## 4 Discussion  
Dental implants have a favorable success rate, especially when implanted in highly mineralized bone [24; 25]. It has been confirmed that the posterior maxilla has the poorest bone quality (D4) [26; 27]. Many procedures have been proposed to augment local bone volume to allow for implant placement into the posterior maxilla [28]. [PERSON] pioneered the osteetome technique as a less invasive alternative for sinus floor elevation with simultaneous grafting to increase the primary stability of posterior maxillary implants [11]. Piezoelectric ultrasound was employed as an alternate approach for performing osteetomies in maxillary sinus lift procedures because it reduces trauma and the rate of sinus membrane perforation during surgery [13]. [PERSON] and [PERSON] presented a technique using Densah burs for maxillary sinus lifts, providing a safe strategy with fewer complications [29]. It is evident from the obtained results that the Densah group shows the highest mean implant primary stability; the osteetome group shows a lower mean value, and the piezosurgery group shows the lowest mean implant primary stability. This finding is similar to those of other studies [30; 31] that demonstrated the highest implant stability to characterize the Densah group. However, our finding contradicts other studies that reported no significant difference concerning primary stability between the Densah and \begin{table}
\begin{tabular}{c c c c c c c c} \hline \hline \multirow{2}{*}{**Time**} & \multicolumn{2}{c}{**Densah (n = 7)**} & \multicolumn{2}{c}{**Piezo (n = 7)**} & \multicolumn{2}{c}{**Osteetome (n = 7)**} & \multirow{2}{*}{\(p\)**Value \({}^{*}\)**} \\ \cline{2-2} \cline{5-8}  & **Median** & **Range** & **Median** & **Range** & **Median** & **Range** \\ \hline Baseline & 266.4 & 106.6–464.4 & 224.8 & 124.9–412.1 & 248.8 & 166.2–523.9 & 0.754 \\ At 6-month follow-up & 660.3 & 350.9–740.2 & 560.4 & 388.1–701 & 530.4 & 444.8–890.7 & 0.580 \\ \hline \hline \end{tabular} \({}^{*}\) Kruskal–Wallis test.  
\end{table} 
Table 4: Median comparison of bone density measurements (HU) among the groups. \begin{table}
\begin{tabular}{c c c c c c c c} \hline \hline \multirow{2}{*}{**Side**} & \multicolumn{2}{c}{**Densah (n = 7)**} & \multicolumn{2}{c}{**Piezo (n = 7)**} & \multicolumn{2}{c}{**Osteetome (n = 7)**} & \multirow{2}{*}{\(p\)**Value \({}^{*}\)**} \\ \cline{2-2} \cline{5-8}  & **Median** & **Range** & **Median** & **Range** & **Median** & **Range** \\ \hline Buccal & 0.24 & 0–0.96 & 0.7 & 0.45–1.2 & 0.6 & 0–1.14 & 0.193 \\ Palatal & 0.08 & 0–0.64 & 0.66 & 0.3–0.9 & 0.4 & 0–0.82 & 0.071 \\ Overall & 0.2 & 0–0.73 & 0.66 & 0.4–1.05 & 0.43 & 0–0.97 & 0.073 \\ \hline \hline \end{tabular} \({}^{*}\) Kruskal–Wallis test.  
\end{table} 
Table 5: Median comparison of crestal bone loss (mm) in the three groups. osteotome techniques [32; 33]. Secondary stability measured after 6 months shows a statistically significant difference in the mean implant stability measurements among the three groups; again, Densah has the highest mean implant stability, which is in agreement with previous results [32; 34]. On the other hand, the results were also compared with those of another study [24; 33], which reported no statistically significant difference between the piezosurgery and osteotome techniques; both showed lower mean implant stability measurements that were statistically significant. Bone density shows a significant difference from baseline to 6 months in all of the groups, but no difference in bone density was observed among the three groups. The increased implant stability in the Densah group can be attributed to the technique. The technology and associated drilling protocol were principally responsible for the considerable variation in stability among the three groups. Compared to the osteotome and piezosurgery groups, the Densah group had greater bone density values around the implant, owing to the osteotomy site's motorized expansion and the Densah burs' unique qualities.