The End of the Composite Drawer: One Material for Every Case?

Workflow simplification, in my opinion, only works when the material supports it. By using one composite system across the anterior and posterior indications, you know, I reduce inventory, eliminate unnecessary decision points, and increase consistency. So where simplification fails is when materials don't live up to their claims. Welcome to Austin, Texas, and welcome to the Phil Klein Dental Podcast. For decades, dentists have been trained to believe that different clinical situations demand different composite materials, one for strength in the posterior, another for aesthetics in the anterior, and often several more just to manage shade. But today, material science is challenging that long-held mindset. In this episode, we're taking a hard look at whether we've truly entered the era of the universal composite. a single material that can deliver predictable strength and durability in posterior restorations, while also achieving the aesthetics, polishability, polish retention, and shade blending we demand in the anterior zone. We'll dig into what today's universal composites can and can't do, how advances in filler technology and shade systems are changing the game, and where simplification helps versus where it can get clinicians into trouble. The big question is no longer if universal composites are improving. but whether we've reached a point where one material can confidently handle nearly all everyday direct restorative dentistry without compromise. Our guest today is Dr. Sam Simos, an implant, restorative, and cosmetic dentist practicing in the Chicago area. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Simos, it's a pleasure to have you on the show. Thanks, Phil. It's great to be with you today. Yeah, we're very happy to have you. You're a well-known expert on restorative dentistry for sure. You've been around the block a little bit. You've tried a lot of different products. You've been a product evaluator for many years. So it's really good to ask you some of these questions. So let's begin by addressing the elephant in the operatory. A lot of dentists still believe that a one composite fits all approach automatically means compromise. And I understand that from dealing with these products in the past. And that compromise involves either sacrificing strength in the posterior or aesthetics in the anterior. From your clinical experience, Is that concern still justified today, or is it simply outdated mindset that hasn't kind of kept up with modern material science? Yeah, it's a great question. And I think that that concern used to be valid. But when we're talking about modern high filler universal composites, I think it reflects an outdated mindset. And to be clear, there are a lot of great products on the market today, some better than others. And not all universal composites have the same filler technologies. But for the sake of simplicity in today's session, I'm going to give the audience a consistent clinical reference point when we're talking about these materials. And I'm going to use one example throughout the conversation of a newer composite. that I've been using. It's VOCO's Grandioso for You. And it really illustrates how far composite material science has come compared to earlier generations. And those earlier generation materials forced us to choose between strength in the posterior and aesthetics in the anterior. But what's changed is really material engineering. And Grandioso 4U is a great example of this because it's built on a nano hybrid, extremely high filler load, which is directly translating into improved mechanical strength, wear resistance, and polish retention. Yeah, let me ask you this. So in the past, when you had these materials that were very strong, they obviously, to get that strength and reduce that polymerization shrinkage, They reduced the amount of resin compared to the filler. But the downside was obviously the aesthetics because the filler rate was so high. And also the handling wasn't great, right? Because it was kind of thick and difficult to handle. How did this particular universal composite that you're talking about overcome that challenge where the handling is quite creamy? That's what I hear. I'm not using it, but that's what I hear. And the aesthetics. you get this really nice natural translucency in the anteriors that you're looking for. How did they do that with such a high filler rate? Which, by the way, according to VOCO, is 91% filled by weight. Well, it's funny because I've coined a phrase with all of the lecturing that I've done and all of the materials that I've used and evaluated. And the phrase that I've coined is, modern dentistry is chemistry, right? I mean... We are living in a chemistry world in our operatories. And I think the clinician really has to understand that. So to your question, the advances we've seen in composite chemistry and dental materials overall have been dramatic because when you combine that modern resin chemistry and the old trade-offs, they largely disappear because of the fillers and because of the resins. But not that long ago, I was lecturing on posterior composite survival rates of just a few years. And today, long-term studies. show survival rates in the 85 to 90% range at 10 years. Yeah, 10 years. Yeah. So that's interesting because one of the doctors that I interviewed not that long ago, Dr. Gammicia, he uses direct composites for teeth that, you know, five years ago, we would say no way. No way. Yeah. And it's a combination of the adhesive materials and the composite itself. But he just feels that instead of extracting a tooth from a patient that can't afford A crown or an implant, especially on a younger patient who's 11, 12 years old, he puts these heroic, large direct composites in, expecting them to last a few years just to get them through this stage where they can maintain their occlusion and everything else until they have the resources to go further. And then he finds out 10 years later, the thing looks just like it did when he put it in. Are you seeing the same thing? yeah for sure and i think it's it's about our mindset right i think that in europe when you go to europe i mean they do these composite crowns and they do a chair side and because because of their reimbursement system and everything else but i'm telling you i've seen some incredible craftsmanship in in europe with larger universal composites and they're just as beautiful in the anterior. So yes, I've seen that 100%. What's the definition of a composite crown? What does that mean clinically? Oh, so instead of sending it to the lab and having a crown made, you're covering a couple of cusps or you're covering all of the cusps. You're literally building that crown from the ground up in composite. Okay, because obviously we do have blocks now that are hybrid blocks that you could actually mill in five minutes that are primarily composite. And they look great and they work. They're obviously not going to handle a tough occlusion. Or, you know, someone who's grinding away or has a heavy load on a few teeth to support the occlusion. But when you mentioned composite crown, you're talking about just literally manually putting it in chair side. Correct. I mean, in America, we wouldn't think about. you know, covering three cusps and building up the, you know, in the central groove and everything else. I mean, we wouldn't think of building a three quarter crown on a tooth. We'd go right to a crown, right? I think, and I think when you're talking about these. hybrid composites. You're talking about failure rates. Failure is more often tied to technique and inclusion. Inclusion is huge. Then the material itself in that context, using a universal composite, it's not a compromise. It's a reflection of how far the material science has really advanced. Yeah. And you have to obviously make sure you choose, your case selection has to be good because- 100%. Right. Otherwise it's kind of doomed from the beginning, but that's with everything we do. Everything. Yeah. You don't want to pick a Bruxer in a case like that and expect it to have a long survival. But at the same time- You know, it just depends on the case. Yeah, now what's interesting about this particular product, Grandioso for You, that's the one you brought up as an example of a really innovative new universal composite that has really... push the limits, and it's working really well, actually, because what I hear, the success rate of these cases so far has been very positive. It's excellent, yeah. Right. What's nice about it is, though, you can actually get a good depth of cure on this. It's basically somewhat translucent before it's cured. Tell us about that part of it as far as the clinical technique of doing these posterior fillings pretty quickly. Oh, my gosh, yeah. So when I think about a posterior restoration... I'm looking at more than just compressive or flexural strength. Those numbers definitely matter for sure. But what often gets overlooked is polymerization, shrinkage, stress, because that's what shows up clinically at the marginal breakdown, sensitivity, or long-term failure. And so every time... a composite cures one of the things that i think about when i'm doing a posterior is that your first load is not when the person goes home and has something to eat it's when you're curing that composite if you think about it Every composite, when you cure it, wants to shrink. And that contraction can generate several megapascals of stress at the bonded interfaces, especially in the posterior restorations, where the composite is bonded on every surface. So when it cures and shrinks, the stress has nowhere to go and gets transferred directly into the bond. By having the ability to do four millimeters, you're saying that essentially results in less polymerization stress. Correct. And it's funny. In the old days, it was the other way around. They used to say small increments would reduce the stress. But apparently that misconception has been disproved over the years. Yeah. And you know, it's funny because when I lecture, I ask people, well, what's your major concern with doing a bulk fill? And they'll say. You know, we're not, we don't trust it. We don't. And again, the technology in these composites is amazing. And because when you put it into the tooth, it's kind of translucent until you cure it. And, you know, you just have to trust the material. So I'll put in an A2 and it'll be a little bit light, to be honest with you. But then when you cure it. it's amazing how it blends with the rest of the two so so the goal isn't just strength it's how the material manages stress while it polymerizes so when you put the in the we're going to move out of the posterior to the anterior in a second but just to finish up on this bulk fill uh curing capability where you can go four millimeters and that's with a very filled material that's because it's the light could could transmit through the material before it's before it's fully cured and that gives it the opportunity to cure and then when it cures it becomes natural tooth structural looking um but meanwhile you got the four millimeters cure in i mean is that that sums it up yeah yeah that sums it up when there's Less resin matrix available to shrink in the first place. That directly translates into lower overall volumetric change and better stress distribution. And stronger. It's essentially stronger. For sure. Yeah, it's amazing how these companies like Voco actually reach out to people like you, Dr. Simos, and ask you for your opinion and say, not only how does it feel and handle and all that stuff, but even during the development stage, they're reaching out to KOLs like yourself and saying, what are you looking for? for in your clinical workflow. And then they go back to their chemists, like you said earlier in the show, how everything is based on chemistry, which it is. There's no question. Dentistry is a materials profession in many ways. As long as you, like we said, case selection. and technique along with the right materials and you got to believe in the company that makes the products you have to have confidence yeah you have to have confidence in them for sure right you know you don't want to buy something and then it works great but the consistency and the quality control ain't that great then you're looking no right then you're looking you don't even know why it failed correct and you know the funny thing is with voco for instance um they are so great when they're in their development stage of a product or they're they're looking to bring something on They'll get some of the best clinicians in the country together and start brainstorming. It's really a fantastic collaboration. And then you can follow that along. And it's really a wonderful, wonderful relationship. They really get a good idea of what the market needs. And they're not afraid to. release multiple iterations of this to the evaluators before they go to the general dentist population. Okay, so now let's flip to the other end of the spectrum, the aesthetic zone. You'll often hear some dentists say, yeah, I can't depend on a universal composite for my aesthetic zone, my social. eight, or whatever they're doing, because my patients won't be satisfied. They're looking for very high-end aesthetics, and a universal composite's not going to give it to them. I may not need to go with a veneer, although often I do use veneers. They're saying this. But if I do use a direct composite, it's certainly not going to be a universal. It'll be a more complex, multi-layered technique that I use. I need a different composite in my inventory. What is your response to that? You know, I think this is... You're right. This is where a lot of dentists still hesitate. But again, the hesitation is rooted in old materials. Grandioso 4U benefits from modern filler technology that allows controlled translucency and a refractive index matching, which are the real drivers in aesthetic integration, not how many layers you place. So we know that polish retention is critical as well, especially in the anterior, right? and restorations that look great day one but then loses the gloss over time is a failure in the patient's eyes so the high filler density and surface hardness of grandioso four for you contribute to excellent long-term polish retention, which is supported by both lab data and clinical feedback. But it's interesting because I just did a case and it's going to be in an upcoming webinar. And it's an anterior case that I use Grandioso for on a lady that, she wasn't a patient, she was referred and it was at the end of the day and she came in, she was freaking out because she had broken two anterior teeth. And I said, well, heck let's use this literally i bulk filled it and i've got the pictures to show it it's it's an amazing case eight nine you're talking about tooth number eight nine nine and ten nine and ten trauma trauma yeah she was getting something out of the cupboard fell right on her tooth and um you know she was freaking out so how did it blend how did you blend it in where it looks i should show you can i show you No, it's all, this is all audio. Yeah. This is an audio podcast. Oh, is it? Yeah. We got plenty of people with a headset on now or earbuds in the gym listening, but they're not watching. Yeah. All right. So that's unfortunate. But try to tell us, you can talk us through the imagery. Sure. Yeah. No. So, so the, the image is this, is that the, uh, buckle incisal distal surface of number nine was totally broken off. And then the mesial incisal was broken off of number 10. And I'm a better carver than I am a sculptor. So I just bulked this all on and then carved it back in and then polished it with an enhanced cup. And I'm telling you, or an enhanced disc. And it was... Way better than you expected. Way better than I expected. And really, she wasn't... bleach white she wasn't um yellow but she was you know in that normal a2 category so i just thought well heck let's just use a2 and um the material apparently has a very good chameleon effect unbelievable right yes it blends with the adjacent teeth where optically it looks like the shade matches probably better than it really does but it appears to match It does. And I think shade matching is where dentists feel the most stress sometimes in these areas, and rightfully so. Single shade systems promise simplicity, but often failed across a wide value range, right? So what differentiates Grandioso for you is the cluster shade concept, which is fundamentally different. Voco's data shows that... Um, five cluster shades can cover 16 Vita classic shades and, and that's not marketing magic. It's, it's optics. I mean, it's, again, it's, it's the man, it's the, it's the engineering of this material. Yeah. I mean, yeah, I've heard this before. In fact, and I do want to talk about the cluster shade system a little bit more depth in a second, but you mentioned polish retention. And I don't know if you know, Dr. Susan McMahon, she's been on the show several times. And that was one of the big, issues she had with using some of these composites these universal composites on the anterior teeth they would look great when she put them on and then the patient would come back a couple of months later and it would be dull as anything so um that polish retention they seem to have solved that issue which is a major thing because if if that tooth starts to dull and look drabby the patient's going to be unhappy and they're going to be you know from their excitement of the initial placement to the stage where the tooth starts to dull, you get this disappointment. And that's not a way to grow a practice, certainly not a way to grow an aesthetic practice. So they did solve that problem. I just want to point that out. I think they solved it. And it's interesting because, you know, you're a little leery when you try these products. But I've been using this product now for about six months. And I'm telling you that the shine stays. And, you know, sometimes you'll do an anterior composite and you'll get that darkening or you'll get the line at the junction between the enamel and the composite. And I haven't seen that in this material. So it's a nice material. And one thing we haven't talked about, Dr. Simos, is inventory. I mean. That's a big deal when you can reduce inventory. I mean, what has that done for you, Dr. Simos, as far as reducing inventory on your direct restorative cases? Because I evaluate so many products and I have a lot of inventory of product out there, especially composites. But what it can do for you is I don't need, I need an A1, an A2 to really... cover the spectrum, maybe an A3, but not very often. So you can reduce the amount of composite you have in your arsenal up to 80%, I think. Which makes it easy, obviously, for inventory control, but also your staff, right? Oh, yeah. Less mistakes. There's less waste. They're not confused. Right. And how much material were you throwing away in the past? You know what? You go into your drawer and you see that it's, it's, it's, it's, it's already expired and you just like, oh my God, you know, what a waste. And so, yeah, you, you, you end up throwing away a lot. You end up not using a lot. It's just, and you know, then, then there are those materials where you only use once a year or twice a year. Well, you don't need to do that anymore, you know, because these materials so optically correct that you just need to have a limited inventory. Let me ask you this, Dr. Simos. There's a lot of conversation right now about simplifying restorative workflows from A to Z, the whole thing. Everything is workflow, digital workflow, simplifying. And it makes sense. I mean, that's what we want to do. and working with our labs, obviously, for our indirect cases. But from your perspective, where does simplification truly elevate clinical outcomes as in the use of a universal composite like what we're discussing? And where does it start to work against us where it crosses into oversimplification? Yeah, that's a great question. And I think it's something that the clinician... should think about. Workflow simplification, in my opinion, only works when the material supports it. And Grandioso 4U does that by using one composite system across the anterior and posterior indications. You know, I reduce inventory, eliminate unnecessary decision points, and increase consistency. So the literature consistently shows that operator-related factors like isolation, bonding, curing are the dominant predictors of success. And when a material like Grandiosa for you allows you to simplify choices without compromising performance, it actually improves outcomes by allowing clinicians to focus on fundamentals, really. you know, getting it right. So where simplification fails is when materials don't live up to their claims. And that's not the case here with Grandioso 4. Simplification really enhances precision rather than undermining it. You made a really good point because you could have the best material in the world, the best universal composite in the world, and you could be disappointed with it, even though it's gone through years of R&D and testing. And it's been out there with lots of cases to back it up. If you're not isolating well with composite, you get away with a little bit more with Glossionomer. But if you're not isolating well with composite, it ain't going to work, right? Correct. And, you know, that's one thing that I'll tell clinicians all the time is that I will isolate with rubber dam 98% of the time. It just works better. It's five-star dentistry. you don't have to guess you and and do it properly you know so that so that you don't have the leakage now sometimes in the anterior or in in the in the sides you can get away with cotton roll isolation that's fine um and and i'm not saying that that it's that you shouldn't do that. But I'm just saying that, yes, isolation is really, really important in my opinion. And these factors, this preparation, it's like anything else. When you build a foundation to a home, once the foundation is built and then the next team comes in and starts framing it up and then all the inside stuff is done. If you don't have a good foundation, you're looking at all sorts of problems down the road. So talk us through tooth number 30, DO, you got an old decay in there with amalgam from... 35 years ago, and they need to take it out. Tell us how you use this universal composite step-by-step so that you're doing everything you can clinically and your staff is on board to make sure that you can get 10 years or more out of this, maybe 15 years out of this direct composite. Well, the first step is isolation and making sure that you have everything isolated. The next thing is, what matrix are you going to use? I'll have all of that out on my cart ahead of time. So we have everything out and ready to go. And I'm a real believer in being prepared for what you're doing. You don't have to get up from the chair 15 times to go get material. But beyond that, my workflow is this. We'll take and clean out all of the old restoration. Once we clean out the old restoration, we'll make sure that everything is solid. We don't have any other decay in there. And then we will use a conditioner, phosphoric acid. And I'll use a selective etch because I use a universal adhesive. So I will put the etch around the enamel margins. And I use a sectional matrix like a Paladin Plus or a Garrison. And once we have the etch all done and rinsed out, then I'll go ahead and use it. a universal bonding agent and the universal bonding agent i use is futurabond you and that's a vocal product as well but the thing i like about The clinician has to be very careful about the bonding agents they use and the composites they're using it with so that they make sure they're compatible. That's a whole other lecture. Yeah, I mean, no doubt about it. And I've talked to you, and I don't want to break your flow here because we're up to doing the adhesive right now. And talk about scrubbing it in and that kind of thing because that's important. But before we resume that, there are a lot of dentists that feel much more comfortable staying within one system. Because if there's any troubleshooting to be done and they contact the manufacturer, the manufacturer who's making the composite is going to say, what kind of adhesive system are you using? And when they find out it's not theirs, they'll say, well, and then when you contact the adhesive company, they'll tell you what kind of composite did you put over it. By staying within the system, there's some accountability, number one. And number two, you know that the company that's manufacturing both of those products set the whole thing up so that they're compatible. That's right. You're taking the guesswork out and that's what you need. As a dentist, there's too many variables. There's so many variables. Let's get rid of the guesswork. All right. So you're at the point where- So adhesive, yeah. Yeah, the adhesive. And the important thing there is that this is another overlooked piece that I really think is important is your- light. Your light curing has to be spot on. Your light has to be a quality light. And so I'm a real believer in that. So again, we'll light cure. And I use a 20 second cure. Now that's the beauty of this. Then we can just go ahead and then I'll measure how deep my restoration is. Some of those depths in the box, in the proximal box are deeper than four millimeters. That's for sure. So when we're taking out an old amalgam, you can almost bet that it will be deeper than four millimeters. So your layer, you'll have to layer twice with these, with this grandiose. Do you use a flowable? on top of the adhesive at all? I do. I'll use the Grandioso Flowable. And what I like about that is it's a great technique. I started using that a number of years ago, but it'll just make sure that everything flows into the matrix and into the cable surface margins and things like that. So absolutely, we'll do that sometimes, especially in a posterior where maybe you don't have visual on that distal box. so yeah that's a great technique um we'll go ahead and put the grandiose for you now that adapts really really well to these cable surface margins and we'll we'll fill it up into four uh four millimeter increments maybe we'll use in that situation two layers but we'll do a 20 minute cure a 20 second cure sorry um and um do you overfill overfill it the second i'll usually overfill it but i'll also use a um an instrument to go ahead and brush it into my into my margins and and that's before that's before you cure the second four millimeters yeah yeah and you didn't mention about scrubbing in the adhesive Just tell us about that real quick. I think that's a really important point. I think that you should scrub in your adhesive. That monomer, that has to get into those dentinal tubules. And a lot of times I'll see clinicians, they'll just lacklusterly put in these adhesives and, oh yeah, it's in there. But no, you scrub it for 20 seconds and all over the inside cable surface margins of the tooth. And I think that's a really important process that you do. Absolutely. Basically, from the time that patient sits down and you enter the operatory, how long are they sitting there until they're ready to go and that DO on 30 is done and they're out the door? For me, I'm a pretty fast operator, especially with Grandioso 4U. It's, you know, with two fills and the 20-second cure, it's they're out the door from start to finish on a lower because you have to sometimes wait for anesthesia, I would say 40 minutes. Okay, without the anesthesia. Without the anesthesia, you're, you're looking at 20 minutes, 10 minutes, 10, 15 minutes to, to put everything in. Right. So 15 minutes, you can do the whole procedure. I think that's including isolation. For sure. Yeah. Yeah. Cause you know, once you, and I, and I challenge clinicians to start using isolation because once you start using isolation, it becomes a really easy patients love it. Assistants love it. And you'll love it. In closing, as we wrap it up, Dr. Simos, and again, we appreciate your time. Do you think we're at the point now where one material can confidently handle nearly all everyday direct restorative dentistry without compromise? Yeah, I think for everyday direct restorative dentistry, I think we're there. I think Grandioso for you is a strong example of that reality. And one material can now... When you use this one material, you can now confidently handle the vast majority of direct restorations without compromise in strength, aesthetics, and longevity. So you'll keep evaluating new products as they come along because companies reach out to you for this. So contact us. Let us know if you find something better, find something that you even think is more advanced. But what I'm hearing about this one is we're getting to the point where, Anything else could just be incremental where it's not going to really make a difference clinically because we're at the point where we've really reached a level of chemistry that kind of addresses all the issues. Yeah, I think while materials continue to evolve, absolutely. But the bigger opportunity right now is helping dentists trust what's already available. And so Grandioso for You represents how far universal composites have come and how they can simplify dentistry without lowering the standards. And that's really what it's all about, is just being confident in what you're using to make the patient happy, to make your team happy, to make you happy, to reduce stress. So are we there? I think we're there. I think we're there. But I think that, you know, you're going to see better materials as our technology improves. Yeah, that's one of the... Which is exciting. Yeah, that's one of the things that keeps our career exciting and that things are... I mean, what's changed in the past 10 years in dentistry is mind boggling. I mean... Oh my gosh. Right. I mean, you've been practicing how many years now? 35. 35 years. So what you've seen change in the last 10 digitally, and it's just... and now with a ai moving into so many parts of our of our business oh my gosh phil it's it's like a whole from 10 years ago it's like a whole different world our workflows are not even similar to what yeah i mean in some ways it sounds like a really good thing but for a guy like you who's been doing it 35 years it's challenging because you know you're talking about new equipment uh new ways of doing things just yeah you were very comfortable you thought you had it all figured out 15 years ago right i mean yeah but but i will tell you i wouldn't go back to the old ways of doing it because i think that um it all of this new technology the CBCT’s the inter-oral scanning the 3d printing you know it it makes life so much better so much easier and all you have to do is just embrace the workflow you have to learn the workflow it's a little bit tedious at the beginning but really you know If you're not part of the evolution, you're really... Left in the dust. Left in the dust, yeah. CBCT is becoming standard operating. Oh, for sure. I mean, a dentist that examines a patient for the first time and does a full workup that does not either farm out to a CBCT somewhere else or have one machine of his own, his or her own, is not practicing. what i would say is acceptable level of dentistry today i mean cbct just offers so much information so dentists that are dentists that are resisting that have to be careful they have to be very careful yeah and you have to play you know if you think about it, you have to play on a level playing field. And I think your patients deserve that. I think that they're coming to see you for the trust to fix their problems. Without a doubt. See, that's exactly, you just hit the nail on the head. That's what we do. That's the whole purpose of... being a healthcare provider, patients are coming to you, you're the one that knows how to fix them and make them better. And if you're not utilizing the proper materials, techniques, tools, going to continuing education programs and learning things from your colleagues and staying up, I'm not saying you have to read PubMed every night and read every article, but there's lots of ways of getting the information without not enjoying the rest of your life. Oh, for sure. Oh, today, more than ever, because you've got AI that you can plug in anything now and get the answer. Right. Well, you have to be careful of that to some extent. Yeah, you do. We look at ChatGPT all the time. Yeah, you have to correct it. You can't trust it. Half the stuff is wrong. Yeah. But they'll get there eventually. All right. Well, listen, Dr. Simos, great conversation. I love your candor. It's always good to have you on. I need to get you on the show more often. Oh, that'd be nice. Yeah. Thank you so much for your input. My pleasure. Thank you. Thank you, Phil. Appreciate it.