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Objectives: over the years a device has been developed, the Magnetic Mallet, which allows a very high control and stability of the applied forces, able to perform procedures that were the safest possible for the patient and the surgeon himself. The handpiece has been designed so that different shock waves are emitted according to the type of surgery, with the possibility of inserting different inserts according to the technique / procedure that is being applied. The Magnetic Mallet can be used in different surgical procedures; Dental extractions, implant placement, implant site preparation (osseodensification), maxillary sinus lift procedures or crestal expansion procedures.
Materials and methods: In the following clinical case, the extraction of element 2.7 is conducted with the simultaneous insertion of two implant fixtures in place 2.6 and 2.7 and simultaneous regenerative therapy. The implant in site 2.6 was positioned with a traditional method, with the help of the implant motor, while the post-extraction implant in site 2.7 was inserted with the use of the Magnetic Mallet.
Results: At one week the sutures were removed and the tissues showed good healing. The patient is then placed in a maintenance and follow-up program to monitor healing after some time.
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en
M. Nagni
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Annali di stomatologia
Regenerative surgery
Use of the magnet mallet in a case of extraction and post-extraction implant site preparation, in combination with regenerative therapy on hypertensive patient: a case report and literature review
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Original Article
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2023-03-09
2023-12-04
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M. Nagni
2023/03/09
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MSc, Dental School, Vita-Salute San Raffaele University, Milan, Italy and Department of Dentistry, IRCCS San Raffaele Hospital, Milan, Italy
1971-1441
1
Regenerative surgery
en
34
Use of the magnet mallet in a case of extraction and post-extraction implant site preparation, in combination with regenerative therapy on hypertensive patient: a case report and literature review
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                                                                                                            Original Article


Use of the magnet mallet in a case of extraction
and post-extraction implant site preparation,
in combination with regenerative therapy
on hypertensive patient: a case report
and literature review



Oddi C.*                                                          Keywords: Magnetic Mallet, Implant positioning, Tooth
Collina G.*                                                       extraction, CBCT, Regenerative surgery
Ceresoli L.*
Ferri S.*                                                         Introduction
Grassi A.*
Nagni M.**                                                        The first electrified dental hammer was projected in 1873
                                                                  by William Bonwill, in order to fill the cavities with gold [1].
                                                                  Over the years this hammer has been modified and im-
*Dental School, Vita-Salute San Raffaele University,              proved in order to make the most of its qualities. It is a de-
Milan, Italy and Department of Dentistry,                         vice that allows an high control and stability of the applied
IRCCS San Raffaele Hospital, Milan, Italy                         forces, allowing to perform procedures that are as safe
                                                                  as possible for the patient and the surgeon himself [2-3].
**MSc, Dental School, Vita-Salute San Raffaele                    Magnetodynamic technology exploits the physical prin-
University, Milan, Italy and Department of Dentistry,             ciples of electromagnetism to be able to apply controlled
IRCCS San Raffaele Hospital, Milan, Italy                         forces on a body, in order to minimize the impact time
Corrisponding Author: Giorgio Collina                             [4]. Nowadays, in fact, the Magnetic Mallet (MM) is used
email: giorgio.collina95@gmail.com                                in oral surgery, in many different fields [5]. It is charac-
                                                                  terized by a handpiece powered by a power control de-
                                                                  vice, which has the ability to deliver forces according to
Abstract                                                          the application time, precisely four force modes 75, 90,
                                                                  130 and 260 daN with an impact time of 80 μs. Different
Objectives: over the years a device has been developed,
                                                                  shock waves are emitted from the handpiece depending
the Magnetic Mallet, which allows a very high control and
                                                                  on the type of surgery. In addition, on this handpiece you
stability of the applied forces, able to perform procedures
                                                                  can go to insert different inserts according to the tech-
that were the safest possible for the patient and the sur-
                                                                  nique / procedure that is being applied.
geon himself. The handpiece has been designed so that
                                                                  The Magnetic Mallet is thus used in different oral surgi-
different shock waves are emitted according to the type
                                                                  cal procedures, such as: dental extractions, in the place-
of surgery, with the possibility of inserting different inserts
                                                                  ment of implants, in the preparation of the implant site
according to the technique / procedure that is being ap-
                                                                  (osseodensification), in sinus lift procedures or in ridge
plied. The Magnetic Mallet can be used in different sur-
                                                                  expansion procedures. [6-7-8-9-10]
gical procedures; Dental extractions, implant placement,
implant site preparation (osseodensification), maxillary
sinus lift procedures or crestal expansion procedures.            Materials and methods

Materials and methods: In the following clinical case,            In October 2022, a 58-year-old female patient, suffering
the extraction of element 2.7 is conducted with the simul-        from hypertension, came to our attention for pain located
taneous insertion of two implant fixtures in place 2.6 and        near the second quadrant. During the first visit after a
2.7 and simultaneous regenerative therapy. The implant            careful intra- and extra-oral clinical examination, a first-
in site 2.6 was positioned with a traditional method, with        level orthopantomography (OPT) radiographic examina-
the help of the implant motor, while the post-extraction          tion was performed in order to evaluate the patient’s oral
implant in site 2.7 was inserted with the use of the Mag-         condition even more carefully (Fig. 1).
netic Mallet.                                                     In the second quadrant there was a prosthetic bridge that
                                                                  extended from element 2.4 to element 2.7 with element
Results: At one week the sutures were removed and the             2.6 bridge. The prosthetic artifact had some mobility per-
tissues showed good healing. The patient is then placed           haps due to the carious lesion that extended below the
in a maintenance and follow-up program to monitor heal-           prosthetic crown of element 2.7, previously devitalized
ing after some time.                                              and covered with a Richmond crown (Fig. 2).


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     Use of the magnet mallet in a case of extraction and post-extraction implant site preparation




                 Figure 1. OPT



                                                                                   After evaluating the condition of the element and prepar-
                                                                                   ing a treatment plan that was as predictable as possible,
                                                                                   it was agreed to extract element 2.7 with the simultane-
                                                                                   ous insertion of two implant fixtures in place 2.6 and 2.7
                                                                                   and simultaneous regenerative therapy (Fig. 3-4-5).
                                                                                   After signing the information form, local anesthesia was
                                                                                   carried out with 4% articaine and adrenaline 1:100,000
                                                                                   (Ubistesin 40 mg/ml, 3M ESPE, Italy), element 2.7 was
                                                                                   estracted with the aid of the Magnetic Mallet (MM).
                                                                                   This tool has allowed a safe, predictable and fast ex-
                                                                                   traction, reducing the possible complications in which it
                                                                                   could be incurred (Fig. 6).
                                                                                   Subsequently, two implants were placed in place 2.6 and
                                                                                   2.7 at the same time as regenerative therapy, by elevat-
                                                                                   ing a full-thickness flap with parasulcular incision and
                                                                                   insertion of a biomaterial, a xenograft of bovine origin
                                                                                   (Bioss collagen) (Fig. 7). [11]
                                                                                   The implant in site 2.6 was positioned with a traditional
                                                                                   method, with the help of the classic implant motor, while
                                                                                   the post-extraction implant in place 2.7 was inserted
                                                                                   with the Magnetic Mallet. The 2.6 site plant is a 3.8X11




     Figure 2. Carious lesion in position 2.7.



     The patient was explained the situation and the fact that
     it was considered necessary to remove the prosthetic
     bridge in order to assess whether element 2.7 was sal-
     vageable or not. Already assuming the disastrous con-
     dition of the element and the difficulty in being able to
     save it, the patient was prescribed a second level CBCT
     examination in order to evaluate three-dimensionally the
     amount of bone for the possible insertion of implant fix-
     tures (Fig. 3).
     At the next appointment, the prosthetic artifact was re-
     moved and the disastrous condition of element 2.7 came
     to light.                                                                     Figure 3. CBCT and implant treatment plan planification.



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C. Oddi et al.




  Figure 4. CBCT and implant treatment plan planification.




             Figure 5. CBCT and implant treatment plan planification.




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     Use of the magnet mallet in a case of extraction and post-extraction implant site preparation




     Figure 6. Extraction of the element in position 2.7 and implant positioning in position 2.6. post-extractive implant positioning in
     association with the use of Mangnetic Mallet in position 2.7.




     Figure 7. Regenerative therapy on site 2.7 with insertion of                  Figure 8. Flap suture with detached stiches with 4/0 absorb-
     biomaterial (xenograft of bovine origin).                                     able thread.




     Winsix TTI system, while the 2.7 on-site plant is a 4.5X9                     DISCUSSION
     Winsix TTI.
     The flap closure was carried out with a suture with de-                       Patient’s medical hystory is foundamental to state the cor-
     tached stitches with 4/0 absorbable thread (Vicryl, Ethi-                     rect treatment plan, especially when we are talking about
     con, Johnson & Johnson, New Brunswick, NJ, USA)                               surgery. When implant surgery is performed in patients
     (Fig. 8-9).                                                                   with cardiovascular disease, concerns are related to the
                                                                                   possible bad consequences of the use of anticoagulants
                                                                                   preoperatively or to changes in blood pressure caused by
     RESULTS                                                                       vasoconstrictors contained in local anesthetics.
                                                                                   The retrospective study by Tonini KR. et al., investigates
     One week after surgery, the sutures were removed and                          the association of hypertension and the use of antihy-
     the tissues were in a good state of healing. Finally, the                     pertensive drugs with dental implant failure rate. 1877
     patient was placed within a maintenance program with                          implants were placed in a total of 602 patients. 71.43%
     periodic clinical and radiographic checks to assess heal-                     of the patients were normotensive, while 28.36% were
     ing and bone regeneration over the years.                                     hypertensive. The success rate of implant positioning in



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C. Oddi et al.




    Figure 9. Post-surgical control OPT


the normotensive group was 93.98% while in the hyper-          Although in some cases the insertion of axial implants
tensive group was 92.99%, and their success rate was           in basal bone may be hindered by insufficient residual
similar whether they had taken antihypertensive drugs          bone height, the insertion of implants in native bone
or not. It is possible to assume that hypertensive pathol-     should be always preferred. [22]
ogy, also in combination with the use of antihypertensive      Type of fixtures choice and prosthetics can influence the
drugs, cannot be associated with implant failure [12].         success rate in the short and long term; It follows that
Wu X. et al., in their review, discuss how hypertensive        pre-surgical planning represents a fundamental starting
drugs such as beta-blockers, thiazide diuretics and ACE        point for rehabilitation[23][24]. All the procedures were
inhibitors can have a positive effect on implant survival      carried out in compliance with the rules provided for the
rate [13].                                                     Covid-19 pandemic situation, to promote the safety both
The use of vasoconstrictors in anesthetics do not appear       of patients and staff [25]. Professional and home hygien-
to be contraindicated. In fact, Montebrugnoli L. et al.        ic maintenance is one of the main prerequisites for suc-
showed how the presence of adrenaline does not cause           cessful implants. [26][27]
an increase in pressure, because its use produces less         A recent systematic review of 2022 aimed to answer
stress than would occur with the production of endog-          the question of whether the use of Magnetic Mallet was
enous catecholamines released following the adminis-           effective or not used in oral surgery, in terms of tissue
tration of anesthesia without vasoconstrictors [14].           healing, and complications, comparing it to the use of
Failure to control intra-operative pain could create the       traditional instruments.
activation of important cardiovascular responses [15].         Of 252 articles, 14 were included in the review (3 for
The administration of approximately two vials of local         tooth extraction and 11 for dental implantology). Out of
anesthetic with adrenaline 1:100,000 or 1:80,000, in           a total of 619 tooth extractions (256 patients) performed
hypertensive patients, does not significantly alter blood      with the magnetic mallet, no complications were re-
pressure [16]. Following the injection of one vial of lido-    ported. The implants included were 880 (525 patients):
caine (1.8 ml) at 2% with epinephrine 1:100,000 (0.018         640 in the Magnetic Mallet group (382) and 240 in the
mgr), plasma levels of epinephrine increase two to three       control group (133). The survival rate of the implants
times without causing significant changes in blood pres-       was 98.9% in the Magnetic Mallet group and 95.42% in
sure and heart rate; three vials increase levels five to six   the control group. Seven patients experienced benign
times and are accompanied by hemodynamic changes               paroxysmal positional vertigo after implant surgery, all
without symptoms; on the other hand, stress itself can in-     in the control group. The results are not sufficient to
crease plasma levels of endogenous catecholamines 40           establish the effectiveness of the Magnetic Mallet but it
times [17]. Cardiovascular response that occurs as a re-       seems to be an effective option in oral and implant sur-
sult of stress can be related to the dental procedure rather   gery procedures [28].
than to the use of anesthetics containing vasoconstrictors     The usefulness of the Magnetic Mallet had already been
[18]. Becker DE et al., on the other hand, suggests that       studied in 2014 by Crespi, R. et al. in a work whose pur-
despite the properties of vasoconstrictors, in patients with   pose was to evaluate its effectiveness in the field of tooth
cardiovascular diseases and in hypertensive patients, in-      extractions and in maintaining the integrity of the alveo-
voluntary intravascular injection of adrenaline is associ-     lar bone after the extraction. The extractions were con-
ated with adverse cardiovascular effects. [19]                 ducted using a Magnetic Mallet, which moving the blade
Dental implants are currently a successful therapeutic         in a longitudinal movement along the central axis up and
alternative that can also be applied in patients with sys-     down towards the space of the periodontal ligament, pro-
temic diseases, which are nowadays increasing with the         viding a mechanism for guiding longitudinal movements.
rase of average age [20][21].                                  No fracture or loss of cortical bone has been observed in



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     Use of the magnet mallet in a case of extraction and post-extraction implant site preparation

     tooth extractions conducted with Magnetic Mallet. All the                     14. Montebugnoli L, Pelliccioni GA, Borghi C. Effetti dei vaso-
     sockets showed complete secondary soft tissue healing                             costrittori durante l’anestesia locale [Effects of vasocon-
     2 weeks after complete root extraction. At the follw-ups,                         strictors during local anesthesia]. Dent Cadmos. 1990 May
                                                                                       31;58(9):62-71.
     there were no signs of inflammation or exposed bone in                        15. Becker DE. Preoperative medical evaluation: part 1: general
     any of the cases. A clinical study is also reported, show-                        principles and cardiovascular considerations. Anesth Prog.
     ing how maximum alveolar preservation and related gin-                            2009 Autumn;56(3):92-102; quiz 103-4. doi: 10.2344/0003-
     gival structures can be maintained after atraumatic tooth                         3006-56.3.92.
     extraction by Magnetic Mallet [29].                                           16. Serrera Figallo MA, Velázquez Cayón RT, Torres Lagares D,
     In the context of oral surgery, Magnetic Mallet seems to                          Corcuera Flores JR, Machuca Portillo G. Use of anesthet-
                                                                                       ics associated to vasoconstrictors for dentistry in patients
     be a suitable alternative, but other studies should be con-                       with cardiopathies. Review of the literature published in the
     ducted with a larger sample to confirm this hypothesis.                           last decade. J Clin Exp Dent. 2012 Apr 1;4(2):e107-11. doi:
                                                                                       10.4317/jced.50590.
                                                                                   17. Cáceres MT, Ludovice AC, Brito FS, Darrieux FC, Neves
     Conclusion                                                                        RS, Scanavacca MI, Sosa EA, Hachul DT. Effect of lo-
                                                                                       cal anesthetics with and without vasoconstrictor agent
     As we can see from this clinical case, the use of the                             in patients with ventricular arrhythmias. Arq Bras Cardiol.
                                                                                       2008 Sep;91(3):128-33, 142-7. English, Portuguese. doi:
     Magnetic Mallet (MM) in the dental field is useful in dif-                        10.1590/s0066-782x2008001500002.
     ferent oral and implant surgery procedures, because it                        18. Spivakovsky S. Injectable local anaesthetic agents for den-
     is a safe, predictable, fast to use and manageable tool.                          tal anaesthesia. Evid Based Dent. 2019 Jun;20(2):42-43.
                                                                                       doi: 10.1038/s41432-019-0021-x.
                                                                                   19. Becker DE, Reed KL. Essentials of local anesthetic phar-
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