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Aim: The objective of this paper was to show a case report of maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement.
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Annali di stomatologia
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Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report
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MD, MFS, Associate Professor, Director of Oral Surgery School Specialization, Dental School, Vita-Salute San Raffaele University, Milan, Italy and Department of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy; Dental School, Vita-Salute San Raffaele University, Milan, Italy and Department of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy
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Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report
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                                                                                                      Original article


Maxillary sinus lift with crestal access using
the Magnetic Mallet technique and bio-material
placement: case report


Matteo Nagni*1                                                the basal bone, homologous bone is placed in addition to
Luca Arduini**                                                a small amount of autologous bone in the upper part of
Daiana Zuccaro**                                              the elevation supported by collagen. After 4 months from
Tania Arduini*                                                surgery with a bone height of 9 mm, a 3.8x11 mm implant
Raffaele Vinci*2                                              fixture (Winsix, Biosafin, Ancona, Italy) was placed and
                                                              then prosthetically restored by deferred load method.
1 DDS, MSc, Dental School, Vita-Salute San Raffaele
   University, Milan, Italy and Department of Dentistry,
   IRCCS San Raffaele Hospital, Milan, Italy;                 Conclusion
2 MD, MFS, Associate Professor, Director of Oral Sur-
                                                              The Magnetic Mallet could be a valuable aid to support
   gery School Specialization, Dental School, Vita-Salute
                                                              implant procedures in the absence of adequate residual
   San Raffaele University, Milan, Italy and Department of
                                                              bone height.
   Dentistry, IRCCS San Raffaele Hospital, Milan, Italy;
* Dental School, Vita-Salute San Raffaele University,
   Milan, Italy and Department of Dentistry, IRCCS San        Introduction
   Raffaele Hospital, Milan, Italy;
** DDS.                                                       With the increase in average age, the placement of den-
                                                              tal implants to replace missing teeth could be a success-
*Corresponding author:                                        ful practice in all categories of patients (1-3).
Matteo Nagni                                                  The loss of teeth, in addition to other factors (4,5), caus-
DDS, MSc, Dental School, Vita-Salute San Raffaele Uni-        es bone resorption which, in posterior maxilla, increases
versity, Milan, Italy and Department of Dentistry, IRCCS      due to pneumatization of maxillary sinus (6,7).
San Raffaele Hospital, Milan, Italy.                          When residual bone height is too reduced for traditional
                                                              axial implants placement, maxillary sinus elevation pro-
                                                              cedures could be indicated in rehabilitation of edentu-
Abstract                                                      lous posterior atrophic maxilla, proving excellent long-
Aim: The objective of this paper was to show a case           term (≥5 years) implants survival rate (8-10).
report of maxillary sinus lift with crestal access us-        The main approaches are lateral window technique and
ing the Magnetic Mallet technique and bio-material            osteotome mediated technique (OSFE).
placement.                                                    The first can be employ when residual bone height is
                                                              less then 5 mm, the second, requires a minimum of 5
Keywords: Magnetic Mallet, bone condensation, re-             mm to be applied (11-13).
sidual bone height, dental implant.                           Lateral window approach was introduced for the first
                                                              time by Tatum in 1977 (14) and then was described by
                                                              Boyne and James in 1980 (15).
Materials and Methods                                         The surgical procedure provided the creation of a bony
A 46-year-old woman, required the replacement of a            window on lateral sinus wall to allow sinus membrane
prosthetic bridge on natural teeth (from 2.4 to 2.7), which   elevation and biomaterials insertion. Implants placement
caused her pain when chewing and thermal input. The           could be performed at the same time of surgery or after
elements supporting the rehabilitation needed endodon-        bone healing (approximately 4 months later) (16).
tic treatment.                                                The Osteotome mediated technique (OSFE) was intro-
In addition to conservative treatment of the residual tooth   duced by Summers in 1994 as less invasive alternative:
abutments, it was decided to restore tooth 26 by implant      osteotomes of progressive diameter concurrently allowed
placement.                                                    Schneider’s membrane elevation and bone compaction,
                                                              allowing an immediate insertion of the implants (17).
Results                                                       According with several complications associated with
According to the insufficient residual bone height for the    traditional maxillary sinus augmentation procedures
insertion of the fixture, the osteotome sinus floor eleva-    (18,19), the aim of this paper was to show a case report
tion technique was performed.                                 of maxillary sinus lift with crestal access using the Mag-
Subsequently, since the elevation is greater than 30% of      netic Mallet technique and bio-material placement.
Annali di Stomatologia 2019; X (1-4): 6-16                                                                                   6
    Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report

    Case report                                                     At the first visit, the patient already expressed her specific
                                                                    request for a prosthetic restoration with single elements.
    The patient, a 46-year-old woman, required the re-
                                                                    Objective and radiological examination showed the pres-
    placement of a prosthetic bridge on natural teeth, which
                                                                    ence of prosthetic bridges from 2.4 to 2.7 and a scarce
    caused her pain when chewing and thermal input, and
                                                                    amount of basal bone in the area to be rehabilitated with
    in fact the elements supporting the rehabilitation needed
                                                                    implant fixtures in site 2.6. (Fig. 1-4)
    endodontic treatment.




                  Figure 1.




         Figure 2.                                               Figure 3.




                              Figure 4.

7                                                                                        Annali di Stomatologia 2019; X (1-4): 6-16
M. Nagni et al.

In agreement with the clinical and radiographical diag-       tached to assess its correct mobility and avoid any injury
nosis it was decided to perform a sinus lift with crestal     during the insertion of biomaterial.
access using a minimally invasive biphasic technique.         Once mobilized, the collagen is placed in direct contact
Before surgery, diagnostic tests are performed to choose      with the displaced bone. It allows blood to be drawn in and
the technique to be performed and the amount of bioma-        stabilize the clot. It has been shown that the creation of a
terial to be placed.                                          space between the sinus membrane and the residual bone
Under local anaesthesia, a full-thickness access flap is      promotes the migration of stem and mesenchymal cells
performed to expose the cortical bone.                        within the blood clot; the differentiation of these cells into
Once the cortical bone is exposed, preparation begins         osteoblasts and the formation of new bone then occurs.
through compaction with a 300 flat osteotome. The corti-      Subsequently, since the elevation is greater than 30% of
cal bone is fractured and displaced apically using the con-   the basal bone, homologous bone is placed in addition
cave osteotome 200 until the sinus floor is broken. The       to a small amount of autologous bone in the upper part
compacted bone is invaginated during the simultaneous         of the elevation supported by collagen.
elevation of the Schneiderian membrane. The osteotome         In this case, since a rise of at least another 6 mm was
in the photo was the angled prototype of the new easy-in      required, 4.5 cc of osteoconductive material was placed
kit bent to simplify the procedures in posterior sectors.     according to the estimate described above 0.6x6=
Once the sinus cortical is broken, the membrane is de-        3.6+30%=4.68. (Figure 5-15)




Figure 5.                                                     Figure 6.




Figure 7.                                                     Figure 8.




Figure 9.                                                     Figure 10.

Annali di Stomatologia 2019; X (1-4): 6-16                                                                                     8
    Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report




    Figure 11.                                                      Figure 12.




    Figure 13.                                                      Figure 14.




                        Figure 15.


9                                                                                        Annali di Stomatologia 2019; X (1-4): 6-16
M. Nagni et al.

After 4 months from surgery a radiological control is per-   Once the bone had matured and stabilized through com-
formed to evaluate the extent of the elevation obtained.     paction, the implant site was prepared. (Fig. 18-26)
With a bone height of 9 mm, it was decided to place a        The operative sequence of the sharp concave tip oste-
3.8x11 mm implant fixture (Winsix, Biosafin, Ancona, It-     otomes of the AZ easy-in kit was:
aly). (Fig. 16-17)                                           100-160-200. The step with the first osteotome 100P




Figure 16.


                                                             was omitted due to the lack of mature cortical bone being
                                                             newly angiogenic bone. The site preparation was taken
                                                             up to a length of 11 mm thus proceeding with a new mini
                                                             sinus lift.
                                                             Follow-up visits were performed one week after surgery,
                                                             at 3 and 6 months and then once a year for the next
                                                             years (5 years follow-up - Fig. 29-31). The patient was
                                                             inserted in a professional oral hygiene program to avoid
                                                             possible complications (20, 21) and monitoring dental
                                                             implant.
                                                             The final prosthesis was performed, according with the
                                                             healing time of the upper jaw, about four months after
                                                             surgery.

                                                             Discussion
                                                             As reported by several Authors, both Sinus Floor Eleva-
                                                             tion Techniques could have many complications as Sch-
                                                             neider membrane perforation (22), bone graft infections
                                                             (23), acute or chronic sinus infection (24), vascular lesions
                                                             (25), paroxysmal positional benign vertigo (PPBV) (26),
                                                             wound dehiscence, bone graft and implants loss (27).
                                                             Membrane perforation represents the most common
                                                             issue both for lateral and transcrestal approach, with a
                                                             prevalence of 3.6% to 56% and 23.6 to 44% respectively
                                                             (28, 29).
                                                             If this complication occur, bone graft migration into the
                                                             sinus antrum could cause an acute or chronic sinus in-
           Figure 17.                                        fection (23).

Annali di Stomatologia 2019; X (1-4): 6-16                                                                                   10
     Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report




     Figure 18.




                                                      Figure 20.




     Figure 19.




                                                      Figure 21.

11                                                                                        Annali di Stomatologia 2019; X (1-4): 6-16
M. Nagni et al.




Figure 22.                                   Figure 23.




Figure 24.                                   Figure 25.




                                             Al-Dajani et Al. in a Meta-Analysis concerning incidence,
                                             risk factors, and complications of Schneiderian mem-
                                             brane perforation in sinus lift surgery, also described the
                                             role of membrane thickness and sinus septa on this is-
                                             sue. (30) According with Ardekian et Al. (31), there was
                                             a significant correlation between membrane perforation
                                             and sinus membrane <1 mm thick, with a higher preva-
                                             lence in presence of bony septa.
                                             Another possible complication of sinus floor elevation’
                                             procedures could be the injury of alveolar antral artery
                                             (AAA), which could have either an intraosseous or in-
                                             trasinusal course (as minority) (32).
                                             The consequence could be a several bleeding, which
                                             could increase according to vessel diameter (33).
                                             To reduce these possible issues, as suggested by Torel-
                                             la et Al. (34) and Vercellotti et Al. (35), piezoelectric in-
Figure 26.
                                             struments should be preferred: during the creation of
                                             bony window on lateral sinus wall they could prevent
                                             both Schneider’s membrane perforation and AAA lesion.
                                             Moreover, a Cone-Beam Computed Tomography per-
                                             formed before surgery is necessary to evaluate position
                                             and features of these anatomical structures (36).
                                             Another possible complication of sinus floor elevation is
Annali di Stomatologia 2019; X (1-4): 6-16                                                                   12
     Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report




     Figure 27.



                                                                     a postoperative maxillary sinusitis, with an incidence rate
                                                                     of up to 20% (37).
                                                                     The possible consequence is a partial or complete ob-
                                                                     struction of the ostium-meatal unit, altering the physio-
                                                                     logical activity of the mucosal airway system (38).
                                                                     Concerning benign paroxysmal positional vertigo
                                                                     (BPPV), it was related only with transcrestal sinus floor
                                                                     elevation. BPPV can be described as a vestibular end
                                                                     organ disorder often characterized by episodes of ver-
                                                                     tigo. (39)
                                                                     Although the symptoms involved within about a month, if
                                                                     not identified properly and managed correctly they could
                                                                     be enough severe to hinder patients from carrying out
                                                                     normal daily activities (13).
                                                                     To reduce the incidence of complications, which is much
                                                                     higher in lateral approach breast augmentation, in the
                                                                     last few years we have tried to extend the indications for
                                                                     transcrestal augmentation also in case of residual bone
                                                                     height below 5 mm (40, 41).
                                                                     With the new minimally invasive transcrestal elevation
                                                                     techniques, the frequency of perforation has decreased
                                                                     to an average of 3.8% for transalveolar elevation (42),
                                                                     whereas it is about 5 times more frequent for lateral el-
                                                                     evation (43).
                                                                     Membrane integrity is a key determinant of bone graft
                                                                     and implant survival: perforation is associated with a
           Figure 28.                                                higher incidence of postoperative complications, such
                                                                     as graft failure and infection; furthermore, the size of the
                                                                     perforation is inversely proportional to implant survival
                                                                     (44).
                                                                     Sinus lift performed with magneto-dynamic osteotomes
                                                                     could be performed in total safety, with a survival rate of
                                                                     98.9%, as confirmed by the present clinical case (45,46).




13                                                                                        Annali di Stomatologia 2019; X (1-4): 6-16
M. Nagni et al.




Figure 29.




                                             Figure 31.

                                                          Conclusion
                                                          Within the limitations of this study, this case report could
                                                          represent significant evidence of the efficacy of maxillary
                                                          sinus lift with crestal access using the Magnetic Mallet
                                                          technique and bio-material placement.




Figure 30.



Annali di Stomatologia 2019; X (1-4): 6-16                                                                               14
     Maxillary sinus lift with crestal access using the Magnetic Mallet technique and bio-material placement: case report

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Annali di Stomatologia 2019; X (1-4): 6-16                                                                                                16
