What is the right fee?

If you thought dental school was tough, just try determining a fee that is fair for your customers and profitable for you. Here are some tips that will make the bottom line comfortable for both parties.

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If you thought dental school was tough, just try determining a fee that is fair for your customers and profitable for you. Here are some tips that will make the bottom line comfortable for both parties.

Samuel M. Strong, DDS, and

Joseph J. Massad, DDS

Once a clinician has mastered any of the disciplines of dentistry, the next most-formidable task is to determine a fair fee for the services being performed. The challenge is particularly difficult when those services include restoring dental implants.

The typical clinician handles implant cases far less frequently than standard restorative procedures, making it more difficult to estimate the total chairside time required for case completion. In addition, laboratory and component costs can vary widely. The types of abutment(s) used, whether the prosthesis is removable or fixed, whether retention is achieved with screws or cement, the expertise of the laboratory, and other hardware choices are all variables not generally found in restorations applied solely to natural dentition. Because of these variables, the old formulas of laboratory cost multiples for fee determination do not apply to implant cases.

Dentists across the country testify that the issue of fee determination is one of the most vexing problems facing the implant clinician today. It so intimidates many practitioners that their enthusiasm and confidence in offering patients implant services is inhibited. In all too many cases, the clinician unknowingly quotes an inappropriately low fee and loses money on the case. Alternatively, he or she may upgrade the fee after the initial quotation, but this option is not conducive to building patient confidence in the clinician`s honesty or ability.

This article is intended to provide an organized, rational method for determining implant-case fees. A thorough analysis of costs, overhead, and clinical time required for case completion provides the basis for this determination. To illustrate the methodology, the formula for fee determination will be applied to a common implant procedure. Use of this method requires some essential information, including:

> a knowledge of all potential laboratory and prosthetic component costs

> a working figure for the clinician`s personal hourly operating overhead

> an estimate of the total number of hours required to complete the case in chairside or clinical time

To illustrate this method, let us examine the costs and fees for restoring four Steri-Oss implants (manufactured by Nobel Biocare of Yorba Linda, Calif.) with a typical bar-retained overdenture. Let us assume that the four implants have been placed between the mental foramina (fig. 1) on the mandibular arch. Retention attachments for this case include a Hader bar and clip (manufactured by Attachments International of San Mateo, Calif.) for the anterior (midline) section and ERAs (manufactured by Sterngold of Attleboro, Mass.) cantilevered distally off each posterior-most implant site (fig. 2).

In order to begin the fee-determination analysis, we must know what the total costs to perform the case will be. This figure - the Total Case Cost - includes three major components: laboratory costs, component costs, and overhead costs.

Laboratory costs

An experienced dental laboratory can provide the clinician with an accurate estimate of the costs for any case. The lab typically provides:

> a surgical stent for implant placement

> a custom tray for the master impression

> a soft-tissue model with implant analogs

> a cast bar (noble or high noble metal)

> a "boltdown" baseplate with a wax rim for facebow and/or bite registration

> a premium denture teeth setup in wax

> a processed denture with a Hader clip in metal housing and ERAs with metal housings

It may also be advisable to have the lab prepare a duplicate overdenture, so that the patient can receive two dentures at delivery. When (not if) the patient subsequently breaks a tooth on a removable implant overdenture or needs repair of some sort, the duplicate overdenture can be used and negative feelings mitigated.

When duplicate dentures are to be provided, the additional laboratory cost is included in the fee estimate. In this example, however, we assume that only one overdenture will be fabricated. Sample lab fees are listed in Table 1 and total $1,250. Note that individual lab fees can vary widely depending on geographical location, personnel expertise, and other factors. The sample fees are used as examples only and are not intended to be those recommended by the author or any specific lab.

Component costs

This category represents purchases from an implant manufacturer or supplier of any hardware (components) that allow the dentist/dental lab to complete the necessary prosthetic procedures. In this example, the clinician must purchase impression pins (also called transfer assemblies) to record an impression of the coronal portion of the implant. The position of all dimensions of the implant can thus be transferred to a working, or master, model. Additional required components include analogs (replicas of the coronal portion of the implants) and abutments. These abutments become part of the bar casting and are retained to the implant with a screw. For purposes of this example, we will limit the purchase of components to these items. However, some cases will require additional hardware. These components and their costs are listed in Table 2 and total $676. This results in a combined laboratory and component cost of $2,072 (including tax and shipping).

Overhead costs

People often incorrectly assume that the clinician`s costs can be determined by considering laboratory and component costs alone. But the clinician`s overhead costs must also be examined and applied to the chairside time required to complete the case. Overhead costs, like lab fees, can vary widely, even within narrow geographical areas. Items such as office rent, staff salaries, office décor, capital-equipment expenditures, and other factors will determine an individual clinician`s overhead. It is essential to know one`s daily and hourly overhead in order to accurately ascertain a proper fee determination. Furthermore, it is necessary to estimate, as well as possible, how many hours of chairside time will be required to complete the implant case.

In our example, we will assume that the dentist averages a $200-per-hour office overhead. Again, this can vary widely from one clinician to another and requires an individual determination. The next task is to determine how much of the dentist`s time each appointment will require. The author typically utilizes a five-appointment protocol to complete a bar-retained overdenture case, plus some post-operative chairtime. These appointments and estimated time frames are listed in Table 3. A total of 5.5 hours is estimated to complete and follow up on the sample case. This assumes that the wax try-in is approved in one appointment without the need for additional visits. Additional time might also be required if the bar does not fit passively and accurately, necessitating a section-and-solder procedure. The experienced clinician will recognize that, in the real world, these contingencies do occur with some frequency. Accordingly, one might wish to increase the estimated number of hours required for case completion to allow for such potential problems.

After determining the laboratory, component, and overhead costs for a given implant case, the next essential step is to determine the clinician`s hourly profit when doing a comparable non-implant prosthetic procedure. The appropriate comparison in the current example would be with the creation of a conventional denture (Table 4).

By multiplying the clinician`s hourly overhead by the chairside hours required for the standard denture, we arrive at an overhead cost for the standard denture. Adding this to an estimated laboratory cost of $275 for a conventional denture, we arrive at a Total Case Cost of $775 (Table 5).

Now let us make some other assumptions, recognizing that these figures are used for illustration only and are not to be construed as suggested fees. Assume that the clinician`s fee for a conventional full denture is $1,100. Subtracting the Total Case Cost from that figure reveals a case profit of $325 and an hourly profit of $130 (Table 5).

Finally, we have enough information to determine an appropriate fee for the implant procedure. Some authorities will recommend a modest increase in profit for implant cases vs. standard removable prosthetics. However, the author feels that the clinician deserves a significantly higher profit margin for implant cases due to their greater complexity and the additional investment in training and equipment required to achieve proficiency. For purposes of these calculations, the author suggests a desired hourly profit figure that is twice that of the comparable non-implant case.

These calculations are illustrated in Table 6. Once the clinician knows his or her Total Case Cost, evaluates the implant case vs. a typical hourly profit from a comparable non-implant procedure, and determines a desired hourly profit for the implant case, it becomes a simple procedure to determine an appropriate fee. A serendipitous result of these calculations is a detailed analysis by the clinician of what materials and methods are best utilized in any particular case. At the very least, one becomes aware of a threshold figure required in order to break even. Unfortunately, all too often, a case is initiated without an organized analysis of costs. As a result, the dentist may either lose money or compromise the case in order to achieve some level of profitability. Neither scenario should occur if one devotes a modicum of time and effort to utilizing this method for case analysis and fee determination.

Consultation with the surgical dentist, dental laboratory, and implant manufacturer will allow the clinician to assemble all necessary lab and component costs for the proposed implant case. It is important to discuss contingencies such as the range of implant numbers, locations, and their impact on final prosthetic design. The laboratory can be particularly helpful in this regard by providing a least- and greatest-cost estimate of lab and component costs relative to different treatment plans. With all these resources at the clinician`s disposal, he or she need never begin a case without confidence that profitability is reasonably assured.

For more information about this article, contact Dr. Strong at (501) 224-2333 or by e-mail at strongdds@aol.com. Contact Dr. Massad at (918) 492-8400. A biography of the author appears on page 8.

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figure 1

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figure 2

Table 1 -- Laboratory Costs

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Implant case surcharge ($40 X 4 implants).........................$160

Custom tray........................................................$25

Surgical stent....................................................$100

Baseplate/Wax rim (with 2 plastic boltdown abutments)..............$80

Overdenture bar (noble metal casting) with 1 Hader clip/2 ERAs....$550

Metal Housings for attachments ($20 X 3 attachments)...............$60

Processed denture with premium teeth..............................$275

Total lab costs $1250

Table 2 -- Component Costs

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Non-hexed direct abutments ($112 X 4).............................$448

HL analogs ($20 X 4)...............................................$80

Hexed transfer assemblies ($37 X 4)...............................$148

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Total component costs.............................................$676

Lab/Component costs.............................................$1,926

Tax $116 Shipping...............................................$30

Total lab/component costs $2,072

Table 3 -- Overdenture Appointments and Time Frames

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Appointment 1 (Transfer impression).........................60 minutes

Appointment 2

(Contour wax rim/facebow transfer/bite registration)........60 minutes

Appointment 3 (Wax set-up try-in)...........................45 minutes

Appointment 4 (Bar try-in) 60 minutes

Appointment 5 (Deliver processed overdenture and bar).......45 minutes

Post-delivery appointments..................................60 minutes

Total chairside time 5.5 hours

Table 4 -- Conventional Denture Appointments and Time Frames

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Appointment 1 (Master impression)...........................30 minutes

Appointment 2 (Facebow transfer/bite registration)..........30 minutes

Appointment 3 (Wax set-up try-in)...........................30 minutes

Appointment 4 (Deliver processed denture)...................30 minutes

Post-delivery appointments..................................30 minutes

Total chairside time 2.5 hours

Table 5 -- Conventional Denture Costs and Profit

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Lab costs for processed denture...................................$275

Case overhead costs ($200/hour X 2.5 hours).......................$500

Total denture case cost...........................................$775

Fee for conventional denture....................................$1,000

Total denture case cost...........................................$775

Total conventional denture case profit............................$325

Hourly profit ($325/2.5 hours) $130

Table 6 -- Fee Determination

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Implant overdenture lab/component costs..........................$2,072

Case overhead ($200/hour X 5.5 hours)............................$1,100

Total overdenture case cost......................................$3,172

Desired profit/hr. ($130/hour X 2).................................$260

Desired case profit ($260/hour X 5.5 hours)......................$1,430

Total case cost..................................................$3,172

Desired case profit..............................................$1,430

Case fee $4,602

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