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Immediate, Early or Late in the Aesthetic Zone?

What is the best protocol for implants in the Aesthetic Zone?

When dealing with implants in the Aesthetic Zone, one might be confronted with a lot of choices. Different surgical protocols are presented all the time, from immediacy to socket shield or partial extraction, to early placement with GBR, or late placement. And on top we might have to consider in-between choices such as ridge preservation, soft tissue augmentations with Connective Tissue or different types of Xenografts and more. Finally the restorative protocols are very much intermingled with our surgical choices and the timing and type of the provisional restoration will bring another critical set of decisions! What is the best protocol to follow? Is there really a golden standard?

Whether the timing of surgical protocol, the management options of soft and hard tissue and the choices of the restorative pathway, all decisions are intermingled! Each choice affect every other aspect and should all be part of a strategic plan :)

Do not generalise - individualise!

The truth is that all the above and many more are valid protocols, many of them with significant evidence base. Nevertheless, they all have limitations, indications and contraindications. Nothing works for everyone in every case and the real mastery is to plot the right path for the patient in front of you, combining the most suitable protocols and techniques!
Successful implant therapy in the aesthetic zone is the sum of two important parametres:

- First, decision making! One will have to successfully navigating the many protocols we have and select the best combination for the individual patient! From immediacy to early or late placement, immediate temporisation or loading, and all restorative designs and pathways.
- Second, one will have to master the respective techniques, from bone and soft tissue augmentations, GBR, two stage augmentations and tissue conditioning with provisional restorations and more.

Master Decision Making - Master the Techniques!

This video is a final reflection from one of our latest online courses and sums up in a few seconds the decision making tree in the aesthetic zone. It reviews the major "checkpoints" and offers some hints of how to prioritise among the many complex choices in a simple "navigation" chart!

Immediacy in the aesthetic zone will be very different if the technique is flapless than when a flap is used. A ridge preservation would preserve the clinical volume of the alveolar ridge but will delay the implant placement and might compromise the quality of the tissue we will have available. Early placememt with GBR will present with significant challenges in terms of remaining bone but might offer the best conditions to control the bone, but might  offer very good "buffer" of soft tissues for surgical manipulations. two stage augmentations will slow down the treatment, but might be inevitable in certain compromised anatomies. Submerged or transmucosal healing is another important choice that can help us improve soft tissue outcomes when properly utilised. And then comes the restorative choices, where removable and fixed provisional restorations will offer another set of advantages or limitations...
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