By: Michael J. Melkers, DDS, FAGD

Profitability of direct vs. indirect restorations
A common misconception in dental practices is that higher fee procedures are always more profitable than lower fee procedures. While this may certainly be the case in multiple unit cases, the ‘bread and butter’ single unit restoration that is the reality in many of our practices is not always the most profitable.

In the first part of the survey, Townies were asked to provide their fees and time required for an anterior crown. The results are listed in Table 1.

For the second portion of the survey, Townies were asked to consider a specific scenario involving two fractured central incisors (Fig. 1). They were asked their preference for a direct versus an indirect restoration, the fee per tooth if the case was restored with direct composite, how many colors would be utilized and how long the procedure would take.

For a single central incisor, the production per hour for indirect restorations in the survey revealed an average of $428/hour without a crown build-up and $519/hour with a crown build-up. Production/hour = (total fee–laboratory fee)/total treatment time. The production per hour for direct restoration in the survey revealed an average of $474/hour.

In the scenario presented in figure 1, it could be argued that a crown build-up would not be necessary. If such was the case, a single anterior restoration could be more profitable as a direct rather than an indirect restoration. The direct restoration would also be performed in one visit, decreasing the incidental cost of additional operatory setup and related supplies. This would further increase the profitability of the choice of direct restoration.

Fee considerations in an insurance environment
As practitioners are exposed to the advantages and enjoyment of anterior direct composite artistry and increase their application from small and medium restorations to larger, more polychromatic offerings, fee considerations can be a challenge. In Dr. McDonald and my hands-on programs, we are asked, “How can we charge appropriately for these restorations and what is the role of insurance?” From a skills standpoint, the practitioner is ready to provide a direct restoration that is comparable to an indirect restoration. The challenge now becomes insurance related.

This can be easily addressed and offered as a choice for our patients. In the above indirect fee survey, the single anterior restoration average fee was $842. Depending upon the given insurance plan, crowns are typically covered at 50%. This would translate to an ‘out of pocket’ expense for the patient of $421. If a crown build-up was also involved, again, using the fees from the survey, the total out-of-pocket cost to the patient may climb to $492. Given this observation, it could then become feasible to offer direct restorations to our patients in the range of $421-492. As long as the patient’s needs and goals are addressed in the treatment, the financial influence on the decision between the two treatment options can be removed.

It should be noted that in this scenario, no insurance coverage has been mentioned for the direct restorative option. Utilizing the direct composite veneer code and an appropriate narrative, practices may be able to obtain benefits at the increased fees mentioned. Even if the procedure is down-coded to an anterior four-surface restoration, covered at “UCR”, some benefit should be anticipated, further decreasing the patient’s out-of-pocket expense.

Conclusion
The purpose of this article is not to admonish the use of indirect restorations in the anterior dentition but to offer an alternative perspective of viable treatment options as well as related financial considerations. Direct composite artistic restorations can provide our patients with conservative, repairable and affordable alternatives to indirect restorations with comparable results. The clinician is rewarded not only financially, but professionally and artistically, knowing the restoration was entirely fabricated by their own hands.

Author’s note
The actual restorations provided in the case shown were restored in approximately 25 minutes using three shades ($238/restoration) utilizing the traditional four-surface anterior code for an hourly production of $1,142 (Fig. 2).

Dr. Melkers is a 1994 graduate of Marquette University School of Dentistry and practices general dentistry in Spokane, Washington with his wife Jeanine McDonald, DDS. Their practice emphasis is comprehensive and restorative care. Drs. Melkers and McDonald regularly present lecture and hands on programs on direct composite artistry and other topics in the United States and abroad. Dr. Melkers can be contacted at drmelkers@aol.com or on the www.dentaltown.com message boards.