Twelve patients (4 males and 8 females) ranging in age from 25 to 60 years were included in the study. All patients have bone height ranging 3–5 mm below the sinus membrane. They all performed closed sinus lifting and simultaneous immediate implant insertion.

Under local anesthesia, the flap was elevated and retracted exposing the crestal and buccal bone. A trephine bur 4 mm diameter on hand drill was used to make a small round window on the buccal wall of the sinus apical to the proposed implant length (Fig. 1). The trephined bony part was easily detached from the sinus membrane and placed in a bone well and covered by saline solution 0.9 ml to prevent its dryness. A rigid 1.9-mm endoscope fitted on 2.4-mm trocar with 70° lens (Karl Storz, Tuttlingen, Germany) was introduced through the prepared hole on the lateral sinus wall to visualize the actual sinus membrane lifting procedure by osteotomes and held in place by a surgeon to monitor the dynamic lifting procedure and guide the other surgeon who will use the osteotomes and place implants to achieve a safe lifting. Initial pilot drill was used to penetrate the crestal cortical bone to locate implant site.

Lifting technique: it consisted of two consecutive malleting instruments (Fig. 2). First was the bone splitter: a sharp, graduated arrow-like osteotome used to penetrate the maxillary bone with gentle malleting directly after using the initial drill. The splitter blades were placed on mesio-distal direction, aligned with the ridge axis and carefully malleted leaving about 1 mm of bone before reaching the sinus membrane. The second malleting instrument was the magic sinus lifter, which is a cylindrical hollow sharp-edged osteotome that was placed in a mesiodistal direction as the splitter. Under the endoscopic monitoring, the sinus lifter was gently malleted to fracture the remaining 1 mm of bone lifting it together with its attached sinus membrane toward the sinus cavity. The membrane was carefully elevated from 6 to 8 mm depending on visual assessment of the stretching capability of the membrane (Fig. 3).