Over the last few years a tremendous development of new surgically implanted hearing devices is taking place, with a subsequent overlapping of indications. This creates serious difficulties for the selection of the appropriate device, especially for the novice otologist. Bone conduction hearing implants and active middle ear implants share multiple indications. The precise selection of the correct device depends on hearing factors, anatomical conditions, patient characteristics and, last but not least, the experience of the treatment team. This lecture deals with the advantages and disadvantages of the Vibrant Soundbrige and the Bonebridge. The indications and usefulness of these devices for patients with conductive or mixed hearing loss will be addressed and clinical cases in different ear conditions will be presented. Main issues concerning the Vibrant Soundbridge will be the best approach in open cavities –to close or not to close the EAC-, the role of electrocochleography for choosing the FMT location, the best interposed tissue between the round window membrane and the FMT, and the usefulness of the Vibrogam. For the Bonebridge the discussion will focus on the mastoid vs the retrosigmoid approach, the need of preoperative bone measures (CT scan vs 3D slicer and other software), the alternative techniques when bone thickness is reduced, and how to deal with dura and sigmoid sinus during surgery. Audiological and anatomic indications as well as the results according to different approaches and positions of the implants will be shown. The impact of the surgery on quality of life, the postoperative pain in patients implanted with Bonebridge, and the difficulties of performing postoperative imaging following implantation will also be discussed.