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Digitising your implant practice

CBCT volume to aid in planning for mandibular implant placement. (Image: Dr Ross Cutts)

Dr Ross Cutts

Thu. 3. May 2018

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Undoubtedly, digital dentistry is the current topic. Over the last five years, the entire digital workflow has progressed in leaps and bounds. There are so many different digital applications that it is sometimes difficult to keep up with all the advances. Many dentists are excited about the advantages of new technologies, but there are an equal number who doubt that the improved clinical workflow justifies the expense.

I have many times heard the argument that there is no need to try to fix something that is not broken. It is so true that impressions have their place and there are certainly limitations to the digital workflow that anyone using the technology should be aware of. For me, however, the benefits of digital far outweigh the disadvantages. In fact, the disadvantages are the same as with conventional techniques.

Chairside CAD/CAM single-visit restorations have been possible for over 20 years, but it was only recently that we became able to mill chairside implant crown restorations after the release of Variobase (Straumann) and similar abutments. I made my first CEREC crown (Dentsply Sirona) back in 2003 with a powdered scanner, and the difference from what I remember then to how we can make IPS e.max stained and glazed restorations (Ivoclar Vivadent) now is amazing.

An investment not an expense

The results of a survey regarding the use of CAD/ CAM technology were published online in the British Dental Journal on 18 November 2016. Over a thousand dentists were approached online to take part in the survey and the 385 who replied gave very interesting responses. The majority did not use CAD/CAM technology, and the main barriers were initial cost and a lack of perceived advantage over conventional methods.

Thirty per cent of the respondents reported being concerned about the quality of the chairside CAD/CAM restorations. This is a valid point. We must not let ourselves lose focus that our aim should always be to provide the best level of dentistry possible. For me, digital dentistry is not about a quick fix; it is about raising our performance and improving predictability levels by reducing human error.

In the survey, 89 per cent also said they believed CAD/CAM technology had a major role to play in the future of dentistry. I really cannot imagine that once a dentist has begun using digital processes that he or she would revert to conventional techniques.

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What is digital implant dentistry?

Many implant clinicians have probably been using CAD/CAM workflows without even realising it, as many laboratories were early adopters, substituting the lost-wax technique and the expense of gold for fully customised cobalt–chromium milled abutments (Fig. 1).

One of my most important goals in seeking to be a successful implantologist is to provide a dental implant solution that is durable. We have seen a massive rise in the incident of peri-implantitis and have found that a large proportion of these cases can be attributed to cement inclusion from poorly designed cement-retained restorations (Fig. 2). Even well designed fully customised abutments and crowns can have cement inclusion if the restoration is not carefully fitted (Fig. 3). This has led to a massive rise in retrievability of implant restorations, with screw-retained crowns and bridges now being the goal. However, making screw-retained prostheses places even greater emphasis on treatment planning and correct implant angulation.

With laboratories as early adopters, we have been milling titanium or zirconia customised abutments for over ten years (Fig. 4). What has changed recently in the digital revolution is the rise of the intraoral scanner. We now have a workflow in which we can take a preoperative intraoral scan and combine this with a CT scan using coDiagnostiX (Dental Wings) in order to plan an implant placement accurately and safely. We can also create a surgical guide to aid in accurate implant placement, have a temporary crown prefabricated for the planned implant position and then take a final scan of the precise implant position for the final prosthesis.

Accuracy of intraoral scanners

Figures 4 to13 show the workflow for preoperative scanning, which includes the implant design, guide fabrication and surgical placement of two fixtures. Intraoral scanners have improved over the last few years, and their accuracy and speed provide a viable alternative to conventional impression taking. The digital scan image comes up in real time and you can evaluate your preparation and quality of the scan on the screen immediately. Seeing the preparation blown up in size no doubt improves the technical quality of your tooth preparations. The scan can then be sent directly to the laboratory for processing.

While we do not think of intraoral scanners as being any more accurate than good-quality conventional impressions, there are many benefits of scanning, such as no more postage to be paid for impressions, vastly reduced cost of impression materials, almost zero re-impression rates and absolute predictability.

Of course, there are steep learning curves with the techniques, but once a clinician has learnt the workflow, there really is no looking back.

We have three different scanners in the practice: the iTero (Align Technology), the CEREC Omnicam (Dentsply Sirona) and the Straumann CARES Intraoral Scanner (Dental Wings; Fig. 14). The CEREC Omnicam is fantastic for simple chairside CAD/CAM restorations, such as IPS e.max all-ceramic restorations on Variobase abutments. For truly aesthetic results, we, of course, still have a very close working relationship with our laboratory, but, undoubtedly, patients love the option of restoration in a day. Being able to scan an implant abutment and then an hour later (to allow for staining and glazing) fitting the definitive restoration is a game changer. Patients also love watching the production process as they see their tooth being milled from an IPS e.max block.

Figures 15–19 show the production process, including the exposure of the implant, the abutment seating, the scan flag on top of the abutment, the healing abutment during fabrication and the delivery of the final prosthesis. However, for more than single units or aesthetic single-unit cases, we use the iTero and Straumann scanners. The latter we have only had at our disposal since February. While it is a powdered system at the moment, this is due to change this month. Particularly with implant restorations, the need to apply a scanning powder is a limitation, owing to a lack of moisture control contaminating the powder. The technology, however, is superb, as is the openness of the system, which provides the advantage of being able to export files into planning software. A colleague of mine even uses it for his orthodontic cases now instead of wet impressions.

We invested in the iTero scanner five years ago and have used it for everything, from simple conventional crowns and bridges to scanning for full-mouth rehabilitations. When fabricating definitive bridgework, we use Createch Medical frameworks for screw-retained CAD/CAM-milled titanium and cobalt–chromium frameworks. Even though intraoral scanning appears extremely reproducible and accurate, I still use verification jigs where needed to ensure our frameworks are as accurate as possible. There are many intricacies that we consider and tips and techniques that we employ to make the scans more accurate that we have developed over time. The closer the scanbodies are together, the more accurate the scan is. Also, the more anatomical detail, such as palatal rugae or mucosal folds, the better the scans can be stitched together.

Figure 20 shows a CBCT volume to aid in planning for mandibular implant placement (Fig. 21) and realising the implant placement. We exposed the fixtures and placed Straumann Mono Scanbodies (Fig. 22). Then, we took an iTero scan of the fixtures in situ (Fig. 23) and made a verification jig from this (Fig. 24) to ensure passive implant positioning. The iTero models were made (Fig. 25) and a Createch titanium framework was used to support porcelain in a screw-retained design (Fig. 26). The last two figures show the excellent outcome and accurate framework seating (Figs. 27 & 28).

Choosing your workflow

There are many different systems on the market now, each offering a one-stop shop. If you are considering investing in a digital scanner, then take some advice from colleagues. One of the most important things is to ensure the system you opt for is an open one that allows you to extract the digital impression data into different software. We extract our files into CT planning software, model production software, chairside milling for stents, temporaries and definitive restorations, and now orthodontic planning software. I am convinced there will be yet more advances with time. The size of the camera is critical—some can be very cumbersome—and it is worth asking the salesperson what developments are underway.

Some companies are more on the cutting edge than others. My favourite at the moment is the Straumann scanner. Its design is light and user-friendly and it synchronises perfectly with implant planning software coDiagnostiX. Furthermore, while it offers a chairside milling unit, it also synchronises perfectly with my laboratory for larger cases.

To conclude, digital implant dentistry is the future and so why not take advantage of it and help improve your clinical outcomes?

Editorial note: A list of references is available from the publisher. This article was published in CAD/CAM - international magazine of digital dentistry No. 03/2017.

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According to Lina Craven, true excellence in a practice is not defined by the moments that attract attention, but by the consistency and care embedded in everyday routines that quietly shape the patient experience. (Image: GoodIdeas/Adobe Stock)

Lina Craven

Mon. 11. May 2026

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Most practices believe that excellence is built through outcomes—achieved through technology, innovation, reputation or visibility. In reality, excellence is far more ordinary and far more unforgiving. It is built in the everyday moments that no one measures or celebrates—moments that seem too small to matter, too routine to document and too familiar to question. Yet these moments quietly define a practice’s identity long before patients consciously evaluate it—not in the cases showcased or the results published, but in how the practice behaves when nothing out of the ordinary seems to be happening.

This is where excellence either takes hold or quietly erodes. Excellence is not an ambition; it is a pattern. Practices rarely fail because they lack ambition—almost every practice wants to be excellent. They fail when their daily behaviour does not match their stated standards. Excellence is not created in vision statements, strategic plans or annual goals; it is created on ordinary days, under ordinary pressure, through repeated interactions between people who are busy, distracted and human.

Tuesday mornings matter more than planning days. Handovers matter more than mission statements. Everyday decisions matter more than big intentions. Patients never see these moments directly, but they experience their outcomes every time they interact with the practice—through clarity or confusion, calm or tension, confidence or inconsistency. The practices that stand out are rarely extraordinary; they are consistent.

The first interaction sets the tone for the day and is rarely with a patient. It is with the team. How the day begins—proactively or reactively—sets the emotional and operational standard for everything that follows. A rushed start creates reactive behaviour. A disorganised start creates inconsistency. A tense start creates ripple effects faster than most leaders realise.

This is why staff meetings, huddles and informal checkins matter far more than their agenda suggests. They are not administrative necessities; they are cultural signals. In strong practices, meetings create clarity. In weaker ones, they recycle problems without resolution or drain energy instead of creating momentum. The difference is not time. It is leadership. If alignment is optional at the start of the day, excellence becomes optional for the rest of it.

Language shapes perception

Language inside the practice determines behaviour. The language used by leadership and within the team shapes behaviour towards patients. The way expectations are communicated internally shapes how confidently teams communicate with patients. The way feedback is delivered internally determines how responsibility is handled in patient interactions.

Unclear language does more damage than open conflict. It normalises confusion and leaves expectations undefined. Effective practices replace vagueness with precision. Instead of “You know what I mean”, say:

“Let me be specific about what I’m asking for.”
“Here is what ‘good’ looks like in this situation.”

Instead of “We’ll deal with it later”, say:

“This needs a decision. Let’s agree on it now.”
“We won’t resolve this today, but this is who is responsible for it and when a decision will be made.”

Instead of “That’s just how it is here”, say:

“This is our current standard, and we’re open to improving it.”
“If this no longer serves the practice, we need to address it.”

Why this language works

Clear language creates safety. Safety encourages ownership. Ownership supports consistency—and consistency is what patients recognise as excellence.

This is less about scripting and more about precise communication. When expectations are explicit and the reasons behind them are understood, people act with greater confidence and less defensiveness. Excellence does not require politeness; it requires clarity.

“Patients do not experience what you intend; they experience what you deliver.”

Consistency is the true luxury

Patients do not experience what you intend; they experience what you deliver. What they trust is delivery that holds up over time—consistency. Consistency is often mistaken for rigidity, but it is the result of structure, and structure is not about control; it is about relief. Clear roles are not restrictive; they are stabilising.

When team members know what they are responsible for, who decides what, and when to escalate and when to act, they stop second-guessing themselves. Errors decrease, confidence increases and tension drops. Ambiguity is expensive. It leads to duplication, frustration and mistakes that feel personal rather than procedural.

Practices that excel do not rely on strong personalities or heroic effort. They reduce ambiguity through clear roles, clear decisions, and clear escalation so that excellence becomes repeatable, regardless of who is working on a given day. That consistency is felt immediately by patients, even if they cannot articulate why.

The invisible moments matter most

What defines a practice is not how it performs when things go well but how it responds when they do not. Mistakes happen, days unravel, pressure builds. In those moments, the practice’s response—not the problem—reveals the practice’s culture:

Is the issue addressed or avoided?
Is feedback specific or softened into vagueness?
Is accountability supported or personalised as blame?

Feedback is one of the most revealing interactions in any practice. Where feedback is avoided, excellence becomes fragile. Where feedback is inconsistent, standards drift. Where feedback is judgemental, trust erodes quietly.

Strong practices are not conflict-free; they are conflict-capable. They address issues early, calmly and directly—not to control behaviour but to protect standards. Excellence does not require perfection. It requires responsiveness.

Trust is built between appointments

Trust is not built through reassurance; it is built through follow-through. Internally, trust grows when concerns raised in meetings are addressed, decisions are explained and communication loops are closed. Nothing damages credibility faster than conversations that have no outcome. Staff notice what happens after the discussion ends, after the promise has been made, after the issue has been raised.

Patients experience the result of this internal trust indirectly: a confident team speaks with assurance; a supported team stays calm under pressure and an aligned team delivers a smoother experience. Trust is felt emotionally, but it is built operationally, and practices that excel do not rely on memory or goodwill but create systems that ensure that action follows conversation.

The patient experience mirrors the team experience

A practice cannot display calm externally while operating in chaos internally. Empathy cannot be required without support; professionalism cannot be expected without clarity and excellence cannot be sustained without investment in the team experience. Training is often reduced to competence, but competence alone does not create excellence—alignment does. Teams need more than instruction; they need context for decisions, clarity of expectations and consistency in standards.

Context for decisions
Teams must understand why decisions are made, not only what is decided. Without context, even sound decisions feel arbitrary. With context, teams can adapt, prioritise and act with confidence as situations change.

Clarity of expectations
Unspoken or shifting expectations create hesitation. Clear expectations create momentum. When teams know exactly what is expected and what success looks like, second-guessing disappears and consistent performance follows.

Consistency in standards
Standards that collapse under pressure are not standards. What is expected on a quiet day must still apply on a difficult one. Consistency removes uncertainty and builds trust—internally and externally.

When training focuses only on tasks, people comply; when it focuses on understanding, people engage. Practices that neglect the team experience ultimately compromise the patient experience—not through lack of care but through fatigue—because excellence requires energy, and energy requires support.

“Excellence is not avoiding tension. It is managing it well.”

Dealing with difficult situations, not difficult patients

There are no difficult patients; there are unmanaged situations. Most challenges arise from:

poor expectation setting;
inconsistent communication;
unclear boundaries; and
fragmented systems.

Practices that label patients as difficult often avoid examining their own processes. Strong practices do the opposite. They prepare teams for complexity. They define escalation pathways. They support staff when boundaries are tested. They remove emotion from response and replace it with structure.

When teams know how to respond, they remain calm. When they feel supported, they remain professional. When situations are handled consistently, trust is preserved even under pressure.

Excellence is not avoiding tension. It is managing it well.

Leadership lives in the everyday

Leadership is not revealed in vision statements; it is revealed in what is tolerated. What is allowed to continue becomes culture—standards not being met, conversations being avoided, rules being enforced inconsistently.

These moments shape behaviour more powerfully than any policy. The strongest leaders are not the most charismatic but the most consistent. They understand that excellence must hold on difficult days, not only on good ones, and that leadership is revealed in what is addressed immediately—and what is postponed indefinitely.

From interaction to identity

Practices do not become excellent through effort alone. Effort is common. Alignment is not. Excellence emerges when behaviour, expectations and leadership decisions point in the same direction—consistently and quietly. It is not created by teams working harder or reacting faster, nor by leaders asking them to take on more than they can reasonably manage. It is created when everyday interactions are intentional rather than reactive. When interactions are intentional, three outcomes follow: standards hold, teams stabilise and patients trust.

Standards hold
They do not fluctuate with pressure, personality or circumstance. What matters on a quiet day still matters on a difficult one. Standards stop being aspirational and become non-negotiable—when they begin to shape behaviour rather than merely describe it.

Teams stabilise
Clarity replaces uncertainty. People stop guessing, second guessing and compensating for lack of direction. Energy is no longer spent navigating ambiguity or inconsistency; it is directed towards performance, collaboration and care.

Patients trust
Patients look for reassurance. Consistency creates trust, trust reassures the patient. Confidence is conveyed through tone, timing and consistency. Trust grows when nothing feels improvised, even in complex situations.

At this point, excellence stops being something the practice strives for and becomes something it delivers naturally. This is not because the practice is perfect, but because excellence is practised every day in small, repeatable ways.

A final perspective

Working closely with practices reveals a pattern that is difficult to ignore: practices are defined less by their outcomes than by their habits—staff meetings, training conversations, feedback moments, clear roles and consistent escalation pathways. These are not operational details; they are identity-forming moments. If you want credibility, build clarity. If you want visibility, deliver consistency. If you want influence, lead in the everyday. Excellence is rarely announced; it is recognised over time.

Editorial note:

This article was published in aligners—international magazine of aligner orthodontics vol. 5, issue 1/2026.