by Samuel M. Strong, DDS
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The complexities of implant surgical and prosthetic proceduresare numerous and sometimes overwhelming for any grassroots dentists interested in incorporating these disciplines into their general practice. Despite these intimidations, more dentists are learning the skills necessary to offer implants to their patients. Implant dentistry has been a growing part of our practice for 20 years, and it's now a substantial portion of our production.
While many of the surgical and prosthetic protocols, products, and procedures have changed, confusion and frustration regarding how to determine a reasonable fee have persisted. At many of my lectures, dentists have reported that fee determination is the greatest deterrent to their providing implant dentistry to their patients.
Case cost analysis
In order to determine a fair fee to the patient and clinician, we must determine precisely what it costs the dentist to complete the implant case. All of the research needed to determine the fee is actually completed by finding the case cost. Common to any implant case are these costs: lab, implant components, and overhead. Add these together for the total case cost. The case fee then becomes the sum of the total case cost and the desired case profit.
The following three case examples illustrate how to use this fee determination formula.
Case example 1: Mandibular attachment retained implant overdenture with four implants
Prosthesis description: This case has four implants placed in the mandible. Often the implants may be placed anterior to the mental foramina. If sufficient bone exists or can be grafted, two implants may be placed in the cuspid sites with two posterior implants in the second bicuspid or first molar sites. Direct implant abutments, such as Locators (Zest Anchors, Carlsbad, Calif.), ERAs (Sterngold, Attleboro, Mass.), Ball abutments (Nobel Biocare, Yorba Linda, Calif.), or others are threaded into the implants. Height selection of each abutment allows its retentive portion to protrude above the gingival crest. The interior of the overdenture acrylic contains corresponding attachments that snap onto the abutments when the prosthesis is inserted intraorally. The processed overdenture base also has a metal casting as a strengthening framework that does not attach to the implants but is contained within the denture base.
Surgical template $135
Master cast $35
Cast metal strengthening framework $150
Processed overdenture $650
Lab subtotal $1,005
4 impression copings $200
4 implant replicas $100
4 abutments and associated attachments $700
Components subtotal $1,000
Appointment 1: Implant level impression including opposing impression. This appointment involves removing four healing abutments from each implant and connecting impression copings. Then take radiographs to confirm complete seating of the impression copings into the implants. We use a three–step Massad technique for the impression after sizing the Denplant impression tray (Global Dental Impression Trays, Tulsa, Okla.). After removing the impression tray from the mouth, each impression coping is removed from the implant, joined to an implant replica, and replaced into the master impression. The four healing abutments are then replaced into the implants. At this appointment, I often replace a soft liner in the patient's existing or interim denture. Chairtime estimate: 1.5 hours
Appointment 2: Jaw relation records. At this appointment we procure a facebow transfer to mount the maxillary model to the upper member of a semiadjustable articulator. We also use a Jaw Relation Recorder from Global Dental Impression Trays (GDIT, Tulsa, Okla.) to record the patient's centric relation at the correct vertical dimension. This occlusal record allows us to mount the mandibular master cast to the maxillary cast on the articulator. Chairtime estimate: 1 hour
Appointment 3: Wax try–in. This appointment involves removing the four healing abutments and threading the overdenture abutments into each implant. We seat the denture teeth setup in wax intraorally. The overdenture attachments are luted into the baseplate, which allows us to confirm the retention of the case prior to processing. The dentist and patient must approve all aspects of the setup including occlusion, esthetics, and phonetics before returning the case to the lab for processing. If necessary, small changes in the position of the denture teeth can be made chairside. However, major changes in esthetics or occlusion may require returning the case to the lab and further wax try–in appointments.
Chairtime estimate for one try–in: 1 hour
Estimate for additional try–in: 1 hour
Appointment 4: Delivery. The processed overdenture is seated onto the intraoral abutments. I have two of the four attachments processed into the completed overdenture base. Then I customize the remaining two by picking them up intraorally. I spend time finalizing the occlusion and adjusting any obvious pressure points before dismissing the patient.
Chairtime estimate: 1 hour
Estimate for adjustments: 1 hour
Total chairtime estimate: 6.5 hours
Assuming the dentist has an average hourly overhead of $400, multiply the total chairtime estimate of 6.5 hours by $400 per hour. This number represents how much it takes the dentist to run the office while completing this case.
Overhead subtotal: 6.5 hours x $400/hour = $2,600
Lab Bill $1,005
Implant Components $1,000
Overhead Costs $2,600
Case Cost $4,605
To determine a fee, the dentist should decide how much profit per hour is wanted on this case. This number is an individual decision for each clinician. While we cannot recommend an hourly profit designation, for the purposes of this computation we will assume a figure of $300 per hour.
Desired case profit: $300 x 6.5 hours = $1,950
Total Case Fee: Case Cost $4,605
Desired Case Profit $1,950
Fee Estimate $6,555
Case Example 2: Mandibular bar retained implant overdenture with four implants.
Prosthesis description: The only difference between this case and Case Example 1 is that the implants are splinted with a cast metal bar onto which the overdenture snaps in place for retention.
Lab Bill: $2,400 The cast metal bar increases the lab costs compared to the attachment retained overdenture shown in Case Example 1.
Implant Components: $1,500
Overhead Costs: $3,400
Additional appointment time is needed to confirm passive seating of the bar. If the bar requires correction, this figure will increase. For this exercise, we will calculate a total chairtime estimate of 8.5 hours x $400/hour operating expense.
Total Case Costs Estimate: $7,300
Profit Desired $300/hour x 8.5 hours = $2,550
TOTAL FEE ESTIMATE:
Fee estimate $9,850
Case Example 3: Hybrid appliance screw retained to four implants.
Prosthesis description: This appliance is bolted to four implants. It consists of a cast metal or milled titanium framework to which denture acrylic and denture teeth are added. Because of the framework, at least one additional appointment is required to confirm its passive seating into the implants. More appointments are needed if it is not determined to be an accurate fit. The framework adds more lab costs.
Lab Bill $3,500
Implant Components $1,500
Overhead Costs 3,400
Total Case Costs $8,400
Desired Profit $300/hour x 8.5 hours $2,850
Fee Estimate $11,250
It's important to note that the figures in these estimates are fictional and not representative of all lab, components, and overhead costs in various cases. The figures are used as representatives in order to calculate the total case costs and fee determination. What is important to understand is the formula in which these figures are used.
The fees computed are in no way offered as recommendations for actual charges for any of these cases.The clinician should consult the dental lab for a full accounting of expected lab bill costs. Then he or she should research the specific costs for all implant components to be used. Finally, a comprehensive evaluation of all appointments, complete with possible contingencies, should be made. This analysis is critical in order to determine the total number of hours needed to complete the case.
Employing this formula provides the dentist with a method for analyzing the case value in real monetary terms. Because there are no guidelines from insurance coverages, the dentist is often at a loss for confirming what a fair fee should be for different cases. These methods will help the clinician establish a fee structure.
Dr. Samuel Strong is in private practice in Little Rock, Ark.. Reach him at (501) 224–2333, or visit www.strongdds.com.