Tooth extraction initiates a well-documented cascade of biological remodeling, often leading to significant dimensional changes in the alveolar ridge (Araújo et al. 2005; Araújo et al. 2015). These alterations are strongly influenced by the thickness of the buccal bone (Chappuis et al. 2013). A wide variety of approaches have been developed to mitigate this tissue collapse, ranging from grafting and membrane placement to guided bone regeneration and soft tissue augmentation (Noelken et al. 2018; Tavelli et al. 2021; Puisys et al. 2022; Romito et al. 2022; Canullo et al. 2022). While many of these strategies have shown benefits, their stability and predictability remain inconsistent and are highly dependent on surgical skill, patient anatomy, and procedural timing (Seyssens et al. 2020; Buser et al. 2013).

Immediate implant placement has emerged as an appealing option in well-selected cases, as it may reduce treatment time for the patient (Van Nimwegen et al. 2016; Wittneben et al. 2023). However, achieving stable hard and soft tissue outcomes in such scenarios does not depend on the timing of implant placement but rather on the timing of the implant restoration (Gallucci et al. 2018). Mucosal recession, flattening of the emergence profile, and the loss of facial gingiva are frequent complications when peri-implant soft tissues are not adequately supported during healing (Block et al. 2009; Pitman et al. 2022; Siegenthaler et al. 2022). Standard stock healing abutments, although widely used, offer limited biological or prosthetic benefit in this context, as they neither preserve mucosal architecture nor contribute meaningfully to the formation of an optimal emergence profile (Amato et al. 2022). In the anterior zone this can be avoided by using an immediate implant provisional after implantation, which has been demonstrated to preserve the peri-implant mucosa after the tooth is extracted, significantly improving the esthetic result (Van Nimwegen et al. 2016; Yan et al. 2016).

Being able to perform immediate loading on an immediately placed implant can be challenging due to the limited quantity of available bone in an extraction socket (Todorovic et al. 2023). Primary stability plays an important role in all implantation protocols, but for immediate implant placement combined with immediate loading it is a conditio sine qua non. Primary stability is a binary outcome which cannot be quantified per se and is either present or absent (Roberts et al. 1984; Brunski 1993; Szmukler-Moncler et al. 1998). However, the insertion torque, measured in Ncm, and resonance frequency analysis (RFA) are usually employed to quantify the stability of an implant after placement (Walker et al. 2011; Lages et al. 2018; Monje et al. 2019; Feher et al. 2021). When it comes to quantifying the necessary stability for immediate implant placement, there is no current consensus. For immediate loading, an arbitrary threshold of 35 Ncm has been widely accepted, although this is not based on evidence, but rather on recommendations from implant manufacturers (Aniuta et al. 2016; Abi-Aad et al. 2019; Trimpou et al. 2022; Wigl et al. 2016). Therefore, when this threshold of insertion torque is not met, immediate loading might be contra-indicated. At the same time, immediate implants in the molar sector have been frowned upon for the longest time. This is partly due to the fact that immediate restoration in the posterior region is inherently more risky than in the anterior because the patient’s occlusion and applied forces to the area are much more difficult to control during the initial healing phase (Roccuzzo et al. 2009). On the other hand, the literature did not report the same success rates for posterior immediate implants as for anterior immediate implants and also not the same success rates as for delayed implant placement protocols, which are still the standard of care to date (Gallucci et al. 2018; Zhou et al. 2021). The reason for these lower success rates comes from a more historic approach to immediate implant placement, in which wide diameter implants were used to occupy a large aspect of the extraction socket, oftentimes raising a full thickness flap to extract the tooth and place the implant (Prosper et al. 2010; Tallarico et al. 2017). In an attempt to offer a solution for both the molar sector as well as anterior implants with an insertion torque below the threshold of 35 Ncm, more contemporary approaches like the sealing socket abutment (SSA) have been proposed for the initial healing period (Alexopoulou et al. 2021; Elgendi et al. 2025; Fernandes et al. 2021; Finelle & Lee 2017; Finelle et al. 2021; Lilet et al. 2022).