Clinician preferences and decision-making patterns in the rehabilitation of severe maxillary atrophy: an international cross-sectional survey using a standardized cawood and howell class VI case.

Background: Severe maxillary atrophy represents a complex clinical condition requiring individualized implant-prosthetic rehabilitation strategies. Although several therapeutic approaches are available, including graftless implant solutions, regenerative procedures, and hybrid strategies, the decision-making rationale underlying clinicians' preferences remains incompletely defined. Objective: This international cross-sectional survey aimed to investigate clinician-reported decision-making profiles, perceived advantages, and expected outcomes associated with different therapeutic strategies for the rehabilitation of severe maxillary atrophy. Materials and methods: An international questionnaire-based survey was conducted among clinicians with experience in complex implant-prosthetic rehabilitation. A total of 178 questionnaires were submitted. After exclusion of respondents reporting fewer than five complex rehabilitations per year, 155 eligible responses were included in the final analysis. Participants evaluated a standardized anonymized CBCT clinical case of severe maxillary atrophy classified as Cawood and Howell Class VI and selected their preferred therapeutic strategy. According to this choice, respondents were allocated into three groups: alternative implant strategies, regenerative approach with bone grafting, and hybrid/combined strategy. Descriptive statistics were used to summarize clinician-reported perceptions regarding safety, predictability, immediate loading, expected implant survival, treatment duration, aesthetic and functional outcomes, maintainability, morbidity, maintenance costs, patient satisfaction, and quality-of-life improvement. Results: Alternative implant strategies were the most frequently selected approach, reported by 83 clinicians (53.5%), followed by regenerative approaches with bone grafting in 45 cases (29.0%) and hybrid/combined strategies in 27 cases (17.4%). Alternative strategies were more frequently associated with immediate loading and shorter treatment duration, whereas regenerative approaches were more commonly perceived as advantageous for aesthetic volume reconstruction and soft-tissue support. Expected five-year implant survival, masticatory function, maintenance burden, and clinician-reported patient satisfaction were generally perceived as favorable across all groups. Conclusions: Within the limitations of a perception-based survey design and a relatively limited sample size, the findings suggest that therapeutic decision-making in severe maxillary atrophy is not based on a rigid hierarchy of techniques. Instead, clinicians appear to balance treatment timing, surgical morbidity, anatomical reconstruction, prosthetic objectives, aesthetic expectations, maintainability, and patient-related priorities. These results should not be interpreted as evidence of clinical superiority of one approach over another. Further prospective multicenter studies using standardized clinical endpoints and validated patient-reported outcome measures are needed to clarify the comparative effectiveness of these strategies.