The TeethXpress team recently sat down with Dr. Jonathan Ouellette, lecturer and owner of Dream Dental Services, a dental practice in Altamonte Springs, Florida, to discuss the emerging photogrammetry technique in full-arch implant dentistry. Dr. Ouellette is enthusiastic about using photogrammetry in his practice, and we wanted to know exactly why. As anticipated, our discussion was insightful, and we’re happy to share his rich insights with you here. 

TeethXpress: Thank you for this opportunity, Dr. Ouellette. Would you mind if we start this discussion by having you share how long you have been performing full-arch, fixed, immediate-load procedures in your practice? 

Dr. Jonathan Ouellette: Sure. I’ve been performing full-arch procedures in my practice for the last 12 years and immediate load for about six years now. Immediate load has been a game-changer in my practice. However, early on, most of those full-arch restorations were performed using analog methods. I learned a lot about the limitations of analog impressions in all-on-x procedures.  

TeethXpress: What led you to adopt a photogrammetry approach to restoring your full-arch implant cases? 

Dr. Jonathan Ouellette: An increased level of accuracy was the main reason I decided to adopt a photogrammetry protocol. Every article I could find in the literature stated that photogrammetry is more accurate than scanning or analog methods. We can achieve an accuracy within 5 microns with photogrammetry. This allows me to achieve complete passivity at the highest levels of predictability. 

Incidentally, two years ago, a friend of mine convinced me to use a traditional analog jig to save money on my laboratory expenses. Everything was perfect with my records but the lab tech they sent couldn’t figure it out. I ended up doing the conversion myself, and it cost me a lot time. At that moment I vowed never to do another jig again. 

TeethXpress: For your all-on-x restorations, did you find the process of switching from analog impression protocols to photogrammetry methods to be difficult? 

Dr. Jonathan Ouellette: Not at all. Switching to photogrammetry is not a steep learning curve. I felt like it was a pretty seamless process. And nowadays it’s even easier and more cost effective to make the change.  

TeethXpress: In your experience, what are the main benefits of using photogrammetry over analog approaches for full-arch restorations? 

Dr. Jonathan Ouellette: In addition to the higher levels of predictability that I mentioned previously, some patients don’t tolerate traditional full-arch implant impressions very well ¾  they gag. By switching to a photogrammetry workflow, I was able to eliminate the use of jigs. Suddenly, gagging became a nonissue for a significant percentage of my patients. Also, the time I save using photogrammetry allows me to help more people, which ultimately makes my practice more productive.  

Also, by today’s standards, patients love to see a digital workflow. They like telling their friends and family that their dentist is on the cutting-edge which increases my “cool-factor” and new patient referrals. Lastly, photogrammetry makes performing these procedures way more fun and interesting. 

TeethXpress: How does photogrammetry save you time and money? 

Dr. Jonathan Ouellette: Accuracy means fewer re-dos or faulty impressions. It cuts down on chairtime and chairtime is the most expense overhead in dentistry. The average dental lab fee for these full-arch cases can range anywhere between $5,000 to $9,000. Someone recently told me they pay $9,000 for their all-on-x lab fee. 

A full digital case will cost me about $3,000 to $4,000. Additionally, digital cases look better and fit better. Again, this significantly reduces my chairtime. To this point, my patients understand that two try-ins are included with the cost of their all-on-x cases. Any additional try-ins requested by the patient come with a $1,000 fee. Guess how many try-ins patients request above the initial two try-ins? Zero. In fact, 99% of the time, no more than one try-in is required. Photogrammetry allows for this level of predictability over traditional analog approaches. And, I still have flexibility in working with my local lab on final restorative options. 

TeethXpress: Can photogrammetry be used in conjunction with guided surgery such as  MagnetiX™, the Yomi® robot, X-Nav® and the like? 

Dr. Jonathan Ouellette: Absolutely. Photogrammetry is merely an impression of the implant positions. It will not affect the guided surgery, whether it be MagnetiX, X-Nav, Yomi or any of the other available guided surgery methods. 

It’s worth noting that currently, photogrammetry is designed to only perform at the multi-unit abutment level; it will not perform at the implant platform level. Hopefully this will change in the future since it would be beneficial to use the accuracy of photogrammetry when multiple implants are involved, such as with a three-unit implant bridge. 

TeethXpress: What equipment is required to perform a full-arch digital workflow? 

Dr. Jonathan Ouellette: I like using a photogrammetry camera. An intraoral scanner, such as the 3Shape scanner, is needed. Most practices these days should already have some type of an intraoral scanner. As for a printing system, I like the SprintRay® Ecosystem. It’s their complete system. It includes the SprintRay Pro 2 3D Printer, the Nano Cure and the Pro Wash S. Now that BioHorizons has become a distributor for SprintRay, I would encourage doctors to reach out to their BioHorizons representative to see what deals are available. They may be able to offer a bundle deal that includes dental implants. 

TeethXpress: In your estimation, how many arches, each year, should an office be performing for it to be worth investing in a photogrammetry and printing setup? 

Dr. Jonathan Ouellette: When I decided to take my full-arch restorations digital, I was doing about two to three arches per month. I think it’s generally a good idea for an office to invest in photogrammetry once they’re averaging between 1.5 to three arches per month. If you’re doing 18 to 36 arches per year, you will definitely benefit from incorporation a photogrammetry workflow in your office.  

But if the office performed less than 18 arches in, say, the past 12 months, I would suggest working with a local laboratory that can come into the office and take digital impressions with their own equipment..  

TeethXpress: What is the learning curve for photogrammetry? 

Dr. Jonathan Ouellette: My photogrammetry camera that I use is extremely easy to learn. The guy who invented it used his 14-year-old daughter as a test subject. He figured if she could be taught to use the software accurately and quickly, any dental professional could. 

TeethXpress: Would you recommend a doctor attend a photogrammetry course before adopting this process in their practice? If so, why? 

Dr. Jonathan Ouellette: Yes, 100 percent. Attending a course — preferably one that offers hands-on training — will help the doctor increase their knowledge of the product and the proper workflow. Suitable training will decrease chairtime by eliminating wasted efforts through trial and error. 

TeethXpress: Please explain the different protocols that can be used for photogrammetry. And if you don’t mind, please also share the approach that you most prefer. 

Dr. Jonathan Ouellette: There are three approaches to photogrammetry that I am aware of:  

1. The first is the bone screw method. This method is quite common. In the maxilla, usually three screws are placed in the pallet, or one large screw with a fiduciary marker. If it’s the mandible, two screws are usually placed in the retromolar pad, on each side. Those are the reference points once the teeth come out and the implants go in. Many surgeons prefer this approach. 
2. Another approach is the denture method. I prefer this method because it allows me to make a visual check. Basically, I use an inexpensive 3D-printed denture to serve as my reference.  When I place this denture in the patient’s mouth, I can see it in relation to their face. I can then take a bite with the same 3D-printed denture. I can also take photos with the denture in place. Then I am able to relay these details to my lab. I find that when a lab is equipped with references, the stitching is better. This is the method I teach at my courses. 
3. And the third method is the tooth method. This is my least favorite photogrammetry technique. If the teeth are unstable, the stitching may not match up well. I never use this method in my practice. 

TeethXpress: Dr. Ouellette, this has been a great conversation. Thank you so much for giving us an opportunity to share a few of your invaluable experiences with our audience and customer base. We look forward to continuing this dialogue with you. 

Dr. Jonathan Ouellette: My pleasure.