Purpose <p>In immediate implant placement, both open and closed healing techniques are used, but their comparative esthetic and tissue stability outcomes remain under debate. This study aimed to evaluate and compare these two approaches to support clinical decision-making.</p> Methods <p>In this prospective, randomized controlled trial, 46 patients received a total of 48 implants, assigned to either an open healing group (<i>n</i> = 25) or a closed healing group (<i>n</i> = 23). Clinical and radiological assessments were conducted at three time points: T1 (pre-extraction), T2 (3 months post-op), and T3 (12 months post-op). The primary endpoint was the Pink Esthetic Score (PES), which assesses seven soft tissue parameters. Secondary endpoints included implant survival and volumetric tissue changes. PES was analyzed using a linear mixed-effects model.</p> Results <p>The open healing group showed significantly higher PES outcomes compared to the closed healing group (mean difference: -1.49; 95% CI: [-2.36, -0.62]; <i>p</i> = 0.0014). A higher baseline PES was also significantly associated with better esthetic outcomes at follow-up (0.3638, 95% CI: [0.1890, 0.5386], <i>p</i> = 0.0002). Smoking had no significant effect. Volumetric analysis revealed soft tissue volume loss from T1 to T2, with partial recovery by T3. Although the open healing group showed slightly less volume loss, this was not statistically significant. No implant losses occurred in either group.</p> Conclusion <p>The study demonstrated esthetic advantages of the open healing technique compared to the closed healing technique in immediate implant placement.</p>