One of the greatest challenges in immediate implants is a deficient labial bone plate. Elian and colleagues introduced a socket classification that helps clinicians assess the risk of tissue collapse. Evidence shows that Type 1 sockets (intact bone and soft tissue) treated with gap grafting and provisionalization demonstrate minimal dimensional change, with studies reporting as little as 0.1 mm reduction in labial bone thickness over 6 months. In more complex Type 2 sockets (intact soft tissue but labial bone loss), reconstructive approaches such as the use of bone graft and collagen membrane or tuberosity block grafting with simultaneous provisionalization have shown predictable outcomes, including ridge width gain, 100% implant survival, stable midfacial levels, and favorable esthetics. ^, Thus, in compromised sockets with missing buccal bone, the combined use of a resorbable collagen membrane, bone graft, and adequate temporization at the time of flapless extraction and immediate implant placement offers a reliable approach to reconstitute the missing labial plate while preserving gingival architecture and ensuring satisfactory esthetic outcomes ( Fig. 1 ).

Buccal bone deficiency following tooth extraction, illustrating the need for grafting to restore ridge contour.

Temporization is a key component of immediate implant protocols, as it seals the socket at the time of placement and provides essential prosthetic support to the gingival margin. By shaping and stabilizing the peri-implant mucosa in the transmucosal zone, a provisional crown or customized healing abutment, often referred to as a sealing socket abutment, helps maintain natural tissue contours that would otherwise collapse after extraction.

The gingival margin of a failing tooth may be positioned coronal, at the level, or apical relative to the ideal gingival margin of the failing or contralateral tooth. When the margin is coronal or at the same level, conditions are generally favorable for immediate implant placement. If the margin is positioned apically, treatment planning should consider the extent of recession. In cases with recession less than 2 mm , immediate implant placement may still be feasible, provided that soft tissue grafting and flap advancement are used to achieve optimal esthetic outcomes. For recessions greater than 2 mm , delayed implant placement is recommended, in combination with pontic site management, orthodontic forced eruption, and soft tissue grafting to maximize esthetic results ( Fig. 2 A–C ).

( A ) Teeth 8 and 9: Gingival margin positioned coronal to the ideal gingival margin. ( B ) Tooth #9: Gingival margin positioned at the level of the ideal gingival margin. ( C ) Tooth 8: Gingival margin positioned apical to the ideal gingival margin.

For immediate implant placement, the presence of adequate apical and palatal bone is essential, as these bony walls provide primary anchorage and initial stability for the implant. Cone beam-based classifications of sagittal root position indicate that when the root lies against the labial plate (Class I), sufficient palatal bone is typically available for implant engagement. This configuration is the most common, accounting for more than 80% of anterior maxillary central incisor cases. Care must be taken to avoid excessive buccal angulation of the implant, as this may necessitate either a cement-retained restoration or an angled screw-channel abutment to correct angulation in order to achieve a screw-retained prosthesis. Roots positioned against the palatal plate (Class III), although rare, are considered highly favorable for immediate implant placement due to the presence of adequate apical bone and a thick labial plate. In contrast, Class IV root positions, in which the root engages both labial and palatal plates, often provide insufficient space for stable implant placement and are generally considered contraindicated for immediate implantation without prior bone augmentation ( Fig. 3 ).

Residual and apical bone importance to provide primary stability for immediate implant placement.

Controversy remains regarding whether the presence of local infection compromises outcomes. Several systematic reviews and meta-analyses support the safety of immediate placement in infected sites when proper debridement and protocols are applied. Chen and colleagues (2018), Saijeva and colleagues (2020), and Alqutaibi and colleagues (2019) reported comparable survival rates and peri-implant tissue stability between implants placed in infected and noninfected sockets. Lee and colleagues (2018) confirmed that immediate implants in infected sites can perform predictably, with keratinized gingiva width being the only differing parameter. Conversely, other reviews highlight potential risks. De Oliveira-Neto and colleagues (2019) and Zhao and colleagues (2016) reported an increased risk of failure, with nearly a 3-fold higher failure rate in infected sockets. While most contemporary evidence indicates that immediate implants can achieve predictable outcomes in well-managed infected sites, infection should still be regarded as a potential risk factor, highlighting the importance of meticulous surgical protocols and careful case selection ( Fig. 4 ).

Presence of buccal and apical infection adjacent to the remaining root structure.

Tooth extraction leads to inevitable alveolar bone loss, beginning with bundle bone resorption and progressing to ridge shrinkage, which can impair esthetic and functional outcomes. Loss is greater in sites with thin labial plates and preexisting pathology. Resorption extent is influenced by systemic health, socket condition, bone thickness, and extraction protocols. Conventional extraction techniques can damage socket walls and papillae, making minimally traumatic approaches essential for preserving anatomy and optimizing implant and esthetic outcomes. ( Fig. 9 A-D ).

( A ) Initial presentation of teeth #8 and 9 with compromised prognosis. ( B ) Minimally traumatic extraction of tooth #9 preserving surrounding tissues. ( C ) Atraumatic extraction of tooth #8 maintaining socket integrity. ( D ) Occlusal view of sockets #8 and #9 following extraction. ( E ) Digital surgical guide positioned for accurate implant placement. ( F ) Implants placed in correct 3D orientation using the digital guide. ( G ) Buccolingual view of implant position demonstrating the buccal gap. ( H ) Temporary abutments positioned for immediate provisionalization. ( I ). Connective tissue graft inserted following soft tissue preparation. ( J ) Buccal gap grafted with biomaterials after CTG placement. ( K ) Immediate provisional restorations placed on teeth #8 and #9. ( L ) Occlusal view demonstrating tissue contours after immediate provisionalization.

The use of advanced extraction systems such as Benex extraction tools, along with periotome-style microtomes and buccolingual root sectioning, allows for controlled removal of teeth while minimizing collateral trauma to the gingival architecture and alveolar socket walls. These techniques reduce the risk of buccal plate fracture and soft tissue collapse, thereby preserving the native anatomy essential for both immediate and delayed implant protocols.

Several factors can help mitigate postextraction bone modeling during immediate implant placement, including the presence of a thick buccal bone wall, ^, a larger alveolar ridge volume, optimal 3D implant positioning, ^, the use of bone graft materials, ^, and connective tissue grafts. Another critical variable is the horizontal distance or buccal gap between the implant shoulder and the facial bone crest. Araujo and colleagues conducted a preclinical study evaluating healing patterns in immediate implant sites with either wide or narrow buccal gaps and without grafting. After 3 months, they found significantly more bone coverage on the buccal implant surface in sites with wider gaps, suggesting that the buccal gap width plays a significant role in preserving facial bone integrity when no graft is used.

In cases of IIP with favorable socket anatomy and intact buccal walls, it is suggested that grafting of the buccal gap may not always be required. When the horizontal gap dimension is ≤1.5 to 2 mm, spontaneous bone fill can occur without the need for biomaterials, provided that the implant is placed in a proper 3D position and the provisional restoration ensures a stable soft-tissue seal at the gingival margin.

Long-term evidence underscores the challenge of maintaining buccal bone integrity following IIP, particularly with regard to esthetic stability. In a 10-year prospective case series, Seyssens and colleagues reported the absence of detectable buccal bone in 3 out of 18 cases each linked to complications such as midfacial recession, peri-implant mucositis, or peri-implantitis. Similarly, a 5-year study by Noelken and colleagues found no facial bone in 4 of 33 cases, identifying facial bone thickness as a crucial factor influencing buccal soft tissue contour. Earlier, Benic and colleagues, in a 7-year prospective study, observed complete buccal bone loss in 5 of 14 patients, accompanied by a 1 mm apical shift in the midfacial mucosal margin. These findings collectively highlight the esthetic and biological risks associated with buccal bone loss after IIP. To mitigate these outcomes, several preclinical and clinical studies have proposed the use of bone grafting materials to fill the peri-implant gap and support tissue preservation. ^, While data from observational studies remain heterogeneous, 2 recent systematic reviews demonstrated that socket grafting significantly improves horizontal buccal bone preservation when used in conjunction with IIP. ^, However, the impact of socket grafting on soft tissue outcomes remains uncertain ^, (see Fig. 9 J).

Soft tissue grafting procedures use various donor techniques, including de-epithelialized free gingival grafts (dFGG), connective tissue grafts (CTG), and grafts harvested from the tuberosity region. Tuberosity-derived grafts provide greater tissue thickness and enhanced volumetric stability; however, their use may be limited by anatomic constraints, accessibility, and the potential for hyperplastic response. A careful understanding of palatal anatomy is essential to avoid injury during harvesting, and the position of the graft relative to adjacent teeth is critical for ensuring graft quality. Optimal grafts consistently include the lamina propria, which provides favorable tissue thickness and integration. Recent clinical studies have demonstrated that adjunctive wound management strategies following dFGG harvesting, such as collagen plugs with cyanoacrylate, platelet-rich fibrin (PRF), or customized palatal stents, can significantly reduce postoperative pain, decrease analgesic use, and enhance patient willingness for retreatment. Among these approaches, palatal stents have been associated with the lowest levels of patient discomfort.

From a surgical perspective, the tunnel technique within the sockets is recommended, as it combines the advantages of minimally invasive access with broad flap mobilization. This approach requires careful 2-layer dissection: within the keratinized tissue, the flap is elevated close to the bone to preserve vascular integrity; beyond the mucogingival junction, the dissection shifts to a more superficial plane, following the submucosal vascular network. During tunnel preparation, it is essential to employ a lateral swinging motion, which helps create a uniform platform and facilitates precise insertion of the CTG. When coronal advancement of the soft tissue is required, vertical incisions in combination with the tunnel approach should be considered to enable tension-free flap mobilization. The CTG is then placed into the supraperiosteal envelope flap at the labial site and stabilized to ensure optimal integration, tissue augmentation, and esthetic outcomes (see Fig. 9 I–J).

IIP reduces the number of surgeries and allows immediate restoration, but it does not prevent natural buccal tissue remodeling after extraction. ^, This often leads to midfacial recession, reported in up to 26% of cases at 1 year and 33% at 10 years especially in thin biotypes and sites with limited facial bone. ^, CTG during IIP has been proposed to thicken soft tissues and improve stability. Seyssens and colleagues showed that CTG reduced vertical recession by 0.41 mm and lowered the risk of ≥1 mm asymmetry 12-fold. While no significant effect was found on bone levels, pink scores, or probing depths, CTG consistently enhanced midfacial soft tissue outcomes, particularly in esthetic areas. ^,, A 1-year RCT by Lee and colleagues confirmed improvements in peri-implant tissue thickness, though without full prevention of recession or interproximal bone loss. Despite supportive findings, systematic reviews highlight that more controlled trials are needed to confirm the clinical benefit of CTG with IIP. ^,,

While traditional protocols recommended delayed implant placement into healed ridges, the current body of evidence supports the clinical predictability of placing implants at the time of tooth extraction, often in conjunction with immediate provisionalization. ^,, The International Team for Implantology has formalized this protocol as Type 1A, wherein implant placement and restoration occur on the day of extraction or within 1 week. Patient-centered benefits such as the preservation of hard and soft tissue morphology and improved esthetic outcomes further enhance its appeal. The literature emphasizes the selective use of Type 1A protocols, particularly in the anterior maxilla, where immediate esthetic restoration can significantly benefit the patient’s psychosocial well-being ^, (see Fig. 9 K–L).

Effective tissue conditioning is pivotal to successful implant therapy. The significance of the critical and subcritical zones within the emergence profile has been highlighted in the context of both immediate implant placement and healed ridges. Additionally, the esthetic biological contour (EBC) concept has been introduced, proposing a biologically driven approach to emergence profile design by delineating 3 distinct zones based on peri-implant tissue characteristics and implant positioning. Soft tissues can be shaped using one of 2 provisionalization strategies: full contour provisionalization or subcontoured provisionalization.

The primary distinction between these techniques lies in the interaction of the esthetic (E), bounded (B), and crestal (C) zones with the surrounding soft tissues, which dictates the apical, coronal, or stable positioning of tissue contours. Careful shaping of these zones is critical for predictable outcomes: the C zone should be concave or straight to avoid impingement on hard tissue adjacent to the restoration, which could lead to resorption; the B zone should be concave to provide adequate space for soft tissue proliferation and to accommodate the connective tissue graft when stabilized; and the E zone should be convex to support the gingival margin, typically extending 0.5 to 1 mm beyond the desired soft tissue level. Selection of the appropriate method should be guided by the specific clinical scenario and desired tissue response ^, ( Fig. 10 A-C ). In cases where occlusal considerations pose challenges, a customized healing abutment or tissue former can be combined with an Essix or snap-on provisional restoration to provide continuous transmucosal support, facilitating predictable soft tissue adaptation and a smooth transition to the definitive restoration.

( A ) Soft tissue EBC Fig. 5 . The EBC concept, where E represents the esthetic zone, B the boundary zone, and C the crestal zone—key characteristics of the temporary restoration’s subgingival area. ( B ) Importance of respecting the EBC concept, where concave profiles promote adequate soft tissue thickness, while convex profiles may result in reduced tissue thickness. ( C ) Emergence profile immediately after removal of the temporary implant crown respecting EBC concept.