## 4 Discussion  
Immediate post-extraction implantation certainly raises numerous questions regarding positive outcomes, especially in the long term. In the literature, the possibility of resorption of the alveolar process occurring within 5 years of implant placement has been described, with the inevitable exposure of the first implant threads and the consequent onset of mucositis and peri-implantitis if the problem remains unresolved [35]. This also has major repercussions in terms of the aesthetics of anterior implants. Other authors have not considered inserting the implant immediately after tooth extraction to be useful for maintaining the alveolar process. Today, the primary objective when positioning an immediate post-extraction implant with provisionalization is to obtain an optimal aesthetic result through maintenance or reconstruction of hard and soft tissues [36]. The immediate placement of an implant, in itself, does not avoid the resorption of hard tissues and the consequent change in soft tissues [33]. Various techniques have therefore been proposed to address this problem, which differ based on the presence or absence of the vestibular cortex. We are faced with two completely different situations: if the cortex is present, we have to counteract its  
Figure 8: CBCT Cases 1–7 Preop (**upper**) & Postop (**down**). Figure 9: CBCT Cases 8–14 Preop (**upper**) & Postop (**down**). reabsorption, and if it is absent, we will have to rebuild it instead. It is not obvious whether it is easier or more predictable to prevent resorption than to reconstruct a lost cortex. The mere insertion of biomaterial inside the alveolus has raised questions about the effectiveness of the graft in maintaining the alveolus, and even if it is maintained, questions are raised about the real quality in terms of regenerated, well-functioning, and revascularization bone. This is an aspect that, in the long term, raises questions about the actual functional permanence of the tooth-implant system immersed in bone mixed with non-resorbed material [34,37]. In 2010, the socket-shield technique was proposed for the first time, in which immediate implant placement is associated with maintaining a buccal portion of the root with its periodontal ligament. This technique, which provides for the insertion of a biomaterial in the event of a large root implant gap, has shown very encouraging results in terms of both the maintenance of hard tissues and the architecture of soft tissues. In 2019, the periosteal inhibition technique was published. With this technique, the goal is no longer to fill the residual gap to compensate for the resorption of cortical bone, but to mechanically prevent it by using a d-PTFE sheet placed in the external portion of the extraction socket. Preosteoclasts from the vessels of the deep periosteum seek contact with the bone wall, and only after bonding with the cortical plate can these cells merge to form osteoclasts, which are then able to resorb the buccal bone. For the first time, there is a technique that aims to avoid osteolytic activity outside the extraction socket. Periosteal inhibition can be associated with the immediate placement of an implant; however, this requires removing the d-PTFE sheet in a second surgical phase after 4 months. Both the socket shield and periosteal inhibition techniques are indicated for sockets with a completely intact buccal wall. In the case of a total absence of the buccal plate, the multi-layer technique (MLT), which was proposed in 2021, can be used. After immediate insertion of the implant, this technique involves taking a connective graft from the palate and placing 0.5 mm Soft lamina and biomaterial in the gap between the fixture and the lamina. The Flex or Soft cortical plate, of heterologous origin (equine or porcine), is completely biocompatible and does not require a second surgery, since it integrates to replace the missing buccal wall.