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Beyond learning the techniques and procedures for successful completion of implant prosthetics lays the problem of fee determination. This can be a thorny issue with many clinicians unless a rational method for analysis of the case can be identified. In order to determine a fair fee for any implant case, we must first know our total costs involved to produce the prosthesis. I suggest breaking down the total case cost figure into three components:

• Lab costs
• Implant component costs
• Overhead costs

We will use the example of an implant overdenture retained by four implants with Locator® abutments (Zest Anchors; Carlsbad, CA) in this article. There are four basic appointments required to complete this kind of case:

Appt. 1 Implant level impression

This appointment typically involves removing healing abutments and connecting impression copings into each implant. Radiographic confirmation of complete seating of the impression copings is required to proceed with this impression. In my prosthetic lectures and articles, I recommend a three-step impression using the Strong-Massad Denplant™ impression tray system (Global Dental Impression Trays; Tulsa, OK). This impression tray can be heat molded and modified to become more accurately fitted to the edentulous ridge than the older custom tray. The impression is then completed using polyvinylsiloxane (PVS) impression material as described in my technique article, "Maxillary and Mandibular Overdentures" (Dentistry Today, May 2009).

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Appt. 2 Facebow transfer and centric relation registration

I strongly recommend use of a facebow transfer procedure to mount the upper cast to the upper member of a semi-adjustable articulator. Combining this step with a centric relation bite registration using a tracing device, the Jaw Relation Recorder (Global Dental Impression Trays), is then completed. This provides us with a predictable and accurate recording of centric relation at the correct occlusal vertical dimension. In order to procure the jaw relation recording, the lab can set up a maxillary baseplate with a striking plate and a mandibular baseplate with pin holder and tracing pin.

Appt. 3 Wax try-in

At this appointment, denture teeth set in wax are tried-in the patient's mouth. The Locator abutments are placed into all implant sites and Locator attachments are luted into the intaglio of the baseplate. This allows us to preview the retention to be gained from the prosthesis. Approval of the esthetics, phonetics and occlusion of this setup is required in order to send back to the dental lab for processing.

Appt. 4 Delivery

All Locator abutments are torqued into place in the implants. The processed overdenture with Locator attachments is seated and adjusted if necessary for occlusion and contour. The patient is typically seen as needed for follow-up appointments to handle any adjustments of occlusion and/or sore spots.

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Component/Lab Bill

This figure can be easily obtained by simply contacting our dental lab. Identification of the type of case, i.e. four-implant overdenture retained by Locator abutments and attachments with a strengthening metal framework in the denture base, allows the lab to provide the most accurate estimate. I always suggest fabrication of an acrylic surgical template to aid in the placement of dental implants, so this item will be included in the estimate of lab costs. The clinician will typically incur the following from the lab bill:

Implant and Facebow/Articulation Components

Esthetic control base and wax rim for the facebow transfer	$ 35
Maxillary baseplate and striking plate	$ 35
Mandibular baseplate and pin holder	$ 35
Impression copings (4)	$ 200
Component subtotal	$305

Glidewell Fees

Processed denture with Locator Attachments
Base price for two implant Locator Overdenture	$990
Each additional implant (Includes all model work, analogs and attachments)	$189
Denture Subtotal	$1368
Premium denture teeth*	$100
Cast reinforcing framework*	$100
Lab bill subtotal	$1568

*Optional, additional fees apply.

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Overhead Costs

The clinician must estimate how much chairtime and personal lab time will be required to complete the case. This figure is to be multiplied by the clinician's personal hourly operating overhead. For the purposes of this article, we will assume six hours of chairtime/lab time will be required. Note this is purely an estimate and will vary from one dentist to another. We will also estimate the hourly operating figure to be $400/hour.

(6 hours chairtime/lab) X (Clinician's personal hourly overhead) (estimated at $400/hour)	$2,400
The sum of these lab, implant components and overhead costs is the Total Case Cost.
Lab Costs	$1,568
Implant Component Costs	$305
Overhead Costs	$2,400
Total Case Costs	4,273

The Case Fee is then determined by adding the Total Case Costs to Profit. Profit is identified as the dollar figure the clinician would desire to make per hour on this particular case multiplied by the number of hours estimated for case completion. We have already estimated six hours required from chairtime and lab time needed in the clinician's office. Therefore the Profit figure is found by the following computation:

If we plug in a figure of $400 per hour as the Desired Profit/Hour, the Case Profit becomes $2,400, a very reasonable figure in my opinion for renumeration on this type of case.

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The final computation for Case Fee becomes:

Total Case Costs	$4,273
Desired Profit	$2,400
Fee Estimate	$6,673

Note: The dollar figures used in this article are not intended to be guides for how much to charge for this case. They are used only as examples for inclusion in the formula for case costs and fee determination.

The use of this formula will allow the clinician to accurately analyze all items that affect the cost to him or her in completion of any implant case. Other methods such as multiples of a lab bill can be very misleading and inaccurate. In addition to providing a rational method for fee determination, this method serves as a valuable aid in planning the case by examining all the procedures required for completion of each appointment. Use of this fee determination should provide the clinician with adequate remuneration and avoid losing money on the case.

Editor's note: Dr. Samuel Strong's article illustrates a simple formula to help you determine appropriate case fees. His article also showcases a system that he and Dr. Joseph Massad developed that consists of impression trays along with a system to accurately obtain occlusal records. If you would like more information on this system, please go to www.gdit.us/products/products.html. If you plan on working with this system or another facebow/transfer system, you will need to provide those components and the articulator when you send in your case. You can obtain our standard step-by-step instructions for use by visiting www.glidewelldental.com/dentist/services/implant-overdentures.aspx.

Locator is a registered trademark of Zest Anchors. Denplant is a trademark of Global Dental Impression Trays Inc.