic anchorage.
Am J Orthod Dentofacial Orthop 2003;124:373-8.
74. Mohammed H, Wafaie K, Rizk MZ, Almuzian M, Sosly R, Bearn DR.
Role of anatomical sites and correlated risk factors on the survival
of orthodontic miniscrew implants: a systematic review and
meta-analysis. Prog Orthod 2018;19:36.
75. Consolaro A, Romano FL. Reasons for mini-implants failure:
choosing installation site should be valued! Dental Press J Orthod
2014;19:18-24.
Tepedino et al 16.e1

Supplementary Table I. Quality assessment tool

Domain Score
Quality of measurement method
Sample size 0 5 less than 20 subjects
1 5 between 20 and 40 subjects
2 5 more than 40 subjects
How many observers? 0 5 not specified
1 5 1 observer
2 5 more than 1
Was the error of the method calculated? 0 5 no, or not specified
1 5 yes, but only t test
2 5 yes, with adequate methods
Which reference point was used? 0 5 contact point
1 5 alveolar crest or midroot
2 5 CEJ
How were measurements reported? 0 5 only graphs
1 5 detailed tables
Quality of diagnostic images
Image type 1 5 CBCT or CT
2 5 micro-CT
Voxel size 0 5 not specified
1 $ 0.3 mm
2 # 0.3 mm
Were images reoriented to a custom reference? 0 5 no, or not specified
1 5 yes, but method not clearly described
2 5 yes with clear description of the method used
Total score 0 to 5 5 high risk of bias
6 to 10 5 moderate risk of bias
11 to 15 5 low risk of bias

CBCT, cone-beam computed tomography; CT, computed tomography.

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Supplementary Table II. Mesiodistal interradicular space for maxillary vestibular anterior area
Hernandez et al Lim et al Lee et al Sawada et al Choi et al Yang et al Tepedino et
Fayed et al (2010)
(2008) (2008) (2009) (2013) (2014) (2015) al (2018)

Mode of assessment CT CT CT CBCT micro-CT CBCT CBCT CBCT

Reference point AC AC CEJ CEJ CEJ CEJ CEJ CEJ

2 mm 2.01 ± 0.48 3.06 ± 0.81 / 3.07 ± 0.99 1.99 ± 0.47**

3 mm 2 ± 1.5 / 3 ± 1.5 2.09 ± 0.58

Space between
4 mm 2.58 ± 0.6 3.69 ± 1 / 3.49 ± 1.2 2.52 ± 0.63** 2.8 ± 0.68 1.8 ± 0.6‡
canine and
6 mm 2 ± 1.8 / 3 ± 1.9 4.5-5.0*† 2.92 ± 0.77 3.96 ± 1.2 / 3.84 ± 1.36 3.16 ± 0.83** 3.24 ± 0.75 2.46 ± 0.49
lateral incisor
8 mm 3.42 ± 1.04 3.89 ± 1.18** 3.88 ± 0.84 2.8 ± 1.2‡

9 mm 3.5 ± 2.5 / 3.5 ± 2.6 3.18 ± 0.38

Space between 2 mm 1.41 ± 0.36 2.52 ± 0.75 / 2.69 ± 0.76 1.46 ± 0.58**

central and 3 mm 2.5 ± 1 / 2 ± 1 1.49 ± 0.43

lateral incisors 4 mm 1.58 ± 0.52 2.91 ± 0.86 / 2.95 ± 0.7 1.86 ± 0.68** 1.9 ± 0.41 1.0 ± 0.4‡

6 mm 2.5 ± 1.4 / 2 ± 1.5 3.5-4.0*† 0.91 ± 0.64 3.03 ± 0.96 / 3.17 ± 0.93 2.32 ± 0.88** 2.28 ± 0.6 1.93 ± 0.64

8 mm 2.19 ± 0.66 3.34 ± 1.12** 2.95 ± 0.9 1.6 ± 0.8‡

9 mm 3 ± 1.8 / 3 ± 1.9 2.4 ± 0.51

2 mm 1.7 ± 0.42 3.23 ± 0.94

3 mm 4±1 1.77 ± 0.5

Space between
4 mm 2.09 ± 0.62 3.77 ± 1.04 2.37 ± 0.67 1.7 ± 0.8‡
the central
6 mm 4 ± 1.5 3.5-4.0*† 2.47 ± 0.74 4.27 ± 1.23 3.01 ± 0.69 2.24 ± 0.41
incisors
8 mm 3.21 ± 1 3.87 ± 0.99 3.3 ± 1.3‡

9 mm 4 ± 1.8 3.18 ± 0.86

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color legend:
green, more than 3 mm of mesiodistal width; yellow, more than 1.5 mm but less than 3 mm of mesiodistal width; red, less than 1.5 mm of me-
siodistal width; when the right/left side are both reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
*The authors reported only a mean value of all the measurement levels; **the authors divided the root length in 4 equal pieces and measured the
space at each quarter; ythe reported values are a range obtained from graphs; zthe authors divided the root length in three thirds and measured the
space at the 1/3 and at the 2/3 of the root length.

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Supplementary Table III. Mesiodistal interradicular space for maxillary vestibular posterior area
Poggio Silvestrini
Hernandez et al Lim et al Lee et al Park and Fayed et al Bittencourt Sawada et al Yang et al Moslemzadeh Tepedino et al
et al Biavati et al
(2008) (2008) (2009) Cho (2009) (2010) et al (2011) (2013) (2015) et al (2017) (2018)
(2006) (2011)

Mode of assessment CBCT CT CT CT CBCT CBCT CT CT micro-CT CBCT CBCT CBCT

Reference point AC AC AC CEJ CEJ CEJ AC AC CEJ CEJ CEJ CEJ

3.18 ± 1.34 /
2 mm 3.0 ± 0.7 2.13 ± 0.59 1.60 ± 0.53 1.6 ± 0.58** 1.6 ± 0.46
3.13 ± 0.98

3 mm 3 ± 0.8 / 3 ± 0.9 2.52 ± 0.57

3.27 ± 1.37 /
4 mm 2.47 ± 0.76 2.18 ± 0.83** 1.9 ± 0.58 1.7 ± 0.7‡
3.24 ± 0.96
Space between 2.21 ± 0.62/ 2.44 ± 0.68/
5 mm 3.4 ± 0.7 1.70 ± 0.58
canine and
2.24 ± 0.80 2.34 ± 0.7
first premolar
3.35 ± 1.44 /
6 mm 3 ± 0.9 / 3 ± 1.4 4.0-4.5*† 3.01 ± 0.87 2.57 ± 1.06** 2.54 ± 0.51 2.0 ± 0.5
3.37 ± 1.05

2.44 ± 0.76/
7 mm
2.45 ± 0.84

2.64 ± 0.61/
8 mm 3.9 ± 1.1 3.16 ± 0.8 2.16 ± 0.85 3.39 ± 1.13** 2.35 ± 0.8 2.1 ± 0.9‡
2.47 ± 0.83

2.67 ± 0.97/
9 mm 4 ± 1.2 / 3.5 ± 1.6 2.69 ± 1.05
2.71 ± 0.96

11 mm 2.81 ± 0.87/

2.75 ± 1.11

3.32 ± 0.67 /
2 mm 2.9 ± 0.6 2.17 ± 0.39 1.45 ± 0.40 2.25 ± 0.58** 2.4 ± 0.67
2.95 ± 0.66

3 mm 3 ± 0.8 / 3 ± 0.9 2.8 ± 0.46

3.44 ± 0.75 /
4 mm 2.81 ± 0.45 2.68 ± 0.73** 3.0 ± 0.78 2.0 ± 0.7‡
3.39 ± 0.74

2.16 ± 0.61/ 2.61 ± 0.51/

5 mm 3.2 ± 0.8 1.41 ± 0.47
2.08 ± 0.65 2.75 ± 0.81
Space between
3.51 ± 0.9 /
first and
6 mm 3 ± 1.2 / 3.5 ± 1.2 4.0-4.5*† 3.16 ± 0.59 3.0 ± 0.91** 3.03 ± 0.37 3.45 ± 0.96
3.25 ± 0.82
second
2.35 ± 0.71/
premolars 7 mm
2.29 ± 0.76

2.66 ± 1.0/
8 mm 3.5 ± 1.1 3.19 ± 0.69 1.55 ± 0.54 3.76 ± 1.14** 3.7 ± 1.05 2.1 ± 1‡
3.03 ± 0.83

2.52 ± 0.79/
9 mm 4 ± 1.4 / 4 ± 1.3 3.2 ± 0.42
2.42 ± 0.96

11 mm 2.79 ± 0.83/

3.17 ± 0.86

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Supplementary Table III. Continued.

3.64 ± 0.95 /
2 mm 2.7 ± 0.6 2.49 ± 0.52 1.75 ± 0.61 2.46 ± 0.63** 2.7 ± 0.64
3.57 ± 0.95

3 mm 3 ± 1 / 3 ± 0.9 2.62 ± 0.54

3.86 ± 1.4 /
4 mm 3.21 ± 0.64 2.73 ± 0.82** 2.95 ± 0.8 2.0 ± 0.6‡
3.66 ± 1.05

2.40 ± 0.86/ 2.66 ± 0.64/

5 mm 2.9 ± 0.9 1.77 ± 0.70
2.53 ± 0.87 2.78 ± 0.79
Space between
4.06 ± 1.59 /
first molar and
6 mm 3 ± 1.2 / 3 ± 1.1 4.5-5.0*† 3.56 ± 0.82 3.53 ± 1.18** 3.11 ± 0.71 2.95 ± 0.95
3.84 ± 1.4
second
2.74 ± 1.08/
premolar
7 mm
2.77 ± 1.03

2.99 ± 0.83/
8 mm 3.0 ± 1.5 3.98 ± 0.91 1.95 ± 0.90 5.01 ± 1.39** 3.8 ± 1.16 2.1 ± 1‡
3.02 ± 1.05

3.30 ± 1.36/
9 mm 4 ± 2.2 / 4 ± 1.4 4.01 ± 0.68
3.35 ± 1.28

11 3.59 ± 1.27/

mm 3.8 ± 1.22

Space between 2.85± 0.90 /

2 mm 2.5 ± 0.7 1.99 ± 0.53 1.29 ± 0.39 1.94 ± 0.59** 2.85 ± 0.78
2.75 ± 0.93
first and

second molars 3 mm 4 ± 0.9 / 4 ± 1 2.29 ± 0.74

2.55 ± 0.92 /
4 mm 2.17 ± 0.74 2.13 ± 0.72** 3.25 ± 1.19 1.1 ± 0.6‡
2.51 ± 1.16

1.63 ± 0.70/ 2.02 ± 0.77/

5 mm 2.3 ± 0.8 1.03 ± 0.39
1.62 ± 0.64 2.16 ± 0.81

2.16 ± 0.86 /
6 mm 3 ± 1.2 / 3 ± 1.1 3.0-3.5*† 1.92 ± 0.91 2.42 ± 0.87** 2.62 ± 0.88 3.75 ± 1.54
2.35 ± 1.2

1.64 ± 0.82/
7 mm
1.70 ± 0.81

2.15 ± 1.05/
8 mm 2.5 ± 1.5 2.07 ± 1.13 1.01 ± 0.35 3.1 ± 1.05** 4.3 ± 1.58 1.0 ± 0.7‡
2.65 ± 1.05

2.04 ± 1.01/
9 mm 5 ± 1.4 / 3.5 ± 1.5 3.49 ± 1.29
2.07 ± 1.05

11 2.43 ± 1.39/

mm 3.02 ± 1.42

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color legend:
green, more than 3 mm of mesiodistal width; yellow, more than 1.5 mm but less than 3 mm of mesiodistal width; red, less than 1.5 mm of me-
siodistal width; when the right/left side are both reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
*The authors reported only a mean value of all the measurement levels; **the authors divided the root length in 4 equal pieces and measured the
space at each quarter; ythe reported values are a range obtained from graphs; zthe authors divided the root length in three thirds and measured the
space at the 1/3 and at the 2/3 of the root length.

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Tepedino et al 16.e5

Supplementary Table IV. Vestibular cortical bone thickness of the maxillary anterior area
Lim et Ohiomoba
Lim et al Lim et al Baumgaertel and Hans Laursen et al Sawada et Choi et al Sadek et
al et al
(2007) (2008) (2009) (2013) al (2013) (2014) al (2016)
(2009) (2017)

Mode of assessment CT CT CBCT CT micro-CT micro-CT CBCT CBCT CT

Reference point AC AC AC AC Root length AC CEJ AC AC

2 mm 1.0-1.5† 2.5-3.0† 0.91 ± 0.18 / 0.85 ± 0.15 0.73 ± 0.19

3 mm 0.83 ± 0.24

Space 1.15 ± 0.94 ±

4 mm 1.0-1.5† 1.5-2.0† 0.99 ± 0.22 / 1.01 ± 0.15 0.94 ± 0.24
between 0.27 0.15‡

canine and 6 mm 1.0-1.5† 1.0-2.0† 1.13 ± 0.27 / 1.17 ± 0.22 2.63* 0.72 (0.47-1.03)§ 1.12 ± 0.32 1.2 ± 0.2

lateral 1.01 ±
7 mm 1.13 ± 0.34
incisor 0.2‡

8 mm 1.16 ± 0.36 1.2 ± 0.13 0.8-1.0†

9 mm 1.14 ± 0.32

Space 2 mm 1.0-1.5† 2.0-2.5† 0.89 ± 0.28 / 0.88 ± 0.39 0.69 ± 0.16

between 3 mm 0.73 ± 0.19

central and 0.90 ±

4 mm 1.0-1.5† 1.0-1.5† 1.0 ± 0.2 / 0.88 ± 0.13 0.86 ± 0.21 1.0 ± 0.3
lateral 0.19‡

incisors 6 mm 1.0-1.5† 1.0-2.0† 1.12 ± 0.26 / 1.16 ± 0.21 1.91* 1.10 (0.16-1.95)§ 0.95 ± 0.25 1.0 ± 0.22

0.96 ±
7 mm 1.01 ± 0.21
0.11‡

8 mm 1.02 ± 0.23 1.1 ± 0.21 0.6-0.8†

9 mm 1.04 ± 0.22

2 mm 1.0-1.5† 0.75 ± 0.18

3 mm

0.83 ±
Space 4 mm 1.0-1.5† 0.85 ± 0.21 0.7 ± 0.27
0.17‡
between the
6 mm 1.0-2.0† 0.99 ± 0.24 1.53* 1.11 (0.16-1.78)§ 0.8 ± 0.3
central
0.9 ±
incisors 7 mm
0.06‡

8 mm 0.9 ± 0.34 0.6-0.8†

9 mm

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color cod-
ing, according to Baumgaertel (2010)19: red, less than 0.5 mm of cortical thickness; green, between 0.5 mm and 1.5 mm of cortical thickness; yel-
low, between 1.5 mm and 2.5 mm of cortical thickness; light blue, more than 2.5 mm of cortical thickness; when values from right/left side are both
reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
*The authors reported only a mean value of all the measurement levels; ythe reported values are a range obtained from graphs; zvalues are retrieved
from normo-divergent subjects; §mean (min-max), values were measured at midroot.

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Supplementary Table V. Vestibular cortical bone thickness of the maxillary posterior area
Lim Ohiom
Lim et Lim et Baumgaert Silvestrini Ozdemir Germek- Veli et Al-Jaf
et al Park and Fayed et al Laursen et Sawada et Zhao et al Sadek et oba et
al al el and Hans Biavati et et al Cakan et al al et al
(2009 Cho (2009) (2010) al (2013) al (2013) (2013) al (2016) al
(2007) (2008) (2009) al (2011) (2013) (2014) (2014) (2018)
) (2017)

Mode of assessment CT CT CBCT CT CBCT CBCT CT micro-CT CBCT micro-CT CBCT CBCT CBCT CBCT CT CBCT

Reference point AC AC AC AC CEJ CEJ AC Root length AC AC AC AC CEJ AC AC CEJ

1.90 ±
1.0- 2.5- 1.11 ± 0.28/ 1.10 ± 0.30/ 0.79 ±
0.57/ 1.84
1.5† 3.0† 1.16 ± 0.18 1.21 ± 0.31 0.19
2 mm ± 0.76

0.85 ±

3 mm 0.22

1.93 ±
1.0- 1.5- 0.98 ± 0.23/ 1.15 ± 0.37/ 1.39 ± 0.93 ± 0.99 ±
0.37/ 1.81 1.44 ± 0.39
1.5† 2.0† 1.03 ± 0.17 1.19 ± 0.31 0.24 ‡ 0.26 0.15‡
Space 4 mm ± 0.75
between 1.21 ±
1.12 ± 0.29/ 1.23 ±
canine and 0.19/ 1.22
1.14 ± 0.44 0.05
first 5 mm ± 0.14
premolar 1.96 ±
1.0- 1.0- 1.22 ± 0.26/ 1.18 ± 0.34/ 0.77 (0.55- 1.16 ± 1.42 ±
2.65* 0.42/ 1.83
1.5† 2.0† 1.28 ± 0.19 1.24 ± 0.32 0.97)§ 0.36 0.31ǁ
6 mm ± 0.83

1.24 ±
1.26 ± 1.1 ±
0.16/ 1.24 1.19 ± 0.3
0.05 0.25‡
7 mm ± 0.14

1.30 ± 0.38/ 1.23 ± 2.03 ± 0.8- 1.45 ±

8 mm

1.23 ± 0.45 0.33 0.51/ 1.77 1.0† 0.29ǁ

± 0.68

1.28 ±
1.28 ± 1.28 ±
0.13/ 1.26
0.35 0.04
9 mm ± 0.14

2.20 ±

0.43/ 1.96

10 mm ± 0.73

1.23 ± 0.38/

11 mm 1.15 ± 0.41

1.96 ±
1.0- 1.16 ± 0.24/ 1.15 ± 0.22/ 0.73 ±
2-2.5† 0.55/ 2.08
1.5† 1.14 ± 0.24 1.28 ± 0.34 0.20
2 mm ± 0.7

0.81 ±

3 mm 0.23

1.97 ±
1.0- 1.5- 1.01 ± 0.24/ 1.18 ± 0.33/ 1.45 ± 0.92 ± 1.46 ± 0.35 0.97 ±
Space 0.68/ 1.84
1.5† 2.0† 1.03 ± 0.20 1.28 ± 0.34 0.22 ‡ 0.29 0.14‡
between first 4 mm ± 0.73

and second 1.22 ±

1.10 ± 0.24/ 1.23 ±
premolars 0.17/ 1.22
1.05 ± 0.47 0.05
5 mm ± 0.17

1.82 ±
1.0- 1.0- 1.29 ± 0.27/ 1.10 ± 0.31/ 0.44 (0.26- 1.08 ± 1.44 ±
2.44* 0.48/ 1.93
1.5† 2.0† 1.32 ± 0.25 1.26 ± 0.35 0.61)§ 0.33 0.36ǁ
6 mm ± 0.62

1.25 ± 1.18 ± 1.24 ± 1.06 ±

7 mm 0.16/ 1.24 0.36 0.06 0.15‡

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Supplementary Table V. Continued.

± 0.13

2.06 ±
1.10 ± 0.37/ 1.25 ± 0.8- 1.46 ±
0.49/ 2.06
1.09 ± 0.47 0.37 1.0† 0.38ǁ
8 mm ± 0.54

1.27 ±
1.30 ± 1.29 ±
0.14/ 1.28
0.38 0.05
9 mm ± 0.16

2.25 ±

0.43/ 2.21

10 mm ± 0.59

1.18 ± 0.38/

11 mm 1.09 ± 0.31

2.03 ±
1.0- 2.5- 1.25 ± 0.27/ 1.12 ± 0.27/ 0.76 ±
0.77/ 2.10
1.5† 3.0† 1.18 ± 0.26 1.28 ± 0.26 0.17
2 mm ± 0.72

0.80 ±

Space 3 mm 0.21

between first 1.0- 1.5- 1.09 ± 0.24/ 1.18 ± 0.30/ 1.45 ± 0.86 ± 1.94 ± 0.5/ 1.44 ± 0.24 0.93 ±

molar and 4 mm 1.5† 2.0† 1.04 ± 0.21 1.27 ± 0.27 0.25 ‡ 0.25 2.05 ± 0.84 ǁ 0.13‡

second 1.22 ±
0.99 ± 0.14/ 1.24 ±
premolar 0.19/ 1.20
0.88 ± 0.30 0.06
5 mm ± 0.18

1.97 ±
1.0- 1.0- 1.34 ± 0.3/ 1.12 ± 0.30/ 0.92 (0.54- 1.02 ± 1.46 ±
2.12* 0.56/ 2.12
1.5† 2.0† 1.34 ± 0.28 1.31 ± 0.31 1.33)§ 0.35 0.41ǁ
6 mm ± 0.77

1.27 ±
1.08 ± 1.28 ± 0.94 ±
0.15/ 1.25
0.32 0.04 0.15‡
7 mm ± 0.15

2.25 ±
1.04 ± 0.50/ 1.16 ± 0.8- 1.42 ±
0.55/ 2.30
0.91 ± 0.40 0.35 1.0† 0.38ǁ
8 mm ± 0.70

1.30 ±
1.20 ± 1.3 ±
0.17/ 1.29
0.34 0.07
9 mm ± 0.16

2.39 ±

0.49/ 2.51

10 mm ± 0.75

1.08 ± 0.23/

11 mm 0.98 ± 0.27

2.05 ±
2.5- 1.23 ± 0.23/ 1.28 ± 0.43/ 0.76 ±
0.66/ 2.03
3.0† 1.20 ± 0.28 1.35 ± 0.35 0.20
2 mm ± 0.60

0.82 ±
Space
3 mm 0.26
between first
1.98 ±
and second 1.5- 1.10 ± 0.19/ 1.19 ± 0.37/ 1.44 ± 0.85 ± 1.44 ± 0.34 0.96 ±
0.91/ 1.73
molars 2.0† 1.06 ± 0.27 1.37 ± 0.31 0.20 ‡ 0.20 0.06‡
4 mm ± 0.52

1.18 ±
1.08 ± 0.21/ 1.16 ±
0.18/ 1.17
1.00 ± 0.53 0.06
5 mm ± 0.15

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Supplementary Table V. Continued.

2.07 ±
1.0- 1.39 ± 0.27/ 0.54 (0.26- 0.97 ± 1.55 ±
2.23* 1.20 ± 0.47/ 0.61/ 2.05
2.0† 1.35 ± 0.26 0.70)§ 0.34 0.43ǁ
6 mm 1.33 ± 0.32 ± 0.59

1.25 ±
1.06 ± 1.22 ± 1.08 ±
0.14/ 1.26
0.36 0.07 0.12‡
7 mm ± 0.15

2.12 ±
1.12 ± 0.48/ 1.11 ± 0.8- 1.49 ±
0.75/ 2.05
1.01 ± 0.38 0.35 1.0† 0.44ǁ
8 mm ± 0.58

1.31 ±
1.14 ± 1.27 ±
0.17/ 1.30
0.36 0.08
9 mm ± 0.19

2.17 ±

0.66/ 2.25

10 mm ± 0.58

1.14 ± 0.44/

11 mm 1.21 ± 0.40

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color cod-
ing, according to Baumgaertel (2010)19: red, less than 0.5 mm of cortical thickness; green, between 0.5 mm and 1.5 mm of cortical thickness; yel-
low, between 1.5 mm and 2.5 mm of cortical thickness; light blue, more than 2.5 mm of cortical thickness; when values from right/left side are both
reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
*The authors reported only a mean value of all the measurement levels; ythe reported values are a range obtained from graphs; zvalues are retrieved
from normo-divergent subjects; §mean (min-max), values were measured at midroot; kvalues were measured in a skeletal Class I sample.

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Supplementary Table VI. Palatal cortical bone thickness of the maxillary anterior area

Sawada et Sadek et al Ohiomoba

Fayed et al (2010) Laursen et al (2013)
al (2013) (2016) et al (2017)

Mode of assessment CBCT micro-CT micro-CT CBCT CT

Reference point CEJ Root length AC AC AC

2 mm 1.77 ± 0.52/ 1.55 ± 0.46 1.09 ± 0.30

3 mm 1.21 ± 0.34

4 mm 1.68 ± 0.53/ 1.66 ± 0.46 1.26 ± 0.29 1.04 ± 0.17‡

Space between canine and lateral incisor 6 mm 1.75 ± 0.59/ 1.74 ± 0.47 1.29 (0.85-1.58)§ 1.27 ± 0.36

7 mm 1.28 ± 0.54 1.21 ± 0.11‡

8 mm 1.32 ± 0.54 1.0-1.2†

9 mm 1.29 ± 0.58

2 mm 1.64 ± 0.58/ 1.54 ± 0.51 0.91 ± 0.27

Space between central and lateral incisors
3 mm 0.98 ± 0.25

4 mm 1.75 ± 0.54/ 1.64 ± 0.50 1.04 ± 0.24 1.08 ± 0.14‡

6 mm 1.85 ± 0.64/ 1.78 ± 0.53 1.29 (0.48-1.86)§ 1.14 ± 0.30

7 mm 1.12 ± 0.37 1.23 ± 0.24‡

8 mm 1.15 ± 0.36 1.0†

9 mm 1.11 ± 0.36

2 mm 1.39 ± 0.43

3 mm

4 mm 1.49 ± 0.49

Space between the central incisors 6 mm 1.75 ± 0.61 1.44 (0.30-2.00)§

7 mm

8 mm 0.8-1.0†

9 mm

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color cod-
ing, according to Baumgaertel (2010)19: red, less than 0.5 mm of cortical thickness; green, between 0.5 mm and 1.5 mm of cortical thickness; yel-
low, between 1.5 mm and 2.5 mm of cortical thickness; light blue, more than 2.5 mm of cortical thickness; when values from right/left side are both
reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
yThe reported values are a range obtained from graphs; zvalues are retrieved from normo-divergent subjects; §mean (min-max), values were
measured at midroot.

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Supplementary Table VII. Vestibular cortical bone thickness of the maxillary posterior area

Silvestrini Laursen Germec- Ohiomoba

Fayed et al Baumgaertel Ozdemir et Sawada et Sadek et al
Biava et al et al Cakan et al et al
(2010) (2011) al (2013) al (2013) (2016)
(2011) (2013) (2014) (2017)
Mode of assessment CBCT CBCT CT micro-CT CBCT micro-CT CBCT CBCT CT
Root
CEJ AC AC AC AC AC
Reference point length AC AC
1.68 ± 0.50/
1.15 ± 0.31
2 mm 1.57 ± 0.50

1.27 ± 0.30
3 mm
1.78 ± 0.54/ 1.75 ±
1.35 ± 0.33 1.42 ± 0.40 1.88 ± 0.52‖ 1.25 ± 0.09‡
4 mm 1.75 ± 0.50 0.36‡
1.33 ± 0.55/
Space 5 mm 1.30 ± 0.54
between 1.83
1.72 ± 0.56/
canine and (1.25- 1.44 ± 0.41
1.78 ± 0.46
first 6 mm 2.99)§
premolar
1.38 ± 0.37 1.35 ± 0.12‡
7 mm
1.61 ± 0.58/
1.39 ± 0.29 1.37 ± 0.42 1.0-1.2†
8 mm 1.57 ± 0.43

1.33 ± 0.46
9 mm
1.27 ± 0.35/
11 mm 1.47 ± 0.87
Space 1.58 ± 0.41/
0.98 ± 0.24
between 2 mm 1.48 ± 0.44
first and
second 1.09 ± 0.27
3 mm
premolars 1.64 ± 0.49/ 1.61 ±
1.22 ± 0.26 1.17 ± 0.33 1.59 ± 0.31‖ 1.06 ± 0.31‡
4 mm 1.55 ± 0.45 0.24‡
1.39 ± 0.53/
5 mm 1.26 ± 0.55
1.16
1.69 ± 0.50/
(1.02- 1.35 ± 0.43
1.66 ± 0.51
6 mm 1.29)§

1.36 ± 0.40 1.23 ± 0.22‡

7 mm
1.48 ± 0.53/
1.38 ± 0.26 1.33 ± 0.39 1.0-1.2†
8 mm 1.51 ± 0.45

1.29 ± 0.42
9 mm
1.31 ± 0.40/
11 mm 1.30 ± 0.33
1.36 ± 0.33/
0.94 ± 0.26
2 mm 1.39 ± 0.34

1.00 ± 0.30
3 mm
1.54 ± 0.39/ 1.54 ±
1.14 ± 0.29 1.09 ± 0.36 1.48 ± 0.26‖ 1.00 ± 0.12‡
Space 4 mm 1.39 ± 0.35 0.28‡
between 1.10 ± 0.30/
first molar 5 mm 1.21 ± 0.49
and second 1.39
premolar 1.63 ± 0.44/
(0.74- 1.25 ± 0.48
1.49 ± 0.40
6 mm 2.17)§

1.34 ± 0.50 1.15 ± 0.26‡

7 mm
1.40 ± 0.54/
1.11 ± 0.24 1.36 ± 0.45 0.8-1.0†
8 mm 1.20 ± 0.34

1.25 ± 0.38
9 mm
1.33 ± 0.37/
11 mm 1.38 ± 0.42

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Supplementary Table VII. Continued.

1.39 ± 0.30/
0.95 ± 0.25
2 mm 1.40 ± 0.38

0.95 ± 0.33
3 mm
1.30 ± 0.37/ 1.49 ±
1.09 ± 0.28 1.11 ± 0.38 1.54 ± 0.31‖ 0.93 ± 0.03‡
4 mm 1.42 ± 0.27 0.23‡
1.14 ± 0.36/
Space 5 mm 0.96 ± 0.40
between 0.84
1.41 ± 0.43/
first and (0.20- 1.23 ± 0.45
1.43 ± 0.22
second 6 mm 1.46)§
molars
1.26 ± 0.49 0.98 ± 0.13‡
7 mm
1.31 ± 0.51/
1.25 ± 0.31 1.31 ± 0.45 0.8-1.0†
8 mm 1.02 ± 0.30

1.22 ± 0.58
9 mm
1.11 ± 0.45/
11 mm 1.25 ± 0.47

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color cod-
ing, according to Baumgaertel (2010)19: red, less than 0.5 mm of cortical thickness; green, between 0.5 mm and 1.5 mm of cortical thickness; yel-
low, between 1.5 mm and 2.5 mm of cortical thickness; light blue, more than 2.5 mm of cortical thickness; when values from right/left side are both
reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
yThe reported values are a range obtained from graphs; zvalues are retrieved from normo-divergent subjects; §mean (min-max), values were
measured at midroot; kvalues were measured in a skeletal Class I sample.

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Supplementary Table VIII. Mesiodistal interradicular space for mandibular vestibular anterior area

Tepedino
Hernandez (2008) Lee (2009) Fayed (2010)
(2018)
Mode of assessment CT CT CBCT CBCT
Reference point AC CEJ CEJ CEJ
1.39 ± 0.50 2.61 ± 0.59/ 3.00 ±0.99
2 mm
2.5 ± 0.6/ 2.5 ± 0.4
3 mm

1.68 ± 0.46 2.94 ± 0.90/ 3.31 ± 1.36 1.5 ± 0.5‡

4 mm
Space between canine and lateral incisor
2.5 ± 0.7/ 3.0 ± 0.4 1.88 ± 0.59 3.28 ± 0.88/ 3.89 ± 1.33
6 mm

2.03 ± 0.66 2.3 ± 1.0‡

8 mm

3.0 ± 0.9/ 4.0 ± 0.6

9 mm

1.09 ± 0.29 2.12 ± 0.68/ 2.21 ± 0.54

2 mm

2.0 ± 0.4/ 2.0 ± 0.2

3 mm

Space between central and lateral incisors 1.17 ± 0.32 2.23 ± 0.61/ 2.15 0.60 0.9 ± 0.3‡
4 mm
2.5 ± 0.5/ 2.5 ± 0.4 1.22 ± 0.35 2.37 ± 0.73/ 2.31 ± 0.64
6 mm

1.22 ± 0.32 0.9 ± 0.5‡

8 mm

3.0 ± 0.7/ 3.0 ± 0.6

9 mm

1.31 ± 0.37 2.20 ± 0.54

2 mm

2.0 ± 0.5
3 mm

1.38 ± 0.36 2.29 ± 0.69 1.1 ± 0.5‡

4 mm
Space between the central incisors
2.5 ± 0.5 1.57 ± 0.46 2.31 ± 0.75
6 mm

1.80 ± 0.54 1.2 ± 0.6‡

8 mm

3.5 ± 0.7
9 mm

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color
legend: green, more than 3 mm of mesiodistal width; yellow, more than 1.5 mm but less than 3 mm of mesiodistal width; red, less than 1.5
mm of mesiodistal width; when the right/left sides are both reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
zThe authors divided the root length in three thirds and measured the space at the 1/3 and at the 2/3 of the root length.

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Tepedino et al 16.e13

Supplementary Table IX. Mesiodistal interradicular space for mandibular vestibular posterior area
Monnerat Park Silvestrini Moslemzad Tepedino
Poggio et Hernandez Lee et al Fayed et al Sabec et
et al and Cho eh et al et al
al (2006) et al (2008) (2009) (2010) et al (2011) al (2015)
(2009) (2009) (2011) (2017) (2018)
Mode of assessment CBCT CT CT CT CBCT CBCT CT CT CBCT CBCT CBCT
Reference point AC AC CEJ AC CEJ CEJ AC AC CEJ CEJ CEJ
3.01 ± 0.91/
2 mm 2.7 ± 0.7 1.91 ± 0.55 1.28 ± 0.56 1.6 ± 0.46
3.09 ± 1.18
2.5 ± 1.0/
3 mm 1.94 ± 0.68
2.5 ± 1.0
3.20 ± 1.03/
4 mm 2.4 ± 0.06 1.9 ± 0.58 1.9 ± 0.7‡
3.22 ± 0.97
1.99 ±
0.69/ 3.03 ± 0.99/
5 mm 2.8 ± 0.9 2.17 ± 0.74 3.42 ± 0.97 2.4 ± 0.6§
2.26 ± 2.49 ± 1.0
Space 0.71
between 3.0 ± 1.2/ 3.32 ± 1.05/
canine and 6 mm 2.76 ± 0.76 2.0 ± 0.65
3.0 ± 1.6 3.12 ± 1.03
first 2.22 ±
premolar 0.82/
7 mm 2.22 ± 0.8
2.59 ±
0.82
3.55 ± 1.2/
8 mm 3.0 ± 1.0 2.86 ± 0.82 1.73 ± 0.83 2.35 ± 0.8 2.6 ± 1.0‡
2.97 ± 0.83
2.46 ±
3.0 ± 1.6/
9 mm 2.44 ± 0.87 0.93/
4.0 ± 2.6
2.9 ± 1.0

10 mm 2.7 ± 0.92

4.21 ± 0.65/
11 mm 2.84 ± 1.03
2.94 ± 0.98
3.87 ± 1.03/
2 mm 3.2 ± 0.6 2.53 ± 0.51 2.22 ± 0.65 2.4 ± 0.66
3.97 ± 1.03
3.0 ± 0.5/
3 mm 2.61 ± 0.71
3.0 ± 0.4
4.35 ± 1.34/
4 mm 3.36 ± 0.59 3.0 ± 0.79 3.0 ± 0.9‡
4.59 ± 1.31
2.71 ±
0.82/ 3.31 ± 0.99/
5 mm 3.7 ± 0.8 3.07 ± 0.91 2.53 ± 0.90 3.2 ± 0.9§
2.97 ± 3.33 ± 1.0
0.78
3.0 ± 0.6/ 4.80 ± 1.42/
Space 6 mm 3.95 ± 0.7 3.45 ± 0.95
2.5 ± 0.6 5.22 ± 1.25
between
first and 3.21 ±
second 0.99/
7 mm 3.49 ± 1.13
premolar 3.49 ±
0.93
3.58 ± 1.11/
8 mm 4.3 ± 0.9 4.10 ± 0.78 2.90 ± 1.11 3.7 ± 1.05 4.1 ± 1.3‡
4.02 ± 1.05
3.61 ±
3.0 ± 0.6/ 1.21/
9 mm 3.74 ± 1.43
3.5 ± 0.9 4.0 ±
1.08

10 mm 4.2 ± 1.18

3.65 ± 1.16/
11 mm 3.94 ± 1.32
4.26 ± 1.51

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Supplementary Table IX. Continued.

Space 4.0 ± 1.03/

2 mm 3.0 ± 0.8 2.61 ± 0.58 1.89 ± 0.68 2.7 ± 0.64
between 4.56 ± 1.38
first molar 3.0 ± 0.9/
and second 3 mm 3.0 ± 1.5
3.5 ± 0.8
premolar 4.15 ± 1.38/
4 mm 3.31 ± 0.65 2.95 ± 0.79 2.9 ± 0.7‡
5.0 ± 1.51
2.81 ±
0.87/ 3.02 ± 0.74/
5 mm 2.9 ± 0.8 3.28 ± 1.66 2.04 ± 0.84 2.9 ± 0.8§
2.73 ± 2.32 ± 0.62
0.75
4.0 ± 1.1/ 4.36 ± 1.46/
6 mm 3.57 ± 0.78 2.95 ± 0.95
4.0 ± 1.9 5.61 ± 2.0
3.25 ±
1.07/
7 mm 3.89 ± 2.22
3.01 ±
0.84
3.5 ± 1.08/
8 mm 3.1 ± 0.9 3.96 ± 0.81 2.24 ± 0.85 3.8 ± 1.16 3.7 ± 1.1‡
3.14 ± 0.97
3.73 ±
5.0 ± 1.3/ 1.24/
9 mm 3.93 ± 2.02
5.5 ± 1.6 3.43 ±
0.92

10 mm 4.3 ± 1.38

3.8 ± 0.78/
11 mm 4.55 ± 2.02
3.46 ± 0.87
4.24 ± 2.88/
Space 2 mm 3.2 ± 0.7 2.75 ± 0.59 2.53 ± 1.07 2.85 ± 0.78
4.18 ± 3.67
between
first and 3 mm 4.5 ± 1.4/ 3.74 ± 0.96
second 5.0 ± 1.5
molars 3.59 ± 1.77/
4 mm 3.25 ± 0.88 3.25 ± 1.19 2.7 ± 0.8‡
4.29 ± 3.88
2.66 ±
0.77/ 2.91 ± 1.14/
5 mm 3.0 ± 0.9 4.17 ± 1.13 2.76 ± 1.22 3.2 ± 0.9§
3.04 ± 3.05 ± 1.01
0.78
4.0 ± 1.7/ 3.96 ± 1.93/
6 mm 3.52 ± 1.13 3.75 ± 1.54
4.5 ± 1.9 5.28 ± 3.46
3.03 ±
0.95/
7 mm 4.95 ± 1.38
3.40 ±
0.92
3.51 ± 1.41/
8 mm 3.5 ± 1.3 4.02 ± 1.39 3.32 ± 1.72 4.3 ± 1.57 3.3 ± 1.3‡
3.5 ± 1.33
3.61 ±
1.43/
9 mm 5.9 ± 1.56
5.0 ± 1.9/ 3.97 ±
6.0 ± 2.7 1.15

10 mm 5.3 ± 1.84

4.12 ± 1.61/
11 mm 6.28 ± 1.48
3.65 ± 1.23

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color legend:
green, more than 3 mm of mesiodistal width; yellow, more than 1.5 mm but less than 3 mm of mesiodistal width; red, less than 1.5 mm of me-
siodistal width; when the right/left sides are both reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
*The authors reported only a mean value of all the measurement levels; **the authors divided the root length in 4 equal pieces and measured the
space at each quarter; ythe reported values are a range obtained from graphs; zthe authors divided the root length in three thirds and measured the
space at the 1/3 and at the 2/3 of the root length; §the reported data are measured on a Class I sample.

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Supplementary Table X. Cortical bone thickness for mandibular vestibular anterior area
Lim et
Baumgaertel and Hans Sadek et al
al Fayed et al (2010) Laursen et al (2013)
(2009) (2016)
(2009)
Mode of assessment CBCT CT CBCT micro-CT CBCT
Reference point AC AC CEJ Root length AC
0.86 ± 0.14/ 0.9 ± 0.19 1.05 ± 0.27/ 1.22 ± 0.29
2 mm

3 mm

1.04 ± 0.25/ 1.05 ± 0.22 1.17 ± 0.28/ 1.23 ± 0.25 1.01 ± 0.14‡
4 mm
Space between canine and lateral incisor 1.25 ± 0.30/ 1.27 ± 0.23 2.41* 1.22 ± 0.23/ 1.24 ± 0.19 0.84 (0.44-1.24)§
6 mm

1.24 ± 0.07‡
7 mm

8 mm

9 mm

0.85 ± 0.14/ 0.82 ± 0.23 1.10 ± 0.3/ 1.21 ± 0.28

2 mm

3 mm
Space between central and lateral incisors
0.96 ± 0.24/ 0.98 ± 0.22 1.16 ± 0.26/ 1.15 ± 0.31 0.87 ± 0.2‡
4 mm

1.1 ± 0.32/ 1.11 ± 0.26 1.93* 1.19 ± 0.37/ 1.12 ± 0.22 0.64 (0.25-1.12)§
6 mm
1.01 ± 0.1‡
7 mm

8 mm

9 mm

0.82 ± 0.23 1.11 ± 0.26

2 mm

3 mm

0.93 ± 0.14 1.09 ± 0.28 0.83 ± 0.11‡

4 mm

Space between the central incisors 1.03 ± 0.20 1.54* 1.1 ± 0.32 0.46 (0.49-0.57)§
6 mm

1.01 ± 0.08‡
7 mm

8 mm

9 mm

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color cod-
ing, according to Baumgaertel (2010)19: red, less than 0.5 mm of cortical thickness; green, between 0.5 mm and 1.5 mm of cortical thickness;
yellow, between 1.5 mm and 2.5 mm of cortical thickness; light blue, more than 2.5 mm of cortical thickness; when values from right/left side
are both reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
*The authors reported only a mean value of all the measurement levels; zvalues are retrieved from normo-divergent subjects; §mean (min-max),
values were measured at midroot.

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Supplementary Table XI. Cortical bone thickness for mandibular vestibular posterior area
Baumgaertel Lim et Monnerat Park and Silvestrini Laursen Ozdemir Germec-
Fayed et al Zhao et al Veli et al Sadek et al Al-Jaf et al
and Hans al et al Cho Biavati et et al et al Cakan et al
(2010) (2013) (2014) (2016) (2018)
(2009) (2009) (2009) (2009) al (2011) (2013) (2013) (2014)
micro-
CBCT CT CBCT CBCT CT CBCT CBCT CBCT CBCT
Mode of assessment CT CT CBCT CBCT
Root
AC AC CEJ CEJ AC AC AC AC CEJ
Reference point AC length AC CEJ
1.95 ±
0.91 ± 0.19/ 1.18 ± 0.33/
2 mm 0.99/ 1.96
1.01 ± 0.23 1.20 ± 0.26
± 0.62
1.56 ±
3 mm
0.29
1.90 ±
1.14 ± 0.27/ 1.20 ± 0.27/ 1.45 ±
4 mm 0.59/ 1.83 1.42 ± 0.39‖ 1.01 ± 0.16‡
1.28 ± 0.29 1.35 ± 0.27 0.32 ‡
± 0.54
1.28 ± 1.46 ±
1.56 ±
5 mm 0.19/ 1.26 0.66/ 1.40 1.29 ± 0.07
0.29
± 0.19 ± 0.64
1.45 1.88 ±
1.39 ± 0.28/ 1.42 ± 0.59/
Space 6 mm 2.71* (0.50- 0.41/ 1.85 1.17 ± 0.03‖
1.49 ± 0.32 1.39 ± 0.35
between 2.50)§ ± 0.53
canine and 1.32 ±
1.67 ±
first premolar 7 mm 0.2/ 1.36 1.37 ± 0.07 1.19 ± 0.11‡
0.29
± 0.21
1.87 ± 1.97 ±
8 mm 0.70/ 1.61 0.66/ 1.88 1.20 ± 0.27‖
± 0.48 ± 0.41
1.44 ±
9 mm 1.8 ± 0.34 0.23/ 1.44 1.51 ± 0.06
± 0.23
1.94 ±
10 mm 0.45/ 1.95
± 0.38
1.82 ±
11 mm 1.8 ± 0.34 0.31/ 1.97
± 0.43
2.11 ±
1.16 ± 0.31/ 1.25 ± 0.41/
2 mm 0.75/ 2.14
1.26 ± 0.23 1.41 ± 0.29
± 0.43
1.78 ±
3 mm
0.35
2.03 ±
1.50 ± 0.42/ 1.45 ± 0.40/ 1.74 ±
4 mm 0.66/ 2.06 1.68 ± 0.43‖ 1.27 ± 0.20‡
1.66 ± 0.42 1.61 ± 0.36 0.33 ‡
± 0.36
1.53 ± 1.69 ±
1.78 ±
5 mm 0.31/ 1.47 0.55/ 1.74 1.63 ± 0.18
0.35
± 0.31 ± 0.60
1.95 2.07 ±
1.88 ± 0.54/ 1.71 ± 0.42/
Space 6 mm 3.52* (0.91- 0.59/ 2.06 1.57 ± 0.33‖
1.96 ± 0.57 1.72 ± 0.30
between first 2.87)§ ± 0.51
and second 1.71 ±
2.05 ±
premolars 7 mm 0.39/ 1.62 1.85 ± 0.18 1.33 ± 0.21‡
0.77
± 0.38
1.90 ± 2.15 ±
8 mm 0.36/ 1.87 0.72/ 2.11 1.71 ± 0.39‖
± 0.49 ± 0.47
1.89 ±
2.01 ±
9 mm 0.41/ 1.83 2.07 ± 0.17
0.54
± 0.42
2.08 ±
10 mm 0.56/ 2.11
± 0.47
1.76 ±
2.01 ±
11 mm 0.43/ 2.18
0.54
± 0.44
2.41 ±
1.32 ± 0.41/ 1.56 ± 0.63/
2 mm 0.64/ 2.50
Space 1.44 ± 0.37 1.70 ± 0.41
± 0.89
between first
1.83 ±
molar and 3 mm
0.36
second
premolar 2.33 ±
1.74 ± 0.51/ 1.74 ± 0.63/ 1.93 ±
4 mm 0.56/ 2.59 1.87 ± 0.42‖ 1.48 ± 0.14‡
1.85 ± 0.47 1.78 ± 0.38 0.38 ‡
± 0.88

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Supplementary Table XI. Continued.

1.78 ± 1.56 ±
1.83 ±
5 mm 0.46/ 1.67 0.42/ 1.74 1.89 ± 0.22
0.36
± 0.42 ± 0.46
1.80 2.61 ±
2.13 ± 0.65/ 2.0 ± 0.71/
6 mm 3.66* (1.02- 0.67/ 2.77 2.15 ± 0.42‖
2.20 ± 0.55 2.08 ± 0.32
2.66)§ ± 0.84
1.96 ±
2.03 ±
7 mm 0.48/ 1.90 2.19 ± 0.21 1.65 ± 0.18‡
0.52
± 0.47
1.72 ± 2.62 ±
8 mm 0.60/ 1.83 0.63/ 2.68 2.25 ± 0.34‖
± 0.70 ± 0.56
2.23 ±
2.14 ±
9 mm 0.67/ 2.16 2.48 ± 0.29
0.54
± 0.48
2.61 ±
10 mm 0.57/ 2.88
± 0.59
2.13 ±
2.14 ±
11 mm 0.37/ 2.25
0.54
± 0.35
2.68 ±
1.45 ± 1.35/ 2.30 ± 0.75/
2 mm 0.64/ 2.80
2.00 ± 0.94 2.38 ± 2.2
± 1.02
2.33 ±
3 mm
0.93
3.19 ±
2.01 ± 0.67/ 2.66 ± 0.69/ 2.35 ±
Space 4 mm 0.95/ 3.35 2.34 ± 0.48‖ 1.75 ± 0.13‡
2.49 ± 0.82 2.61 ± 2.49 0.38 ‡
between first ± 1.24
and second 2.14 ± 2.06 ±
2.33 ±
molar 5 mm 0.57/ 2.20 0.86/ 2.08 2.11 ± 0.35
0.93
± 0.64 ± 0.77
2.56 3.30 ±
2.60 ± 0.72/ 3.0 ± 0.56/
6 mm 3.59* (1.64- 0.98/ 3.37 2.50 ± 0.42‖
2.89 ± 0.74 3.05 ± 2.22
3.83)§ ± 1.01
2.62 ±
2.68 ±
7 mm 0.54/ 2.56 2.66 ± 0.31 2.05 ± 0.17‡
0.67
± 0.59
2.84 ± 3.35 ±
8 mm 0.79/ 2.75 0.84/ 3.4 ± 2.80 ± 0.45‖
± 0.69 0.73
2.89 ±
9 mm 2.6 ± 0.7 0.54/ 2.91 3.04 ± 0.24
± 0.65
3.41 ±
10 mm 0.81/ 3.42
± 0.82
2.79 ±
11 mm 2.6 ± 0.7 0.54/ 2.86
± 0.37

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color cod-
ing, according to Baumgaertel (2010)19: red, less than 0.5 mm of cortical thickness; green, between 0.5 mm and 1.5 mm of cortical thickness; yel-
low, between 1.5 mm and 2.5 mm of cortical thickness; light blue, more than 2.5 mm of cortical thickness; when values from right/left side are both
reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
*The authors reported only a mean value of all the measurement levels; zvalues are retrieved from normo-divergent subjects; §mean (min-max),
values were measured at midroot; kvalues were measured in a skeletal Class I sample.

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Supplementary Table XII. Cortical bone thickness for mandibular lingual anterior area

Fayed et al (2010) Laursen et al (2013)

Mode of assessment CBCT micro-CT

Reference point CEJ Root length

2.10 ± 0.59/ 1.92 ± 0.59

2 mm

3 mm

2.29 ± 0.56/ 2.28 ± 0.50

4 mm

Space between canine and lateral incisor 2.29 ± 0.48/ 2.36 ± 0.53 2.49 (0.84-3.18)§
6 mm

7 mm

8 mm

9 mm

1.63 ± 0.54/ 1.61 ± 0.37

2 mm

3 mm
Space between central and lateral incisors
1.89 ± 0.47/ 1.96 ± 0.46
4 mm

2.12 ± 0.59/ 2.13 ± 0.50 1.24 (0.36-2.21)§

6 mm

7 mm

8 mm

9 mm

1.75 ± 0.35
2 mm

3 mm

2.09 ± 0.48
4 mm

Space between the central incisors 2.19 ± 0.50 1.71 (0.97-2.60)§

6 mm

7 mm

8 mm

9 mm

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color cod-
ing, according to Baumgaertel (2010)19: red, less than 0.5 mm of cortical thickness; green, between 0.5 mm and 1.5 mm of cortical thickness; yel-
low, between 1.5 mm and 2.5 mm of cortical thickness; light blue, more than 2.5 mm of cortical thickness; when values from right/left side are both
reported, the mean between the 2 mean values was considered for color coding.
CBCT, computed tomography; CT, cone-beam computed tomography.
§Mean (min-max), values were measured at midroot.

- 2020
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Issue - American Journal of Orthodontics and Dentofacial Orthopedics

Tepedino et al 16.e19

Supplementary Table XIII. Cortical bone thickness for mandibular lingual posterior area

Monnerat SilvestriniBiavati et al Laursen et al

Fayed et al (2010)
et al (2009) (2011) (2013)
Mode of assessment CT CBCT CT micro-CT
Reference point AC CEJ AC Root length

2 mm 2.39 ± 0.66/ 2.16 ± 0.60

3 mm 1.8 ± 0.34

4 mm 2.61 ± 0.65/ 2.62 ± 0.45

5 mm 2.6 ± 0.52 1.76 ± 0.49/ 1.59 ± 0.45

6 mm 2.50 ± 0.57/ 2.56 ± 0.46 2.99 (2.15-4.18)§

Space between canine and first premolar
7 mm 2.46 ± 0.42

8 mm 1.96 ± 0.25/ 2.21 ± 1.11

9 mm 2.42 ± 0.46

10 mm

11 mm 2.57 ± 0.66 2.13 ± 0.36/ 2.17 ± 0.50

Space between first and second premolars 2 mm 2.13 ± 0.75/ 2.15 ± 0.70

3 mm 2.01 ± 0.54

4 mm 2.50 ± 0.61/ 2.38 ± 0.58

5 mm 2.38 ± 0.66 1.97 ± 0.50/ 1.93 ± 0.65

6 mm 2.44 ± 0.55/ 2.46 ± 0.43 2.59 (1.10-4.70)§

7 mm 2.44 ± 0.49

8 mm 1.89 ± 0.42/ 2.12 ± 0.46

9 mm 2.47 ± 0.45

10 mm

11 mm 2.55 ± 0.5 2.16 ± 0.37/ 2.16 ± 0.45

2 mm 1.96 ± 0.73/ 1.92 ± 0.54

3 mm 2.14 ± 0.54

Space between first molar and second

4 mm 2.26 ± 0.55/ 2.11 ± 0.38
premolar

5 mm 2.06 ± 0.37 1.85 ± 0.51/ 1.92 ± 0.62

6 mm 2.40 ± 0.47/ 2.33 ± 0.38 2.45 (1.37-3.64)§

American Journal of Orthodontics and Dentofacial Orthopedics - 2020
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16.e20 Tepedino et al

Supplementary Table XIII. Continued.

7 mm 2.12 ± 0.38

8 mm 1.90 ± 0.42/ 2.14 ± 0.43

9 mm 2.32 ± 0.78

10 mm

11 mm 2.26 ± 0.6 2.14 ± 0.45/ 2.09 ± 0.49

2 mm 2.07 ± 0.43/ 2.07 ± 1.76

3 mm 2.6 ± 0.7

4 mm 2.12 ± 0.43/ 2.35 ± 1.80

5 mm 2.06 ± 0.37 1.64 ± 0.43/ 1.89 ± 0.66

Space between first and second molars 6 mm 2.21 ± 0.49/ 2.53 ± 1.53 2.31 (1.39-3.90)§

7 mm 2.07 ± 0.39

8 mm 1.86 ± 0.75/ 2.03 ± 0.58

9 mm 2.09 ± 0.53

10 mm

11 mm 2.17 ± 0.42 2.09 ± 0.98/ 2.73 ± 0.80

Note. Values are mean 6 standard deviation. Data are reported as right/left sides, or with a single value if no side distinction was made. Color cod-
ing, according to Baumgaertel (2010)19: red, less than 0.5 mm of cortical thickness; green, between 0.5 mm and 1.5 mm of cortical thickness; yel-
low, between 1.5 mm and 2.5 mm of cortical thickness; light blue, more than 2.5 mm of cortical thickness; when values from right/left side are both
reported, the mean between the 2 mean values was considered for color coding.
CT, computed tomography; CBCT, cone-beam computed tomography.
§Mean (min-max), values were measured at midroot.

- 2020
Vol -
Issue - American Journal of Orthodontics and Dentofacial Orthopedics