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I m m e d i a t e i m p l a n t s i n t h e e s t h e t i c a r e a Immediate placement of dental implants in the esthetic zone Clinical criteria 1 . I n d i c a t i o n s Tooth extraction normally causes a remod- eling process of the alveolar ridge, which normally follows a healing pattern with a dimensional shrinkage of the ridge in both shape and volume.1–3 Thus, as a consequence of the natural healing events, implant place- ment to restore the missing tooth might be limited because of loss of the adequate amount of bone and because of the absence of the ideal volume of the residual ridge.1–3 Several surgical procedures have been pro- posed to preserve or improve the volume of the alveolar ridge after a tooth extraction. Among the several available treatment options to manage a fresh extraction socket, immediate implant placement has been a debated issue in the last 25 years. During a consensus conference in 2003, Chen et al. established that immediate implants showed predictable outcomes in terms of survival rates that were similar to those of implants placed in healed ridges. 4 These authors pointed out the need to better clarify the long-term esthetic outcomes for immediate implants. 4 Moreover, the same authors observed that there was an absence of a clear classification, according to the timing of implant placement in extraction sockets. 4 Thus, different authors 5, 6 have well clarified how to classify the timing for implant place- ment, in an extraction socket; nowadays, the terms “immediate,” “early” and “delayed” in relation to implant placement are universally accepted and recognized. Several publica- tions have reported negative esthetic out- comes associated with immediate implant placement, such as gingival recession, higher marginal bone loss and interdental papillae loss. 5, 7, 8 According to Buser et al., immediate implant placement in the esthetic area accounts for only 5–10% of cases, and for the rest, a different approach should be chosen, mostly early placement with hard-tissue healing (12–16 weeks), so for this reason, the clinician should develop the ability to both identify and successfully treat these few cases. 9 The aim of this review paper is to report the most debated points in the litera- ture and the clinical approach that could be considered predictable in terms of implant functional and esthetic implant success. Immediate implant placement is certainly a delicate technique that requires experience and accurate case selection, based on certain indi- cations, in order to achieve optimal results. The 3-D positioning of an immediate implant, which will be discussed later in this article, requires that the bone housing should allow for a palatal/lingual placement and a sufficient buccal bone thickness that guarantees support for the facial soft tissue, thus decreasing the risk of facial mucosal recession. When a buccal alveolar bone thickness amounts to less than 2 mm, its integrity is at risk of fenestration, dehiscence and soft-tissue recession.10, 11 Also, a possible immediate restoration of the immediate implant should be based on the meas - urement of ISQ (Implant Stability Quotient), the value of which has to be more than 62.12 In order to summarize the indications for immediate implant placement in a short check- list that is easy for the clinician to follow, it can be suggested that the decision in favor of this technique should be made when the operator is facing these local clinical scenarios: integrity of buccal bone wall and absence of soft-tissue recession immediately after tooth extraction, presence of adequate interdental bone around adjacent teeth and presence of bone beyond the tooth apex to allow good implant stability. More- over, the reasons for tooth extraction should be carefully evaluated when considering immediate implant placement, with the aim of identifying clinical conditions that could relatively contra- indicate immediate implant placement. For example, tooth trauma, which is commonly associated with a fracture of the buccal bone plate; and periodontal disease, which is com- monly associated with interdental bone loss, could represent relative contraindications to immediate implant placement (Figs. 1 & 2). The presence of an acute infection, lack of bone beyond the tooth apex, proximity to anatomical vital structures and absence of local ideal clinical conditions should be considered as full contra- indications to immediate implant placement. Finally, it should be underlined that the expe- rience of the clinician is a fundamental factor in the execution of this delicate technique. The esthetic outcomes can be compromised by the inexperience of surgeons, especially when the implants are placed in esthetic areas.13 Journal of Oral Science & Rehabilitation Volume 4 | Issue 1/2018 17