## 4 Discussion  
This study aimed to evaluate any advantages and differences between two surgical protocols in terms of PS enhancement in cancellous bone. Bone height and density are two of the main parameters considered for a predictable successful result in implantology. Several factors such as patient's age, osteometabolic disease and neoplasms can influence bone mineral density [21]. Ordinarily, the symphysis area is characterized by a greater amount of high-density bone, followed by  
Figure 4: Box plot—implant stability quotient (ISQ). Figure 5: Box plot—removal torque. the premaxilla, then the posterior areas of the lower and upper jaw [22]. A study by [PERSON] et al. found significantly worse survival rates for implants placed in moderate/poor bone quality compared with those placed in good bone quality [23]. Furthermore, [PERSON] et al., in a retrospective cohort study analyzing predictors of implant failure, evidenced major peri-implant bone loss in the maxilla compared with the mandible [24]. Nevertheless, bone quality is not the only factor crucial to achieving success in the implant rehabilitation of edentulous jaws. In the last few decades, several types of implant design and surgical protocols have also been developed and tested to increase primary stability success rates [25, 26]. In particular, several authors have noted how surgical procedures may influence primary implant stability in areas with the greatest amount of cancellous bone [3, 17]. An improvement in PS values in soft bone can lead to greater predictability of the success of implant treatment. While several studies have shown that under-preparation of the implant site gives excellent results in terms of PS [27], this procedure removes bone tissue without affecting the surrounding bone quality and may cause healing impairment [28, 29]. The [PERSON] osteotomes technique was introduced for the crestal approach in maxillary sinus augmentation, causing a layer of compacted bone in the apical region [30]. This procedure, in particular, was widely used to allow implant placement in the case of reduced bone height in the posterior maxillary zones; however, this method does not produce any significant change in the surface of the implant site walls. In our study, we considered two different surgical techniques, one using bone compactors and the other using osseedonsification drills, to enhance PS values in poor bone quality. Primary stability was evaluated by insertion torque, resonance frequency analysis and removal torque, which today represent the gold standard indicators for implant stability [31]. While greater PIT mean value was recorded for the BC group, the minimal difference in terms of coronal diameter (3.7 mm BC and 3.8 mm OD) and apical diameter (2.7 mm BC and 2.8 mm OD) did not indicate a significant difference in terms of PIT. The implant stability quotient (ISQ) value is a parameter obtained during resonance frequency analysis (RFA). RFA was defined by [PERSON] et al. as a bending test of the implant-bone complex wherein a transducer applies an extremely small bending force [30]. During this test, the fixture is subjected to lateral force that simulates the conditions of the clinical load, measuring implant displacement and the stiffness between the implant and the surrounding bone walls. According to the literature, there is no clear correlation between PIT and ISQ. Furthermore, ISQ is not an effective one-time measurement parameter; however, it is designed to be a time-related parameter [31]. Our data analysis evidenced no significant differences in terms of ISQ between the two groups. High PIT and ISQ values represent the parameters of good primary implant stability, suggesting a strong stiffness at the implant-bone interface for both groups.