Though both techniques exist more than 20 years, only single studies could be found in which the incidence of membrane perforation was focused comparing both operative techniques. This was the rationale for our meta-analysis. Principally, there is a controversy in the literature concerning the use of piezosurgical devices for MSA. Torrella et al. showed a reduced risk for perforations of the sinus membrane while using ultrasound for lateral approach. They additionally mentioned the improved visibility and hygiene in the operating area and the controlled osseous incision [7]. Wallace et al. recorded a reduced membrane perforation rate, improved intraoperative visibility, reduced intraoperative bleeding and reduced surgical trauma. No perforation occurred during the antrostomy and the initial membrane elevation with piezoelectric inserts. However, using conventional hand instruments, seven membrane perforations occurred in the same study [52]. Stübinger et al. and Toscano et al. also reported on complications during the elevation with hand instruments, especially in delicate situations with underwood septa which have shown to be an additional risk for membrane perforation [54, 61]. In contrast to these studies, Barone et al. observed four membrane perforations in the group treated with piezosurgery and only three perforations in the group treated with conventional instruments. In this randomised controlled clinical trial comparing rotary instruments with a piezoelectric device during maxillary sinus floor elevation, no significant difference was observed between the two groups. The authors concluded that the major limitation of piezosurgery was the time factor. Cutting procedures were substantially longer compared with conventional osteotomy devices [31]. Rickert et al. assessed also in a randomised controlled trial the same issue. In their study, they found no differences in the occurrence of perforations of the sinus membrane during surgery between piezo and conventional approach. They concluded that piezosurgery showed no advantages over conventional rotating instruments. Furthermore, they mentioned that the result is strongly depending on the experience of the respective surgeon with one of the respective techniques [10]. Another randomised controlled trial of Scarano et al. found a statistically significant difference between the incidences of sinus membrane perforation in the two groups. Group 1 used a round oral surgery bur, and the elevation was completed with sinus lift instruments. Group 2 using an ultrasonic surgery created a lateral bony window with nasal suction technique and elevation by using standard sinus lift instruments. Group 1 presented four perforations of the membrane, and no perforation occurred in group 2 [43].