Guided surgery for All-on-6: placing implants from a 3D plan

From scan to plan

Every good All-on-6 begins with a 3D picture of the jaws. The British Society of Periodontology describes the assessment as including clinical examination and images such as X-rays and scans. For full-arch implants, that usually means a CBCT scan, a type of 3D X-ray that shows the bone's height, width and density, and where the nerve in the lower jaw and the sinuses in the upper jaw lie.

Using planning software, the surgeon places virtual implants on the scan: deciding their length, width, angle and position, and checking how they relate to the planned teeth. This is where much of the thinking in All-on-6 happens. What happens next is the difference between guided and freehand surgery.

What guided surgery is

In static guided surgery, the virtual plan is turned into a surgical guide: a rigid template, usually 3D-printed, that fits over the teeth, gum or bone. Metal sleeves in the guide direct the drill at the planned angle and depth. The implants go in where they were planned on screen.

There are also newer approaches: dynamic navigation, where a camera tracks the drill in real time against the plan on a screen, and robot-assisted placement. These are less widely available.

In freehand surgery, the surgeon uses the 3D plan as a map but places the implants by hand, judging position directly in the mouth. Experienced surgeons often combine approaches, for example using a guide for the first drilling and adjusting by eye.

How accurate is it?

A 2018 systematic review and meta-analysis, part of an international consensus in implant dentistry, looked at the accuracy of static guided surgery. It pooled 20 clinical studies with 2,238 implants in 471 patients and found average deviations from the plan of:

The authors concluded that accuracy is within a clinically acceptable range in most situations, but advised a safety margin of at least 2 mm from important structures. They also found accuracy was significantly better in partly toothed jaws than in fully toothless jaws, because remaining teeth hold the guide steadier than gum alone. A 2024 meta-analysis compared static, dynamic and robot-assisted surgery; all three were studied as ways of improving on freehand placement.

Why a few millimetres matter

In the lower jaw, the inferior alveolar nerve runs through the bone and supplies feeling to the lower lip and chin. A 2025 systematic review found that implants placed 1 mm or more from the nerve canal had no recorded sensory problems in the included studies, while implants placed closer than 1 mm, or intruding into the canal, had high rates of altered sensation. In the upper jaw, the sinuses are the main structure to respect. These are the situations where accurate planning, guided or not, pays off. See the lower jaw nerve and the upper jaw sinus.

Guides in All-on-6: what is different

All-on-6 often involves removing teeth and sometimes reshaping the bone on the same day. That makes guided surgery more complex than for a single implant:

• Guide support changes: if the guide rests on teeth that are about to be removed, a sequence of guides may be used.
• Bone reduction: some plans reduce the bone ridge first to create a flat platform, and a bone-supported guide is then used.
• Fully toothless jaws: guides rest on the gum or bone and are pinned in place; accuracy is lower than in jaws with teeth.
• Preparing teeth in advance: knowing the planned implant positions lets the temporary bridge be prepared before surgery, which can help same-day teeth. See same-day teeth.

Guided or freehand: which is better?

Neither is automatically better. Guided surgery offers predictability, particularly where bone is limited and margins are tight. Freehand placement lets an experienced surgeon adapt to what they see once the gum is open, for example bone that is softer or narrower than the scan suggested. Many surgeons use both, depending on the case.

What matters more than the method is that there is a careful 3D plan, that the surgeon is experienced in full-arch work, and that the plan respects safe distances from nerves and sinuses.

Questions to ask

• Will you plan my implants on a 3D scan, and can I see the plan?
• Will you use a surgical guide, freehand placement, or both?
• How close are my nerve and sinuses to the planned implants?
• If the bone looks different on the day, how might the plan change?

The full sequence of treatment is on how All-on-6 works, and what happens in the chair on surgery day.

What the 3D plan should show you

Whether or not a guide is used, the plan made on your CBCT scan is worth seeing. A good plan usually shows, for each implant, its position along the arch, its length and width, its angle, and its distance from the nearest important structure: the nerve canal in the lower jaw or the sinus floor in the upper jaw. It may also show where the teeth of the future bridge will sit, because implants are best placed to support the teeth, not just wherever bone happens to be. This approach, sometimes called prosthetically driven planning, is one of the main benefits of planning digitally.

You don't need to understand every number. But asking a surgeon to walk you through the plan is a good way to understand your treatment and to see how carefully it has been thought through.

Limits of guided surgery

• The plan is only as good as the scan. Movement during the scan, metal fillings or old crowns can blur the image.
• Guides can move. A guide resting on gum can shift slightly, which is one reason accuracy is lower in toothless jaws.
• Mouth opening matters. Guides and long drills need room. People with limited opening may not be suitable for some guided systems, especially at the back.
• Bone surprises. The bone may be softer or narrower than the scan suggested, and the surgeon may need to adapt.

For these reasons, the 2018 review's advice of a safety margin of at least 2 mm from important structures applies even when a guide is used.

Guided surgery and recovery

When guided surgery allows implants to be placed through small openings in the gum, without lifting a flap, recovery can be gentler, with less swelling. In All-on-6, though, teeth are often removed and the bone ridge may be shaped at the same appointment, so the gum is usually opened anyway. Recovery is then similar whether or not a guide was used. Our recovery guide describes what to expect.

Digital planning and the temporary bridge

One practical advantage of planning digitally is that the temporary bridge can be designed and made before surgery, based on where the implants are planned to go. That can make it quicker to fit fixed temporary teeth after surgery, when immediate loading is possible. See temporary teeth.

Common questions

Is guided surgery better than freehand?

It can make placement more predictable, especially when bone is limited or important structures are close. Experienced surgeons also place implants accurately freehand, using the 3D plan as a reference. What matters most is careful planning from a 3D scan.

Does guided surgery hurt less?

Sometimes guided surgery can be done with smaller openings in the gum, which may mean less swelling. In All-on-6 with extractions, the gum is often opened anyway, so the difference may be small.

Can a guide be used if I still have teeth?

Yes. Guides can rest on remaining teeth, on the gum or on the bone. Teeth give the most stable support, which is one reason accuracy is better in partly toothed jaws.

Does guided surgery mean same-day teeth?

Not automatically. Whether teeth can be fitted on the day depends on how firm the implants are, not how they were placed. Guided planning can, however, help prepare the temporary bridge in advance.

Will my plan say whether a guide is used?

Ask. It is a reasonable question, as is asking to see the 3D plan.

Sources

1. Tahmaseb et al. (2018), Clin Oral Implants Res — The accuracy of static computer-aided implant surgery: systematic review and meta-analysis
2. Accuracy of static, dynamic and robot-assisted implant surgery: systematic review and meta-analysis (2024), BMC Oral Health
3. Peña-Cardelles et al. (2025), Med Oral Patol Oral Cir Bucal — Inferior alveolar nerve damage related to implant placement
4. British Society of Periodontology — Patient FAQs: dental implants (assessment with x-rays and scans)

Checked October 2026. Where we give our own view as a clinic, we say so.