Consensus Report of Group 2 of the 1st Global Consensus for Clinical Guidelines for the Rehabilitation of the Edentulous Maxilla: Zygomatic, Standard‐Length, and Short Implant‐Supported Prostheses

ABSTRACT

Objectives

The 1st Global Consensus for Clinical Guidelines (GCCG) in Implant Dentistry introduced an innovative, evidence‐based approach to developing patient‐centered and practical recommendations for the rehabilitation of the edentulous maxilla. Within this framework, Group 2 aimed to formulate clinical recommendations on the use of short, standard‐length, and zygomatic implants in atrophic maxillae.

Materials and Methods

Group 2 followed the S2k‐level guideline framework of the Association of the Scientific Medical Societies in Germany (AWMF), applying a structured nominal group technique. The evidence base included two systematic reviews synthesizing patient‐reported outcomes (PROs), clinician‐reported outcomes (ClinROs), and their respective measures, as well as single‐round international surveys involving expert clinicians, patients, and cross‐disciplinary experts. Draft recommendations were discussed during the in‐person consensus meeting in Boston (June 16–18, 2025) and finalized through anonymous plenary voting. Consensus thresholds were predefined at ≥ 75% and ≤ 95% agreement for consensus and > 95% agreement for strong consensus.

Results

The Group 2 participants formulated 6 clinical recommendations addressing the domains patient selection, surgical treatment options (short, standard‐length, and zygomatic implants), and treatment planning. All 6 recommendations reached consensus.

Conclusions

The Group 2 consensus provides practical guidance for the use of short, standard‐length, and zygomatic implants in atrophic maxillae, balancing surgical complexity, prosthetic feasibility, and patient‐centered care. Remaining evidence gaps—especially regarding standardized outcome sets, loading protocols, prosthetic strategies for zygomatic implants, the use of short implants for full‐arch restorations and maintenance frameworks—should be prioritized in future research.

1. Introduction

The 1st Global Consensus for Clinical Guidelines (GCCG) in Implant Dentistry introduced an innovative, evidence‐based approach to consensus‐building in implant dentistry. The initiative focused on the rehabilitation of the edentulous maxilla, with the goal of developing patient‐centered and practical clinical recommendations. Working Group 2 focused on the recommendations for the use of short, standard‐length, or zygomatic implants for the rehabilitation of the atrophic edentulous maxilla.

This consensus focused on patients with a fully edentulous maxilla or where extraction of all remaining maxillary teeth was indicated, and who may benefit from implant rehabilitation of the maxillary arch. The group discussions were conducted on the premise that the indication for tooth extractions was justified through proper diagnosis and prognosis assessment. Although the reasons for tooth extraction were not specified in this report, the authors emphasize that, in general for all patient treatments, every effort should be made to preserve as much as possible of the patient's residual dentition. Treatment options for patients with a fully edentulous maxilla or where extraction of all remaining maxillary teeth is indicated include complete removable dentures, implant‐supported overdentures, or fixed implant‐supported prostheses. The treatment selection is influenced not only by evidence‐based considerations, but also by patient desires and clinical presentation and whether they are already edentulous or are planned for extraction of all remaining maxillary teeth.

Group 2 focused on atrophic edentulous maxillae, where the bone resorption is such that implant treatment planning options need to consider large bone augmentation procedures or alternative approaches such as short or zygomatic implants. Further alternative implant protocols without large bone augmentation procedures, such as remote anchorage implants (pterygoid and transnasal), and patient‐specific subperiosteal implants were mentioned during the group discussions but not included in the scope of this consensus. The treatment selection may also be influenced by the access to and availability of resources for specific dental treatments, treatment settings, and materials.

Definitions of implant placement and loading protocols were based on existing literature and the International Team for Implantology (ITI) report. (Gallucci et al. 2018; Morton et al. 2023).

2. Methodological Framework and Consensus Procedures of the 1st GCCG

This Working Group was one of four formed within the 1st Global Consensus for Clinical Guidelines (GCCG) for the Rehabilitation of the Edentulous Maxilla, following an S2k‐level framework of the Association of the Scientific Medical Societies in Germany (AWMF).

Group 2 included 28 of the total 105 experts participating in the consensus conference (Figure 1). These 28 experts represented the specialties of prosthodontics (8), periodontics (8), and oral surgery (12).

FIGURE 1.

Participants of Group 2 of the 1st Global Consensus for Clinical Guidelines (GCCG) for the rehabilitation of the edentulous maxilla (Boston, June 2025).

Group recommendations were developed through a structured multiphase process combined with literature searches and systematic reviews with expert and cross‐disciplinary expert input. Preparatory work included systematic reviews on patient‐reported outcomes (PROs), clinician‐reported outcomes (ClinROs) and their methods of assessment, as well as structured surveys involving clinicians, patients, and other cross‐disciplinary experts (Lin et al. 2026; Park et al. 2026; Strauss et al. 2026; Thoma et al. 2026). These data formed the basis for Working Group discussions held during the on‐site meeting in Boston (June 16–18, 2025).

Using the Nominal Group Technique (Harvey and Holmes 2012), each recommendation was developed and refined through individual review, prioritization voting, and moderated discussion. Recommendations were primarily derived from the results of the structured surveys and reviewed in the context of the available evidence and categorized as follows:

• –Aligned with current evidence (survey results consistent with available data)
• –Not aligned with current evidence (survey results diverged from available data)
• –Could not be evaluated due to a lack of existing evidence.

The ClinROs and PROs identified through the systematic reviews served as the foundation for defining a core outcome set. This set was further refined and adopted during the consensus conference using a structured three‐round Delphi process and served for the formulation of the final recommendations (Schwarz et al. 2026).

Final consensus was reached via anonymous plenary voting, with predefined thresholds of agreement (> 95% agreement: strong consensus; ≥ 75% and ≤ 95% agreement: consensus; < 75% agreement: no consensus). Conflicts of interest were disclosed per the International Committee of Medical Journal Editors (ICMJE) standards, and abstentions were documented. The full methodological framework is detailed in the umbrella paper (Schwarz et al. 2026).

3. Summary of the Reported Clinician‐ and Patient‐Reported Outcomes

In preparation for the consensus conference, eight systematic reviews were conducted to identify PROs and ClinROs and their respective methods of assessment. Most of the included studies used standard‐length implants. The systematic reviews reported a lack of studies reporting on the use of short implants in edentulous patients (Park et al. 2026; Thoma et al. 2026). Short implants were defined in the referenced systematic reviews as implants of ≤ 6 mm length (Park et al. 2026; Thoma et al. 2026). However, the group discussion identified < 8 mm implants as a more suitable definition for short implants. In the systematic review on implant‐retained overdentures, 2 out of 21 studies included short implants of 6 mm, used in combination with standard‐length implants (Park et al. 2026). The systematic review focusing on fixed prosthesis also included studies reporting on zygomatic implants (Thoma et al. 2026). However, none of the studies included in the systematic review on implant‐retained overdentures included zygomatic implants (Park et al. 2026).

A brief overview of the findings of two systematic reviews prepared for Group 2 is presented below (Park et al. 2026; Thoma et al. 2026).

3.1. PROs

In the included literature, a variety of PROs addressing overall satisfaction with the treatment and the received prosthesis were identified. Specific domains for patient satisfaction included, for example, function, post‐operative pain, discomfort, phonetics, aesthetics, ease of cleaning and oral health related quality of life (OHRQoL) (Park et al. 2026; Thoma et al. 2026). PROs were evaluated utilizing different patient‐reported outcome measures (PROMs). The identified PROMs varied in their format, response scale, and interpretation. Standardized instruments (e.g., different shortened variations of the original OHIP‐49 questionnaire), visual analog scales (VAS) or unstandardized questionnaires were utilized as PROMs to assess OHRQoL and different domains of patient satisfaction, such as function, aesthetics, comfort, or phonetics. The most frequently used variation of the OHIP‐49 to assess OHRQoL was the OHIP‐14 (Park et al. 2026; Thoma et al. 2026). A limited number of studies used OHIP‐11‐16, OHIP‐20, OHIP‐21, or OHIP‐J54 (Thoma et al. 2026). These standardized questionnaires were used across short, standard‐length and zygomatic implants to capture changes in OHRQoL, including functional, emotional, and psychosocial domains. Most commonly, OHIP was repeated at baseline and at various follow‐ups (e.g., 6–12 months). Unstandardized questionnaires are custom‐prepared forms assessing outcomes such as comfort, ease of maintenance, speech, chewing function, and overall prosthetic satisfaction. They were often tailored to specific study objectives, but they lack a validated scoring system. The identified unstandardized questionnaires included, for example, 5‐point Likert scales to evaluate satisfaction with aspects such as aesthetics, masticatory function, phonetics or general satisfaction with the prosthesis, as well as the likelihood of repeating the therapy. Another study used unstandardized questionnaires with 9 items to assess satisfaction with aesthetics, chewing comfort, function, oral hygiene, and phonetics (Thoma et al. 2026). A further study used an unstandardized questionnaire with 7 items to assess denture satisfaction (Park et al. 2026).

Comparability between studies and statistical synthesis for systematic reviews remain difficult due to inconsistent PROM usage, heterogeneity in outcome measures and tools, and issues of variability and inconsistency in outcome reporting.

3.2. ClinROs

ClinRO measures mainly included objective measures such as implant and prosthesis survival and success, and biological parameters (Park et al. 2026). Objective ClinROs were defined as outcomes measurable with high consistency and minimal interpretive variability. A large variety of objective ClinROs could be identified. Most studies relied on objective measures such as marginal bone loss, implant/prosthesis survival, and type/frequency of complications. Implant survival rates reported in the studies utilizing short and/or standard‐length implants ranged from 80.6% to 100% (Park et al. 2026). Prosthesis survival rates ranged from 80.0% to 100% (Park et al. 2026). Implant success rates varied with values between 78.2% and 95.0%, whereas prosthetic success rates ranged from 55.0% to 90.0% (Park et al. 2026). There were heterogenous success definitions used across studies included in the systematic reviews. Conversely, there were only minimal variations in how implant survival and marginal bone loss were evaluated. Implant survival and marginal bone loss were, for example, consistently used as primary indicators of long‐term success. One of the most frequently included clinician‐reported outcome was the occurrence of complications (Thoma et al. 2026). Zygomatic implants raised additional concerns such as sinus involvement, intraoperative complications and peri‐implant infections. Complication reports are important for understanding the feasibility and long‐term predictability of each approach. Although it is not reported frequently, severe intraoperative complications associated with zygomatic implants, such as orbital perforations, have been documented. Postoperative complications included, for example, sinusitis as one of the most reported complications in association with zygomatic implants (Thoma et al. 2026).

Subjective ClinRO assessments reflect clinician judgment/interpretation. Few studies included subjective ClinROs such as the difficulty of the treatment or postoperative swelling, rated by the clinician using unstandardized scales (Thoma et al. 2026). If captured systematically, subjective ClinROs could be used to inform future practice guidelines. Currently, most data on subjective ClinROs remain anecdotal or narrative. Therefore, a lack of outcomes based on the clinician's perception was identified.

4. Summary of the Key Findings From the Surveys

This section summarizes the key findings from the survey with selected experts focusing on the treatment of patients with fully edentulous maxillae using short, standard‐length, or zygomatic implants (Strauss et al. 2026). Additionally, relevant results from the patient and cross‐disciplinary expert surveys for Working Group 2 were included (Lin et al. 2026). Clinician selection was performed considering the inclusion of wide‐ranging expertise and geographic representation in implantology. Individuals who have experienced receiving dental implants to restore a fully edentulous maxilla were included in the patient survey. Clinical research directors and professionals from leading companies and foundations specializing in implant dentistry and regenerative biomaterials were invited to the survey as cross‐disciplinary experts (Lin et al. 2026). For the expert survey, 199 experts from 37 countries were invited. Out of these 199, 118 participated in the survey, resulting in a response rate of 59.3% (Strauss et al. 2026). Most experts held one (76.3%) or multiple (20.3%) specialty degrees, with only 3.4% identifying as general practitioners. Prosthodontists comprised the largest group (43.2%), followed by periodontists (25.4%), oral surgeons (22.9%), and oral and maxillofacial surgeons (18.6%); 8.5% reported other specialties, such as implantology. Regarding practice settings, 68.6% worked in private clinics, 54.2% in universities, 11.0% in public hospitals, and 1.7% in other environments. Overall, 66.1% worked in a single setting. Out of 68 contacted patients, 41 participated in the survey, resulting in a response rate of 60.3%. For the cross‐disciplinary experts, the response rate was 30.9% with 21 out of 68 contacted cross‐disciplinary experts participating in the survey (Lin et al. 2026).

4.1. Patient Selection

In cases of severe maxillary atrophy, 55.1% of experts preferred standard‐length implants with sinus lifts or bone grafting over short implants or zygomatic implants. When sufficient anterior maxillary bone was available, 50.0% favored placing implants exclusively in that area without grafting. Zygomatic rehabilitations were the least preferred options in both cases.

The majority of patients and cross‐disciplinary experts reported feeling very well‐informed by their dentists regarding treatment expectations and implant longevity.

4.2. Diagnostics

Strong consensus (> 95%) was achieved on the need to assess maxillary sinuses preoperatively, particularly in cases involving sinus lifts (lateral sinus lift: 96.6% strong consensus; crestal sinus lift: 90.6% consensus) or suspected sinus pathology (95.8% strong consensus). Consensus (91.4%) was also achieved for preoperative sinus assessment before zygomatic implant placement. No consensus was achieved for sinus assessment before placing short implants (66.0%) or standard‐length implants in native bone (61.8%).

Nearly all experts (99.2%) assessed mouth opening and temporomandibular joint (TMJ) disorders during planning, with 89.0% doing so routinely and 10.2% in specific cases (e.g., when guided surgery is considered).

When asked about the used diagnostic tools, a strong consensus was achieved for the routine use of CT/CBCT scans (96.5%). Consensus (≥ 75% and ≤ 95%) was achieved for using intraoral scans, photographs, wax‐ups, and mock‐ups for planning. However, no consensus was reached on the use of panoramic x‐rays (67.8%) or facial scans (56.8%). Although the integration of facial scans in digital planning has increased in the past few years, their necessity and impact remain unclear. No consensus was reached regarding the preferred impression method: 67.8% supported conventional impressions, indicating a growing preference for digital tools. Therefore, the question whether digital or conventional impression techniques should be used for edentulous patients remains an open question and warrants further discussion.

In the patient and cross‐disciplinary expert surveys, most respondents stated that they received CBCT scans prior to implant placement. Even though most patients were not concerned about the CBCT scans and associated radiation doses, some did express concerns about this issue. A higher number of cross‐disciplinary experts expressed concerns regarding radiation exposure, especially in cases involving multiple scans. Regarding different impression techniques, most patients and cross‐disciplinary experts reported having no clear preference, although some preferred digital impressions. None of the patients and only one of the cross‐disciplinary experts preferred conventional impressions.

4.3. Treatment Planning

4.3.1. Preferred Implant Type

4.3.1.1. Zygomatic Implants

As 25 experts indicated a lack of familiarity with zygomatic implants and consequently did not complete the corresponding questions, the consensus analysis for the zygomatic‐implant–related items was derived from the responses of the remaining 93 experts. Consensus (80.6%) was achieved that zygomatic implants should be a last‐resort solution when conventional treatments are not feasible. Experts agreed that this procedure requires highly specialized training (95.7%, strong consensus) and that complex cases should be performed in a hospital setting (84%). Consensus (81.7%) was achieved that complications might be difficult to manage in a dental setting.

Regarding the preferred surgical approach, there was no consensus (61.3%) on whether a lateral window osteotomy should be performed for intraoperative visual inspection during zygomatic implant placement. Furthermore, there was no consensus (70.9%) on whether computer‐guided surgery provides higher accuracy compared to freehand surgery for zygomatic implant placement. Based on these results, the optimal surgical approach for zygomatic implant placement remains unclear, as does the question of whether this implant type is associated with increased complexity during the prosthodontic restoration.

For prosthetic considerations, consensus (82.7%) was achieved that all implants should be splinted. However, there was no consensus (61.3%) on whether zygomatic implants are more complex to restore.

4.3.1.2. Short Implants

For short implants, consensus was reached that they offer reduced morbidity (83.1%), lower costs (80.5%), and shorter treatment time (84.0%) compared to standard‐length implants with sinus lifts/bone grafting. No consensus was achieved on the impact of crown‐to‐implant ratio on crestal bone loss; 61.9% of experts disagreed with the statement that an increased crown‐to‐implant ratio would lead to crestal bone loss.

In terms of prosthetic approaches, a preference for delayed loading of short implants was observed probably due to limited evidence supporting immediate loading. Experts agreed that short implants should be splinted (86.5%), have a narrow occlusal table (75.7%), avoid lateral forces (83.1%), and eliminate cantilevers (76.2%) to minimize complications. No consensus was achieved on the impact of short implants on aesthetics; 55.9% of experts disagreed with the statement that short implants are associated with poor aesthetics.

4.3.2. Treatment Options

In cases of severe maxillary atrophy, most experts (55.1%) preferred standard‐length implants combined with sinus elevation or bone grafting. Short implants were rated as the second treatment option (25.4%) while zygomatic implant were the least preferred treatment option (19.5%). When sufficient bone was available in the anterior maxilla, standard‐length implant placement in the anterior zone was the preferred choice (50.0%), followed by standard‐length implants and sinus lift/bone grafting and short implants. Zygomatic implants were chosen as the least preferred option by 60.2% of the respondents.

According to the patient and cross‐disciplinary experts surveys, most preferred a fixed maxillary full‐arch prosthesis over a removable one, even if bone augmentation procedures were required.

Regarding provisional prosthesis, most patients preferred a fixed option. When cross‐disciplinary experts were surveyed, a larger proportion either preferred a fixed provisional prosthesis or did not care if they had a provisional prosthesis. When asked about the preferred extension of the final prosthesis, most patients and cross‐disciplinary experts favored an extension to molars rather than limiting it to the premolars.

4.3.3. Factors Influencing Treatment Selection

According to the respondents, scientific evidence (31.4%) and ease of treatment (68.6%) were the main influencing factors for the selection of treatment procedures. However, no one supported ease alone as a justification for their selection. No consensus was reached on whether technical difficulty plays a decisive role in treatment selection; however, 64.5% agreed that it was a factor to consider.

4.3.4. Timing of Implant Placement and Loading

Experts preferred immediate placement for standard‐length implants in native bone (72.0%) but recommended delayed placement for short implants (59.3%) and for standard‐length implants in combination with sinus lift/bone grafting (49.2%). For zygomatic implants 42.4% of respondents preferred delayed implant placement, while 41.5% preferred immediate implant placement protocols.

Consensus (≥ 75% and ≤ 95%) was reached on following key factors influencing immediate loading: initial torque (89.9%), bone quality (91.5%), number of implants (88.2%), prosthetic factors (89.9%), and the need for augmentation procedures (87.3%). No consensus could be achieved on following factors: implant length (67.9%), patient gender (with 71.3% disagreeing about its significance), patient age (with 65.3% disagreeing about its significance), patient's request (45.0%).

Even though loading protocols are clinically relevant, no consensus could be achieved for most of the implant types and treatment approaches. Consensus in favor of immediate loading was reached only for standard‐length implants in native bone. No consensus could be reached for the preferred loading protocols with short implants, standard‐length implants placed with bone augmentation or zygomatic implants. However, there was a tendency to prefer immediate loading over delayed loading for the restoration of zygomatic implants (71.0%). By contrast, delayed implant loading was preferred by more than 70% of the respondents for short implants and for standard‐length implants combined with sinus lift/bone augmentation, although consensus was not reached.

4.4. Treatment Procedures

4.4.1. Antibiotic Prescription

Most experts prescribed antibiotics as prophylaxis for full‐arch implant placement: 62.7% did so routinely, while 32.2% prescribed them only in specific cases. Postoperative antibiotics were prescribed routinely by 62.7% of respondents, with durations ranging from 1 to 20 days, most commonly 7 days. Antibiotic use was primarily indicated for medically compromised patients and cases involving bone grafting. Despite its clinical importance, there appears to be no clear consensus among clinicians regarding antibiotic prescription protocols.

4.4.2. Guided Surgery

No consensus was reached regarding the preference for non‐guided versus guided (static/dynamic) computer assisted implant surgery for multiple implants in fully edentulous maxilla cases. However, there was a general tendency to disagree with the use of non‐guided surgery. Specifically, the following percentages of respondents disagreed with preferring non‐guided surgery: 57.7% for standard‐length implants in native bone, 52.6% for standard‐length implants and simultaneous sinus lift/bone grafting, 60.2% for standard‐length implants in previously augmented sites, 57.6% for short implants, 45.7% for zygomatic implants. The lack of consensus may be due to the fact that experienced clinicians are comfortable using both, guided and non‐guided, approaches.

4.4.3. Soft Tissue Augmentation

Experts were asked about multiple potential indications for soft tissue augmentation procedures. Among the presented potential indications, consensus (≥ 75% and ≤ 95%) was reached on the need for soft tissue augmentation in cases of absent or thin keratinized mucosa, insufficient (< 2 mm) keratinized mucosa width and lack of vestibule. The anterio‐posterior location of the implant and type of prosthesis (fixed vs. removable) were not considered significant factors.

4.4.4. Factors Affecting Patient Satisfaction

Consensus (≥ 75% and ≤ 95%) was achieved on the importance of aesthetics, chewing function, phonetics, and complications in determining short‐term patient satisfaction. Consensus (≥ 75% and ≤ 95%) was also achieved on the importance of prosthesis type (fixed vs. removable), ease of cleaning, number of surgeries, overall treatment duration, pain and costs in determining short‐term patient satisfaction. No consensus was reached on the importance of preoperative dental status, discomfort during the surgery, invasiveness of the procedure, duration of the surgery, loading protocols or the need for medication in determining short‐term patient satisfaction.

In the patient and cross‐disciplinary expert surveys, participants focused on a variety of major outcomes, such as aesthetics, chewing function, phonetics, ease of cleaning, number of surgical interventions, comfort, costs, and total treatment time. Chewing function was rated as the most important factor. Patients placed the least importance on the number of surgical interventions; this differs from clinical practice, where the number of surgical interventions is often a major concern. The cross‐disciplinary expert gave the least importance to total treatment time.

Regarding potential complications, patients expressed questions and concerns about all suggested outcomes, including pain/swelling, provisional phase, medication, future follow‐up intervals, difficulty with cleaning, difficulty with speech, risk of implant or prosthesis failure and possible changes to bite or joint function. The risk of implant failure received the highest number of concerns/questions, while the need for medication was of least concern among patients. For cross‐disciplinary experts, the most important concerns were the risk of implant failure and increased difficulty of cleaning, while the need for medication was also of least concern.

4.5. Maintenance Care

4.5.1. Maintenance Protocols

When asked about recall intervals, most experts (96.6%) recommended annual or more frequent follow‐ups after prosthesis placement, with 38.1% scheduling them yearly and 58.5% more frequently. Regarding professional hygiene care, 44.9% recommended biannual visits, while 32.2% advised once per year. No consensus was reached on the necessity of performing additional, specific clinical or radiographic examinations in the absence of complications at least once per year during the long‐term follow‐up. While over half of the respondents supported intraoral (71.2%) and panoramic radiographs (62.7%), 63.6% opposed the routine use of CT/CBCT scans. However, no consensus was reached. Similarly, 63.5% of respondents supported full‐mouth six‐point pocket charting, but this also did not reach consensus.

Opinions varied on the need for regular removal of screw‐retained full‐arch restorations for hygiene purposes. Nevertheless, most agreed that removal was necessary in cases of peri‐implantitis. Specifically, 51.7% recommended prosthesis removal at intervals of 1–24 months, while 44.9% recommended removal only in cases of peri‐implantitis. Among non‐prosthodontists, 62.6% favored regular removal, whereas 58.8% of prosthodontists recommended removal only in the presence of peri‐implantitis. For bar‐supported overdentures, 26.3% of experts advised regular removal for hygiene (every 1–24 months), while 66.1% recommended removal only in cases of peri‐implantitis. Among non‐prosthodontists, 37.3% favored regular removal, compared to 80.3% of prosthodontists who recommended removal only in cases of peri‐implantitis. For both types of prostheses (i.e., screw‐retained full‐arch fixed prostheses and bar‐supported overdentures), the majority of experts indicated that they do not replace the prosthetic screws during follow‐up visits.

Based on the clinicians' answers, there seems to be a lack of standardized maintenance protocols and guidelines for follow‐up visits, as no consensus was achieved on many significant topics in this domain.

Similar topics were addressed in the patient and cross‐disciplinary expert surveys. Regarding follow‐up intervals, a similar number of patients preferred intervals of 6 or 12 months as opposed to shorter intervals of 3 months. In contrast, most cross‐disciplinary experts preferred a 3‐month interval.

4.5.2. Home Care and Occlusal Guards

The survey questions addressed multiple tools for regular home care recommendations. Among the presented options, consensus was reached on recommending manual toothbrushes (84.8%), toothpaste (80.4%), interdental brushes (88.2%), dental floss (79.6%), and oral irrigators (76.3%) for patient home care. No consensus was reached on the use of electric toothbrushes (74.5%) or mouthwash (67%).

Occlusal guards were always recommended by 39.0% of respondents, whereas 45.8% recommended them in selected cases based on opposing dentition and restoration material but not based on implant number or length. Only 15.3% did not recommend occlusal guards.

In the patient survey, most patients reported using a toothbrush (87.8%, consensus) for home oral hygiene, followed by a water flosser (70.7%) and interdental brushes (41.5%). Some patients also planned to use dental floss or a mouthwash/rinse. Most cross‐disciplinary experts chose a toothbrush (85.7%, consensus), followed by interdental brushes (71.4%) and water flossers (57.1%).

Regarding the use of occlusal guards, most patients and cross‐disciplinary experts stated that they should be used daily.

4.6. Key Outcomes for Future Studies

In the single‐round survey, key outcomes for future studies were assessed and categorized into PROs and ClinROs. A summary of the results is presented in the subchapters 3.6.1 and 3.6.2.

Regarding the patient and cross‐disciplinary expert surveys, when asked about the overall goals and structure of future studies, a high percentage of respondents preferred studies focusing on the type of implant‐supported prosthesis; this topic reached consensus when patients were asked with an agreement of 80.5%. Patients and cross‐disciplinary experts were also asked whether future studies should evaluate new applications and devices to improve the assessment of efficacy and success of implant‐supported prostheses. However, no consensus was reached on this topic. Similarly, patients and cross‐disciplinary experts did not reach consensus on whether studies should compare patients receiving implant‐supported prostheses and those receiving complete dentures.

Patients reached strong consensus (> 95%) on the use of the following criteria to evaluate the overall success of a study: improvement in quality of life, improvement in activities of daily living and function, improvement in aesthetics from the patient's perspective, and the reduction of complications. Furthermore, patients reached consensus (≥ 75% and ≤ 95%) that the improvement in aesthetics from the clinician's perspective, clinician‐assessed procedural difficulty of the procedure, and cost‐effectiveness should be used to show the overall success of a study. In comparison, cross‐disciplinary experts reached strong consensus (> 95%) that the following criteria should be used to evaluate the overall success of a study: improvement in quality of life, improvement in activities of daily living and function, and clinician‐assessed procedural difficulty of the procedure. Additionally, they reached consensus that the improvement in aesthetics from the patient's perspective, the reduction of complications, and the cost‐effectiveness should be used to show the overall success of a study.

4.6.1. Patient‐Reported Outcome Measures (PROMs)

Experts were asked to select PROMs, which they considered important, from a presented list. Consensus (≥ 75% and ≤ 95%) was achieved for all proposed PROMs, except for micro‐aesthetic questionnaires (from smile close up photos). Consensus was reached on the relevance of following PROMs:

• Quality of masticatory function questionnaire

• Oral health impact profile for edentulous people

• Visual analog scale for satisfaction

• Numerical rating scale for satisfaction

• Chewing ability questionnaire

• Denture satisfaction questionnaire

• Macro‐aesthetic questionnaire (from smile portrait photos)

4.6.2. Clinician‐Reported Outcomes Measures (ClinROMs)

Experts were asked to select ClinROMs, which they considered important, from a presented list. Among the presented options, strong consensus (> 95%) was achieved for the relevance of surgical complications. No consensus was reached for surgery duration, ridge width or height, even though they achieved more than 60% support. Only 50% supported resonance frequency analysis without reaching consensus. Consensus (≥ 75% and ≤ 95%) was achieved for the relevance of following ClinROMs:

• Implant survival

• Vertical bone height assessed on CBCT

• Prosthetic complications

• Marginal bone loss

• Implant primary stability

• Plaque score

• Peri‐implant mucositis and peri‐implantitis

• Keratinized mucosa width

• Clinician's assessment of treatment success

• Recommendations for future procedures

• Surgery difficulty

5. Group Recommendations

To enhance clinical applicability, the following 6 recommendations have been structured according to a logical treatment workflow for the rehabilitation of the edentulous maxilla. This sequence follows the major clinical domains defined by the GCCG framework: patient selection, diagnostics, treatment planning, treatment procedures, and maintenance care. The recommendations developed by Working Group 2 address the clinical domains of patient selection and treatment planning. Each recommendation reflects the outcome of structured consensus discussions and has been classified according to its alignment with the current body of evidence. All 6 recommendations reached consensus.

Recommendation No. 1 (Aligned with current evidence)

Domain	Patient selection
Recommendation	For patients with severely atrophic edentulous maxilla, where there is limited anterior and posterior bone availability, and bone grafting procedures are not feasible, we suggest that zygomatic implants are presented as a treatment option. This would allow the rehabilitation of the patient with a functional implant‐supported prosthesis. For patient safety, we recommend that zygomatic implant placement be performed only in an appropriate surgical setting by experienced surgeons, who have received proper mentored clinical training, which enables them to conduct the treatment and manage potential severe complications.
Supporting expert survey results	–Consensus (80.6%) was achieved that zygomatic implants should be the last‐resort solution when conventional treatments are not feasible. –Strong consensus (95.7%) was achieved that zygomatic implant placement requires highly specialized training. Consensus (84%) was achieved that complex cases should be performed in a hospital setting. –Consensus (81.7%) was achieved that complications might be difficult to manage in a dental setting.
Supporting patient/cross‐disciplinary experts survey results	Patients and cross‐disciplinary experts preferred fixed maxillary full‐arch prosthesis compared to a removable one.
Supporting/contradicting	Consensus papers and systematic reviews on zygomatic implants (Al‐Nawas et al. 2023; Brennand Roper et al. 2023; Gabriele et al. 2023; Kammerer et al. 2023; Lan et al. 2021; Polido et al. 2023; Testori et al. 2024; Varghese et al. 2023; Vrielinck et al. 2023; Wadde et al. 2024): –High survival rates. –Primarily recommended in severe atrophy. –Rated as a potential treatment option only in specific cases if conventional alternatives are unsuitable. –It was advocated for highly skilled surgical teams and stated that this is not a procedure for routine practice. –Significant surgical risk (such as orbital cavity penetration and subcutaneous peri‐malar emphysema), and potential for significant complications (most frequently sinusitis) were reported, supporting the expert survey results that zygomatic implants are indicated as the last treatment option and require special expertise.
Lack of literature	Literature focusing on difficulties in prosthetic restoration of zygomatic implants and appropriate maintenance protocols.
Evidence	The above recommendation is in line with the existing data and survey results.
Recommended ClinROs	Objective – Implant failure – Implant success – Implant survival – Mechanical/technical complications – Prosthesis failure – Prosthesis success – Prosthetic complications – Postoperative complications – Surgical/intraoperative complications – Biological complications – Peri‐implant health (implant level) – Peri‐implant health (patient level) – Peri‐implant mucositis – Peri‐implant suppuration – Peri‐implantitis Subjective – Prosthodontic maintenance events/complications
Recommended PROs/PROMs	–Aesthetic satisfaction –Chewing function/comfort/discomfort –Complications during treatment/maintenance –Ease of cleaning/oral hygiene efficacy –Pain –Patient overall satisfaction with treatment –Patient‐reported complaints –Quality of life (assessed for example with OHIP‐14) –Speech/phonetics/pronunciation function
Strength of consensus	Agree: 87% (Consensus) Agree: 79/Disagree: 5/Abstain: 6/Abstain (Conflict of Interest): 1

Recommendation No. 2 (Cannot be evaluated due to a lack of existing evidence)

Domain	Patient selection
Recommendation	Although short implants are a treatment option with reduced morbidity, no recommendation can be made with regard to the use of solely short implants in the treatment of the atrophic edentulous maxilla with implant‐supported protheses. Due to the lack of long‐term evidence, further research is recommended.
Supporting expert survey results	Consensus was reached that short implants offer reduced morbidity (83.1%), lower costs (80.5%), and shorter treatment time (84.0%) compared to standard‐length implants with sinus lifts/bone grafting.
Supporting patient/Cross‐disciplinary experts survey results	Patients and cross‐disciplinary experts focused on a variety of major outcomes, including number of surgical interventions and costs.
Supporting/contradicting	RCTs reporting 5‐year survival rates support placing ≤ 6‐mm implants in native bone and in full‐arch rehabilitation in either jaw and using 6‐mm implants as an alternative to sinus lift with long implants (Ravida et al. 2024).
Lack of literature	There is limited evidence reporting on short implants for full‐arch restorations. The certainty/quality of evidence for short implants for full‐arch restorations was rated only as moderate at a follow‐up of 5 years (Ravida et al. 2024).
Evidence	The above recommendation is based on expert opinion due to lack of long‐term evidence. Further research is recommended.
Recommended ClinROs	Objective – Implant failure – Implant success – Implant survival – Mechanical/technical complications – Prosthesis failure – Prosthesis success – Prosthetic complications – Implant primary stability – Postoperative complications – Presence of keratinized mucosa – Radiographic marginal bone level – Radiographic marginal bone loss – Surgical/intraoperative complications – Width of keratinized mucosa – Biological complications – Peri‐implant health (implant level) – Peri‐implant health (patient level) – Peri‐implant mucositis – Peri‐implant suppuration – Peri‐implantitis Subjective – Prosthodontic maintenance events/complications
Recommended PROs/PROMs	–Aesthetic satisfaction –Chewing function/comfort/discomfort –Complications during treatment/maintenance –Ease of cleaning/oral hygiene efficacy –Pain –Patient overall satisfaction with treatment –Patient‐reported complaints –Quality of life (assessed for example with OHIP‐14) –Speech/phonetics/pronunciation function
Strength of consensus	Agree: 77% (Consensus) Agree: 69/Disagree: 18/Abstain: 1/Abstain (Conflict of Interest): 2

Recommendation No. 3 (Aligned with current evidence)

Domain	Patient selection
Recommendation	For the rehabilitation of function, esthetics, and phonetics in patients with atrophic edentulous maxilla, where there is sufficient bone available in the anterior area and a highly atrophic posterior bone, we suggest the following three alternatives as treatment options: – Standard‐length implants with bone augmentation/sinus lift – Standard‐length implants (anterior straight and posterior tilted/straight) placed in native bone, if these allow for a significant improvement of anterio‐posterior spread and in prosthetically correct position – In cases where grafting procedures are not feasible and tilted implants do not offer any advantages, we suggest considering the combination of standard‐length implants in the anterior with graftless options for the posterior maxilla (zygomatic implants*). Selection of either treatment option should be based on patient‐specific criteria. This applies for removable as well as fixed prostheses. *See recommendation no. 1
Supporting expert survey results	In cases of severe maxillary atrophy, 55.1% of experts preferred standard‐length implants with sinus lifts or bone grafting compared to short implants or zygomatic implants. When sufficient anterior maxillary bone was available, 50.0% favored placing implants exclusively in this area without grafting. In cases of severe maxillary atrophy, most experts (55.1%) preferred standard‐length implants combined with sinus elevation or bone grafting. Short implants were mainly rated as the second treatment option (25.4%). Zygomatic implant rehabilitations were the least preferred treatment option (19.5%).
Supporting patient/Cross‐disciplinary experts survey results	80.5% of patients and 85.7% of cross‐disciplinary experts indicated they would be open to undergo the hard tissue augmentation procedures for a fixed prosthesis.
Supporting/Contradicting	Standard‐length implants with bone augmentation/sinus lift: – Systematic review on different bone augmentation techniques and related implant survival rate in the edentulous maxilla reported successful outcomes and high implant survival rates (Aghaloo et al. 2016). Zygomatic implants: – Zygomatic implants are the least preferred treatment option. This might be related to the technical difficulty of the treatment and the potential complication risk. Potential complications include sinusitis (more than 10% of the cases), soft tissue infections, paresthesia and oroantral fistulas (Chrcanovic et al. 2016; Lan et al. 2021). Axial/tilted implants: – Systematic review (24 studies) (Aghaloo et al. 2016): – No significant differences in implant survival rates, cumulative survival rates; 5‐year implant survival rate for axial and tilted implants >98%. Survival proportion at 18 years was 93.34% for tilted (95% confidence intervals: 89.76%, 95.70%) and 94.37% for axial implants (95% confidence intervals: 92.55%, 95.75%). – Maxilla: trend for better survival rates for axial implants compared to tilted implants in prospective studies, but without statistical significance. – Systematic review (42 studies) (W. S. Lin and Eckert 2018): – No statistically significant differences between axial/tilted implants for implant survival rates, marginal bone loss. – Systematic review (11 studies) (Goncalves et al. 2022): – No negative impact of tilted implants on implant survival or marginal bone loss within all‐on‐four concept; follow‐up of studies ranged from 3 months—7 years. – Overview of systematic reviews (36 systematic reviews) (Messias et al. 2021) – At least 4 implants recommended for implant‐supported protheses in the edentulous maxilla. Minimum: two anterior axial +2 posterior distally tilted implants, or 6–8 axial implants symmetrically distributed in anterio‐posterior direction. – In general, for these systematic reviews: high heterogeneity, risk of bias, low level of evidence (very limited RCTs). Sometimes lack of standardization regarding the specifics of tilting. – Systematic review (2 RCTs, 10 further prospective, 12 retrospective), cave: risk of bias (del Fabbro et al. 2022): – Significantly higher marginal bone loss for tilted implants, mean difference = 0.18 mm; 95% confidence intervals: 0.16, 0.21 mm; p < 0.0001, but for both groups moderate marginal bone loss. Observed mean difference between marginal bone loss axial vs. tilted < 0.2 mm after 3–7 years follow‐up.
Lack of literature	The evidence is scattered and with a potential for high risk of bias.
Evidence	The above recommendation is in line with the existing data and survey results.
Recommended ClinROs	Objective: – Implant failure – Implant success – Implant survival – Mechanical/technical complications – Plaque index/Oral Hygiene – Prosthesis failure – Prosthesis success – Prosthetic complications – Implant primary stability – Postoperative complications – Presence of keratinized mucosa – Radiographic marginal bone level – Radiographic marginal bone loss – Surgical/intraoperative complications – Width of keratinized mucosa – Biological complications – History of patient compliance – Peri‐implant health (implant level) – Peri‐implant health (patient level) – Peri‐implant mucositis – Peri‐implant suppuration – Peri‐implantitis Subjective: – Prosthodontic maintenance events/complications
Recommended PROs/PROMs	–Aesthetic satisfaction –Chewing function/comfort/discomfort –Complications during treatment/maintenance –Ease of cleaning/oral hygiene efficacy –Pain –Patient overall satisfaction with treatment –Patient‐reported complaints –Prosthesis retention/stability –Quality of life (assessed for example with OHIP‐14) –Speech/phonetics/pronunciation function
Strength of consensus	Agree: 76% (Consensus) Agree: 68/Disagree: 19/Abstain: 0/Abstain (Conflict of Interest): 2

Recommendation No. 4 (Aligned with current evidence)

Domain	Patient selection
Recommendation	For the rehabilitation of function, esthetics, and phonetics in patients with atrophic edentulous maxilla, where there is sufficient bone available in the anterior area and limited residual bone height but sufficient bone width in the posterior area, we suggest considering the following alternative treatment options: – Standard‐length implants with bone augmentation/sinus lift (lateral or transcrestal) – Standard‐length implants in combination with posterior short implants Choice of either treatment option should be based on patient‐specific criteria.
Supporting expert survey results	In cases of severe maxillary atrophy, most experts (55.1%) preferred standard‐length implants combined with sinus elevation or bone grafting. Short implants were mainly rated as the second treatment option (25.4%). Zygomatic implant rehabilitations were the least preferred treatment option (19.5%). When sufficient anterior maxillary bone was available, 50.0% favored placing implants exclusively in this area without grafting.
Supporting patient/Cross‐disciplinary experts survey results	80.5% of patients and 85.7% of cross‐disciplinary experts indicated they would be open to undergo the hard tissue augmentation procedures for a fixed prosthesis.
Supporting/Contradicting	Standard‐length implants with bone augmentation/sinus lift: –Systematic review on different bone augmentation techniques and related implant survival rate in the edentulous maxilla reported successful outcomes and high implant survival rates (Aghaloo et al. 2016).
Lack of literature	Limited evidence for short implants for maxillary full‐arch restorations.
Evidence	The above recommendation is in line for literature and survey results. However, there is limited evidence for short implants.
Recommended ClinROs	Objective: – Implant failure – Implant success – Implant survival – Mechanical/technical complications – Plaque index/Oral Hygiene – Prosthesis failure – Prosthesis success – Prosthetic complications – Implant primary stability – Postoperative complications – Presence of keratinized mucosa – Radiographic marginal bone level – Radiographic marginal bone loss – Surgical/intraoperative complications – Width of keratinized mucosa – Biological complications – History of patient compliance – Peri‐implant health (implant level) – Peri‐implant health (patient level) – Peri‐implant mucositis – Peri‐implant suppuration – Peri‐implantitis Subjective: Prosthodontic maintenance events/complications
Recommended PROs/PROMs	–Aesthetic satisfaction –Chewing function/comfort/discomfort –Complications during treatment/maintenance –Ease of cleaning/oral hygiene efficacy –Pain –Patient overall satisfaction with treatment –Patient‐reported complaints –Prosthesis retention/stability –Quality of life (assessed for example with OHIP‐14) –Speech/phonetics/pronunciation function
Strength of consensus	Agree: 90% (Consensus) Agree: 82/Disagree: 6/Abstain: 1/Abstain (Conflict of Interest): 2

Recommendation No. 5 (Aligned with current evidence)

Domain	Patient selection/Treatment selection
Recommendation	For the rehabilitation of function, esthetics, and phonetics in patients with atrophic edentulous maxilla, where there is sufficient bone in the posterior area and insufficient bone width in the anterior area, we suggest the following alternatives as preferred treatment options: – Standard‐length implants straight and/or tilted in the posterior area, if the anterio‐posterior spread is compatible with the prosthetic solution – Standard‐length implants with bone grafting procedures in the anterior area Selection of either treatment option should be based on patient‐specific criteria. This applies for removable as well as fixed prostheses.
Supporting expert survey results	In cases of severe maxillary atrophy, 55.1% of experts preferred standard‐length implants with sinus lifts or bone grafting compared to short implants or zygomatic implants. When sufficient anterior maxillary bone was available, 50.0% favored placing implants exclusively in this area without grafting.
Supporting patient/Cross‐disciplinary experts survey results	80.5% of patients and 85.7% of cross‐disciplinary experts indicated they would be open to undergo the hard tissue augmentation procedures for a fixed prosthesis.
Supporting/Contradicting	Axial/tilted implants: – Systematic review (24 studies) (del Fabbro et al. 2022): – No significant differences in implant survival rates, cumulative survival rates; 5‐year implant survival rate for axial and tilted implants > 98%. Survival proportion at 18 years was tilted 93.34% for tilted (95% confidence intervals: 89.76% and 95.70%) and 94.37% for axial implants (95% confidence intervals: 92.55%, 95.75%). – Maxilla: trend for better survival rates for axial implants compared to tilted implants in prospective studies, but without statistical significance. – Systematic review (42 studies) (Lin and Eckert 2018): – No statistically significant differences between axial/tilted implants for implant survival rates and marginal bone loss – Systematic review (11 studies) (Goncalves et al. 2022). – No negative impact of tilted implants on implant survival or marginal bone loss within all‐on‐four concept; follow‐up of studies ranged from 3 months—7 years. – Overview of systematic reviews (36 systematic reviews) (Messias et al. 2021): – At least 4 implants recommended for implant‐supported protheses in the edentulous maxilla. Minimum: two anterior axial +2 posterior distally tilted implants, or 6–8 axial implants symmetrically distributed in anterio‐posterior direction. – In general, for these systematic reviews: high heterogeneity, risk of bias, low level of evidence (very limited RCTs). Sometimes lack of standardization regarding the specifics of tilting. – Systematic review (2 RCTs, 10 further prospective, 12 retrospective), cave: risk of bias (del Fabbro et al. 2022): – Significantly higher marginal bone loss for tilted implants, mean difference = 0.18 mm; (95% confidence intervals: 0.16, 0.21 mm; p < 0.0001), but for both groups moderate marginal bone loss. Observed mean difference between marginal bone loss axial vs. tilted < 0.2 mm after 3–7 years follow‐up. Standard‐length implants with bone augmentation/sinus lift: – Systematic review on different bone augmentation techniques and related implant survival rate in the edentulous maxilla reported successful outcomes and high implant survival rates (Aghaloo et al. 2016).
Lack of literature	Evidence on tilted implants is scattered and with a potential for high risk of bias.
Evidence	The above recommendation is in line with the literature and survey results.
Recommended ClinROs	Objective: – Implant failure – Implant success – Implant survival – Mechanical/technical complications – Prosthesis failure – Prosthesis success – Prosthetic complications – Postoperative complications – Presence of keratinized mucosa – Radiographic marginal bone level – Radiographic marginal bone loss – Surgical/intraoperative complications – Width of keratinized mucosa – Biological complications – Peri‐implant health (implant level) – Peri‐implant health (patient level) – Peri‐implant mucositis – Peri‐implant suppuration – Peri‐implantitis Subjective: – Prosthodontic maintenance events/complications
Recommended PROs/PROMs	–Aesthetic satisfaction –Chewing function/comfort/discomfort –Complications during treatment/maintenance –Ease of cleaning/oral hygiene efficacy –Pain –Patient overall satisfaction with treatment –Patient‐reported complaints –Prosthesis retention/stability –Quality of life (assessed for example with OHIP‐14) –Speech/phonetics/pronunciation function
Strength of consensus	Agree: 90% (Consensus) Agree: 80/Disagree: 7/Abstain: 1/Abstain (Conflict of Interest): 1

Recommendation No. 6 (Aligned with current evidence)

Domain	Treatment planning
Recommendation	For the rehabilitation of function, esthetics, and phonetics in patients with atrophic edentulous maxilla, where standard‐length implants in native/augmented bone or zygomatic implants are indicated, we suggest immediate loading with a fixed provisional restoration, if primary stability and cross‐arch stabilization can be achieved.
Supporting expert survey results	In cases of severe maxillary atrophy, 55.1% of experts preferred standard‐length implants with sinus lifts or bone grafting compared to short implants or zygomatic implants. When sufficient anterior maxillary bone was available, 50.0% favored placing implants exclusively in this area without grafting. No consensus was reached on loading protocols for zygomatic implants or implants placed with augmentation. However, there was a tendency to prefer immediate loading over delayed loading for the restoration of zygomatic implants (71.0%). By contrast, delayed implant loading was preferred by more than 70% of the respondents for short implants as well as for standard implants in combination with sinus lift/bone augmentation, but without reaching consensus. Only for standard diameter in native bone consensus was achieved in favor of immediate loading.
Supporting patient/Cross‐disciplinary experts survey results	Patients (58%) and cross‐disciplinary experts (47%) preferred a fixed provisional prosthesis.
Supporting/Contradicting	Standard‐length implants: – Systematic reviews confirming high success rates under ideal conditions (Messias et al. 2023). Systematic reviews suggest that immediate loading protocols with a fixed prosthesis in the edentulous maxilla seem to be a reliable treatment alternative, resulting in similar survival rates as delayed loading (Jiang et al. 2021; Papaspyridakos et al. 2014). Zygomatic implants – Systematic reviews report high survival rates for zygomatic implants with immediate and delayed loading protocols. An overview of systematic reviews suggested that immediate loading could be considered the treatment of choice for zygomatic implants (Brennand Roper et al. 2023; Kammerer et al. 2023; Moraschini et al. 2023; Ramezanzade et al. 2021). – Cave: lack of intention‐to‐treat analysis in most studies regarding immediate loading of zygomatic implants (Polido et al. 2023). – A systematic review indicated that surgical techniques influenced the loading protocols, as the original surgical technique was associated with a 22.3% prevalence of immediate loading and anatomy‐guided approach was associated with an 89.6% prevalence of immediate loading (Kammerer et al. 2023).
Lack of literature	There is a lack of evidence on loading protocols for short implants in full‐arch rehabilitations. A systematic review reported an average implant survival rate of 92.5% for immediately loaded short implants; however, heterogeneity of included studies and a lack of long‐term prospective trials was highlighted (Kulkarni et al. 2021). Furthermore, only a low number of studies were included and the majority focused on single‐unit restorations. No full‐arch rehabilitations were included in this systematic review. A further systematic review evaluating the immediate loading of short single implants included only three studies, but reported no significant differences in implant survival rates compared to conventional loading (Hadilou et al. 2021).
Evidence	The above recommendation is in line with the literature and survey results for standard‐length implants in native bone. No consensus was reached in the survey results for zygomatic implants.
Recommended ClinROs	Objective: – Implant failure – Implant success – Implant survival – Mechanical/technical complications – Prosthesis failure – Prosthesis success – Prosthetic complications – Implant primary stability – Postoperative complications – Presence of keratinized mucosa – Radiographic marginal bone level – Radiographic marginal bone loss – Surgical/intraoperative complications – Width of keratinized mucosa – Biological complications – Peri‐implant health (implant level) – Peri‐implant health (patient level) – Peri‐implant mucositis – Peri‐implant suppuration – Peri‐implantitis Subjective Prosthodontic maintenance events/complications
Recommended PROs/PROMs	–Aesthetic satisfaction –Chewing function/comfort/discomfort –Complications during treatment/maintenance –Ease of cleaning/oral hygiene efficacy –Pain –Patient overall satisfaction with treatment –Patient‐reported complaints –Prosthesis retention/stability –Quality of life (assessed for example with OHIP‐14) –Speech/phonetics/pronunciation function
Strength of consensus	Agree: 75% (Consensus) Agree: 66/Disagree: 19/Abstain: 2/Abstain (Conflict of Interest): 2

6. Summary of Areas for Future Research

Several recommendations for future research were developed based on the identified evidence gaps and lack of consensus during the performed surveys (Table 1). For the diagnostic phase, a lack of literature was identified on the routine use of facial scanning. For the treatment planning and execution phase, multiple areas of focus for future research were identified, especially for the use of short implants for full‐arch restorations and related surgical (guided surgery) prosthetic considerations (e.g., loading protocols, splinting short implants, avoiding cantilevers, and reducing occlusal tables). The survey highlighted a lack of consensus from the experts regarding the optimal occlusal scheme for implant‐supported restorations, particularly regarding short implants. The lack of consensus across several domains highlights critical areas requiring assessment in future research. Evidence‐based maintenance protocols should be established, including the optimal choice of oral hygiene instruments, appropriate recall intervals, and indications for specific clinical interventions such as prosthesis removal or screw renewal. Additionally, studies should assess the necessity and frequency of routine removal of screw‐retained implant‐supported prostheses for professional maintenance. Further investigations should determine the role and diagnostic value of various radiographic techniques in the long‐term implant follow‐up, particularly the routine use of CBCT. Research should also include defining indications and evaluating the effectiveness of occlusal guards. Clarifying how factors such as antagonist dentition or restorative materials influence the need for an occlusal guard would support more standardized and evidence‐based clinical recommendations.

TABLE 1.

Summary of future research questions using the PICOS framework.

Domain	Research focus	P (population)	I (intervention)	C (comparator)	O (outcomes)	S (study design)
Diagnostics	Facial scanning	Patients with fully edentulous maxilla receiving a complete implant‐supported maxillary prosthesis	Diagnostic phase including facial scanning	Diagnostic phase without facial scanning	Aesthetic satisfaction	RCTs, Case control studies
Treatment planning and execution	Short implants for full‐arch rehabilitation	Patients with fully edentulous maxilla receiving a complete implant‐supported maxillary prosthesis	Short implants	Standard‐length implants with bone augmentation	Implant success/survival, augmentation needs, biological and technical complications, marginal bone loss, surgery time, PROMs, ClinROs	RCTs, prospective case series, cohort studies
Treatment planning and execution	Prosthetic consideration for short implants	Patients with fully edentulous maxilla receiving a complete maxillary prosthesis supported by short implants	Cantilever	No cantilever	Implant success/survival, augmentation needs, biological and technical complications, marginal bone loss, prosthesis survival/success, PROMs, ClinROs	RCTs, prospective case series, cohort studies
Treatment planning and execution	Loading protocols	Patients with fully edentulous maxilla receiving a complete maxillary prosthesis supported by short implants	Immediate loading	Delayed loading	Implant success/survival, augmentation needs, biological and technical complications, marginal bone loss, surgery time, PROMs, ClinROs	RCTs, prospective case series, cohort studies
Treatment planning and Execution	Non‐guided versus guided (static/dynamic) computer assisted implant surgery	Patients with edentulous maxilla receiving rehabilitation with multiple implants	Guided (static/dynamic) computer assisted implant surgery	Non‐guided computer assisted implant surgery	Implant placement accuracy, biological and technical complications, surgery time, ClinROs	RCTs, prospective case series, cohort studies
Maintenance	Prosthesis retrieval during recall	Patients with full‐arch implant‐supported prostheses in the maxilla	Prosthesis retrieval and maintenance every X months	Alternative recall interval for prosthesis retrieval and maintenance	Peri‐implant health, marginal bone loss, biological and technical complications, implant success/survival, PROMs	RCTs
Maintenance	Occlusal guards	Patients with fully edentulous maxilla receiving a complete implant‐supported maxillary prosthesis supported by short/zygomatic implants	Occlusal guard	No occlusal guard	Implant success/survival, augmentation needs, biological and technical complications, marginal bone loss, prosthesis survival/success, PROMs, ClinROs	RCTs, prospective case series, cohort studies

Focusing on the recommended patient‐reported outcome measures, no consensus was achieved on incorporating micro‐aesthetic questionnaires in patient‐reported outcomes, reflecting uncertainty regarding the clinical relevance of micro‐aesthetic evaluations. Micro‐esthetic evaluations focus on detailed ratios of teeth, soft tissues, and facial characteristics, and their relationships.

7. Conclusions

The Group 2 consensus provides practical guidance on the use of short, standard‐length, and zygomatic implants in atrophic maxillae, balancing surgical complexity, prosthetic feasibility, and patient‐centered care. As outlined in the six recommendations, treatment protocols vary considerably and are largely influenced by patients' baseline anatomical conditions. Consequently, important evidence gaps remain, particularly regarding standardized outcome measures, loading protocols, prosthetic strategies for zygomatic implants, the use of short implants for full‐arch restorations, and maintenance frameworks. The information presented in this paper should therefore be interpreted within the context of anatomical variability and protocol diversity, underscoring the need for further research in this field.

Zygomatic implants may serve as a valuable option in cases of severe maxillary atrophy where grafting is not feasible, as they enable functional rehabilitation. They may also provide the possibility of immediate loading. However, they are associated with higher intraoperative and biological complication rates compared with standard‐length implants and should be placed only in appropriate surgical settings by experienced surgeons with structured mentored training, ensuring the ability to manage potential severe complications.

Short implants provide a less invasive alternative to grafting or zygomatic implants and may offer advantages in terms of patient‐reported outcomes, such as morbidity, as well as clinician‐reported outcomes, such as treatment complexity. Nonetheless, full‐arch rehabilitation supported by short implants and recommended loading protocols require further evaluation and validation, and future research should focus on confirming their long‐term predictability and outcomes.

Author Contributions

German O. Gallucci, Franz Joseph Strauss, Giulia Brunello, Frank Schwarz, Kevser Pala: writing – original draft. German O. Gallucci, Franz Joseph Strauss, Giulia Brunello, Frank Schwarz, Kevser Pala and participants of Working Group 2: writing – review and editing. Frank Schwarz and German O. Gallucci: conceptualization. Frank Schwarz: methodology. German O. Gallucci: supervision. All contributors and Working Group 2 participants: approval of manuscript.

Funding

The GCCG received funding through grants from the European Association for Osseointegration, the International Team for Implantology, and the Osteology Foundation.

Conflicts of Interest

All delegates disclosed secondary interests using the standardized ICMJE disclosure form. Potential conflicts of interest were actively managed in accordance with Guidelines International Network (GIN) principles.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during this study.