What Happens During All on X Surgery? A Step-by-Step Look at the Procedure
During All on 4 surgery, the dentist numbs the area, removes any remaining teeth in the arch, places four dental implants into the jawbone — two upright at the front and two angled at the back and attaches connectors called abutments. The gum is then stitched, and in most cases a fixed set of temporary teeth is secured to the implants in the same appointment. Here is what happens at each stage, in detail.
This guide focuses only on the surgery itself, the part that happens once you are in the chair. It is written by Dr Kent Boon, Principal Dentist and Implantologist at Kita Dental in Mascot, Sydney.
Step 1 — Anaesthesia and sedation
Before anything begins, the surgical area is fully numbed with local anaesthetic, so the procedure itself should not be painful. Many patients also choose sedation ranging from light oral or inhalation sedation to deeper IV sedation administered by a trained professional to stay relaxed or drowsy throughout. The level of anaesthesia is agreed with you beforehand and tailored to the case and your comfort.
Step 2 — Removing any remaining teeth
If you still have broken-down or failing teeth in the arch being treated, these are removed at the start of the surgery. The dentist also clears away any infected or unhealthy tissue from the sockets and surrounding gum. Removing the teeth and placing the implants in the same appointment is a defining feature of the All on 4 approach.
Step 3 — Exposing and preparing the bone
The dentist makes an incision along the gum ridge and gently lifts the gum tissue to expose the underlying jawbone. This gives a clear view of the bone the implants will anchor into. Where the ridge is uneven, which is common after teeth have been lost or removed the bone may be carefully smoothed or reshaped (a step sometimes called alveoloplasty) to create a level, stable foundation for the implants and the bridge that will sit on top.
Step 4 — Creating the implant sites
Each implant needs a precisely shaped channel in the bone, called an osteotomy. The dentist prepares these using a sequence of surgical drills that gradually widen each site to the exact diameter and depth planned for that implant. This is done slowly and with cooling irrigation to protect the bone. The position and angle of each channel is guided by the planning done before surgery, and on the anatomy the dentist can now see directly.
Step 5 — Placing the four implants
Four implants are then placed into the prepared sites:
- Two front (anterior) implants are positioned relatively upright in the denser bone at the front of the jaw.
- Two back (posterior) implants are placed at an angle, typically around 30 to 45 degrees tilted towards the back of the mouth.
This is the part of the surgery that makes All on 4 distinctive. Angling the back implants lets them reach areas of stronger, more available bone while steering clear of structures such as the sinus cavities in the upper jaw and the nerve in the lower jaw. It also allows longer implants to be used and spreads the support of the bridge further back along the jaw often without the need for bone grafting.
Step 6 — Checking that the implants are stable
As each implant is placed, the dentist checks how firmly it grips the bone. This initial firmness is called primary stability, and it matters a great deal: it determines whether a fixed set of temporary teeth can safely be attached on the same day. If an implant is very stable, immediate temporary teeth are usually possible. If the bone is softer than expected and stability is limited, the dentist may choose to let the implants heal first before attaching teeth, part of the reason Kita Dental works to a staged protocol rather than promising teeth on the day in every case.
Step 7 — Attaching the abutments
Small connectors called multi-unit abutments are screwed onto the top of each implant. Because the back implants are tilted, angled abutments are used to redirect them, so all four connection points line up correctly and the bridge can seat evenly. These abutments are what the temporary and the final teeth attach to.
Step 8 — Closing the gum
The gum tissue is repositioned around the abutments and secured with sutures. These are placed to support healing around each implant. Depending on the type used, the sutures either dissolve on their own or are removed at a later review.
Step 9 — Taking the records for your temporary teeth
To make the fixed temporary bridge fit accurately, the dentist captures the position of the implants using either a physical impression or a digital scan, along with your bite. In many clinics this is sent to an on-site or partner laboratory so the temporary bridge can be prepared while you are still in the chair or shortly afterwards.
Step 10 — Fitting the fixed temporary teeth
In most cases, a fixed set of temporary teeth is then secured onto the abutments before you leave. These let you smile and function during healing but they are not the final result. The permanent set is made and fitted later, once the implants have fully integrated with the bone. The dentist checks and adjusts your bite so the temporary teeth meet evenly before the appointment ends.
Note: All on 4 uses a two-stage approach; temporary teeth first, final teeth after healing. Same-day teeth are temporary, not permanent.
How long does All on 4 surgery take?
Surgery for a single arch commonly takes around two to three hours in the chair, depending on how many teeth need to be removed, the condition of the bone, and the complexity of the case. Treating both arches in one visit takes longer.
Are you awake during All on 4 surgery?
That depends on the sedation chosen. Under local anaesthetic alone you are awake but the area is numb. With sedation, you may feel drowsy, deeply relaxed, or have little memory of the procedure. The approach is decided with you in advance, based on the case and your preferences.
Does it hurt during the surgery?
The procedure is carried out under local anaesthetic and often sedation, so you should not feel pain while the implants are being placed. You may feel pressure or vibration at times, but not sharp pain. Discomfort after the anaesthetic wears off is a separate matter and is managed with appropriate pain relief.
Written by Dr Chin Kent Boon
28 July 2026
All on X treatments at Kita Dental are led by Dr Kent, Principal Dentist and Implantologist, who holds a Master of Oral Implantology. Kita Dental is a dental clinic located in Mascot, NSW, with a strong focus on dental implants.
This article is general information only and is not a substitute for personalised advice from a registered dental practitioner. Outcomes vary from patient to patient.
