Episode 803: Universal Composites with Dr. Marc Geissberger: What Dentists Need to Know

Welcome to Austin, Texas, and welcome to the Dr. Phil Klein Dental Podcast. One of the biggest trends
in restorative dentistry is the emergence of universal composites, materials designed to simplify
shade selection and inventory while still producing highly aesthetic, predictable results.
But what are the real benefits of these materials? And are there any limitations we should know
about? In this episode, we're going to sit down with Dr. Mark Geissberger, a dentist who has
practiced for over 30 years. and was chairman of the Department of Restorative Dentistry for 15
years at University of Pacific Dental School. We're going to have a very candid conversation about
how composite materials have evolved, what you should look for when evaluating a new restorative
material, and how universal composites are changing the way many dentists approach direct
restorations. We'll also talk about a very exciting new universal composite that has some
attributes that really are... very unique and very beneficial to our restorative work.
So if you are a clinician using composites in your practice, I think you'll find this conversation
has some really useful clinical pearls. Before we get started, I'd like to thank all of you for
tuning in. If you're enjoying the show, please follow us on Apple Podcasts and Spotify, and even
better, leave a review. By doing so, you're not only showing support for what we do here, but your
reviews are instrumental in getting more dental professionals to listen and benefit from our
content. We really do appreciate it. Dr. Geissberger, welcome to the show. Thanks, Dr. Kalai.
Good to be here. So let me start with this. It seems like... time you turn around, there's a new
composite on the market claiming to be stronger, more aesthetic, easier to use. These are all
buzzwords we hear all the time. Looking beyond the marketing, what innovations have truly changed
composite dentistry over the past several years? Dr. Klein, that's a great question.
You know, it's really interesting to kind of watch the evolution of composite materials. back in
the day and i'm going back 10 years it was all about number of shades you could put in a box and
you know they probably market those shades to us on ego saying hey doctor you know you're a master
with composites and you need our master's kit and it has 38 shades and four different
translucencies and you'd spend thousands of dollars buying an introductory kit and then you'd end
up using 10 of the shades at most maybe five So there were lots of buzz around you need all these
different shades to do things. But I think the greatest really advance in some of the technology
used in composites is management of glass particles, making them far more translucent and far more
chameleon like. And the markets really responded to those quite well. So we've seen that kind of
evolution. Now, the evolution went super far to one shade to match everything,
which really was a promise that didn't live up to its. it's reality you're talking about those
single shade yeah you know they say oh we can match you know any color on the vita shade guide and
really unless you're colorblind that's an incorrect statement you know they don't match they match
a2 really well and the further you get from a2 they're less likely to to match the tooth super well
so what really happens is you look through the composite to see the color of the tooth And so
there's always a gray tendency. But some of the new technology that I've been blown away with,
especially Voco's new composite we'll talk a bit about, is really revolutionary in color matching.
Yeah, and that has to do with the way they've clustered the shades, right? They've narrowed it down
to five out of the Vita shade guide. It covers 16 shades in the Vita shade guide, but they've got
five shades to do that. But yes, that's it. So it covers 16 shades, but they've got this cluster
matching, which... been just thrilled with its match. It's just unbelievable.
Most of your patients, and I'm an endodontist, so I haven't done a lot of composites in my day,
certainly not the newer ones, are A2, A3, right? Isn't that the bulk of it? Yep. So if I had a
patient, let's say, that wanted whiter teeth, they wanted a higher value than A2, what would you
use in this particular composite that you're talking about now, which is Vocos, called Grandioso
for you? Yeah, Grandioso for you. You jump to the A1, which covers everything from B1,
A1 to C1 and D2 and matches extremely well. Now, is there a body shade as well as an enamel shade
or is it together? No, this system has really simplified how we work.
So a lot of the systems rely on different translucencies. to achieve an aesthetic result what this
has is a very unique transformation that occurs so the first time i used the material i was a
little troubled when i first put in the tooth because when i put it into the tooth i said wow this
really is quite translucent it's quite gray now i hadn't shined a light on it yet which was
fascinating to me and as soon as i irradiated the material with our light there was this visual
transformation that occurred. And it literally turned from translucent to opaque.
And it matched the tooth perfectly. It's wild. It's so weird to sit there and see this.
right before your eyes change from a translucent to an opaque enough to match the tooth.
Right. So this material maintains translucency so that it can depth cure,
I assume, four millimeters. It allows the light to go. Correct. Right. Yeah. So the brilliance here
is, hey, let's have it translucent enough during placement so that when we get to cure it.
We can cure it. And as we cure it, it transforms to a more opaque, more lifelike looking material.
It's fascinating. So the one thing clinicians have to be aware of is that when you're placing it in
the tooth, you're placing this material, you're going to say, hmm, I'm not sure this A1 is going to
do what I think it's going to do. It seems to be a little gray. You'll be shocked the second you
hit it with a light. And it's really quite interesting. And you can do this on a tabletop.
Take a little uncured and put it over a piece of your dental cord. Take another piece,
same size, put it over the dental cord, cure one of them, and you'll see that one, you can see the
cord through, the other you can't. It's fascinating. Yeah, so that is one big advantage. But I want
to ask, and we'll get back to the material itself in a second, but I want to ask you in general
about universal composites. They're marketed to be used posterior. and anterior now on the anterior
you're an aesthetic dentist right you do a lot of cosmetic dentistry how can you achieve the
translucency at the incisal edge for instance in the social four social six With a universal that
you also use for posterior teeth, do you cut back and then add a separate layer on of something
else? Or does this material not need that? Well, you know, honestly, if there was that true
translucency where you're almost blue-gray in appearance, none of the universal limited shade
composites are going to get that effect for you. You'd have to cut back and put something in.
on a regular basis is pretty limited it's only in those youthful teeth where we see a lot of that
translucency as we age we flatten our teeth and we lose most of that translucency so yeah you'd
have to cut back in that particular situation but that means in practice you have to go from five
shades and you may have a few translucent shades of your favorite composite because they're all
compatible right for just that special need right so so basically it's achieved its goal of
reducing inventory right by providing you with absolutely five shades for 16 shades right and
that's a big thing now i do want to talk about radiopacity for a minute Most of us, when we look at
composites, we're looking at aesthetics, we're looking at handling, we're looking at strength, and
all these things are, of course, very important. But radiopacity, from a diagnostic standpoint,
is really super important. And for those of you who are dental geeks out there, and I don't mean to
say that in a disparaging way, I want to talk about how we measure radio opacity, because I think
it's important to know that when you're evaluating different composites. We measure radio opacity.
in what we call aluminum equivalent. And not to get too scientific,
but what that means is if a dental composite has a 200% aluminum equivalent,
it would require a piece of aluminum two millimeters thick to achieve the same radio opacity as one
millimeter of thickness of that composite material. Now, in regard to the product we're talking
about today, Grandioso for You, its radiopacity is off the charts. 900% aluminum equivalent,
which is exceptionally high even by today's standards. So that means to get the equivalent radio
opacity of one millimeter thickness of Grandioso for you, you would need nine millimeters of
thickness of aluminum. And just to put that in perspective, dentin is approximately 100% aluminum
equivalent. Enamel, 200, 250% aluminum equivalent.
Now, the composites that we used to use, I don't know, 7, 10 years ago were 300 to 500 aluminum
equivalent. Now, this product is 900% aluminum equivalent, which makes it one of the most
radiopaque direct restorative composites you can buy. And I think this is a huge help from the
diagnostic standpoint because we're talking about identifying restoration margins,
recurrent decay, hopefully that doesn't happen, voids. and overhangs.
So my point is, when you're evaluating a composite, make sure the radio opacity is where you want
it to be, because diagnostically, you need that radio opacity. Yeah, so this is really interesting.
Basically, you get radio opacity two ways in a composite. The first way to get radio opacity is to
select glass particles made of a very radio opaque material.
the second way you increase radio opacity is to drive the glass content up so the higher percentage
the glass generally leads to a little more radio opacity and if you're thoughtful in the glasses
you choose you can drive up radio opacity so when you think about a composite a highly filled
composite is going to naturally be more radio opaque than the same material that's been kind of
watered down, let's say with resin, more resin. So the classic example of that is if you take a
flowable, flowables are challenged radio opacity because they have to be flowable far less glass.
And it's the glass that gives them radio opacity. Now, in this case, in Grandioso for you,
what they actually did is they're using a high percentage of terbium.
Terbium is what most composite companies add to their barium glass or zirconia glass to increase
its radio opacity. Well, in using terbium, what they found It was the glass that provided this
beautiful change in color. But not only that, they stumbled upon a composite of very high
radiolucency because of the high concentration of... Radio opacity, you mean? Radio opacity.
Right. So the interesting thing about that is I don't think they ever went into this saying, hey,
let's shoot for 900 because that's over the top. When you look at this on a radiograph, it looks
like a mountain. Right. But it's a huge benefit because there's no missing it. I mean, you can see
it. Literally, I took an x-ray of it the first time, like, wow. So if your x-ray technique is
good and your beam is perpendicular to what you're trying to image,
then you should be able to see voids. You should be able to see overhangs pretty easily. Very
easily. I mean, it's a huge advantage to have that high radio opacity. And that came from both the
glass selection and... The fact that the composite's filled at 91% by weight. Yeah,
now- That's a lot of glass. Yeah, now I wanted to ask you about the 91%. I don't think there's any
other composite out there that's filled to that level. I may be wrong, but 91% is just an
extraordinary amount of glass, right? In a resin matrix. How do they get the handling with that?
How does that not be very difficult to handle or flow? You know, that's a great question.
And I believe it has to do with the shape of the glass particles and the combination of the glasses
they used, which is quite interesting because generally speaking, you're right on. You add more
glass, the composite gets stiffer. Most doctors will tell you, I like a composite to be soft and
creamy and malleable. And to get that, generally the filler content wouldn't be down in the high
60s to low 70 rate. And so when I first got this and I said, hey, we're 91% filled,
I had in my mind that this is going to be as stiff as a board and unusable.
And when I took it out, I never tried in a patient first. I tried on a Tylenol and I took it out
and I expressed him like, this can't be 91% filled. There's no way.
This responds like a 75% filled.
They went a long way to engineer this because really, Dr. Klein, I think the most important in any
selection with composites, number one is nothing to do with how many shades it come in.
Number one for doctors is handling. How does it handle? For me, number two is radiopacity.
Like you mentioned, I want to see this in the two structure. And then number three gets down to
that. OK, how aesthetic is this? How functional is it? How simple is it to use? And,
you know, when I think of those top three, this really meets what most clinicians are after.
Yeah. Now, let me ask you this. Having this thing filled at that level reduces shrinkage, right?
Now it's down to like, I think with that material, it's 1.4%. Now,
how does that compare to other composites that are universal? This,
of course, is extremely relevant toward postoperative sensitivity down the road. Yeah.
So, you know, the average flowable now maybe shrinks 3% to 5% depending on the brand.
The average conventional composite might be as low as 2.2%,
2%. And that's still pretty good, but to get it down to 1.4 because of the high filler load,
less resin is really beneficial clinically. You're far less likely to have volumetric shrinkage.
You're less likely to see white line formation at a margin due to polymerization stress.
So there's a lot of benefits really in having a highly filled composite.
And the other thing that's really important to realize with composites, As the higher the filler
content generate lower shrinkage, as you mentioned, higher flexural strength, better wear
characteristics, and improved polishability with a sustained polish.
So everything improves with the addition of more glass except handling.
With one example, this composite. It's got great handling. I was completely impressed by its
handling. You know, again, a lot of these companies make claims. A lot of these companies are
introducing new composites all the time. So it's difficult for, you know, the GP who's not as in
touch like you are with the manufacturers that test this stuff. So when you're evaluating a new
composite, what do you do as part of your evaluation? What protocol do you have before you actually
use it on a live patient? Because I know the true test, you know, eventually will come from using
it on real patients. And then when do you make the decision to say, this is going to be my go-to
composite, for instance? Yeah, it's a real fair question. I think, you know, honestly,
we all have typodons from dental school. And I actually really think that clinicians should get in
the habit of taking a model out or a typodon, expressing the material, handling the material,
placing the material, expose it to a radiograph. And for me, number one is always handling.
So if I'm going to get a new go-to composite, it has to handle as well as my current composite or
better. And then it has to have that high radio opacity. I have a standard that says,
hey, let's be over 300. And that's hard to match sometimes, especially with flowables.
But there are plenty out there that are radio opaque enough to see. So I put it through the gamut
of... it out can i carve anatomy how does it respond do when i put it in my composite warmer how
does it respond because i do use a composite warmer to change the handling of composites i use then
making sure it's got that high radio opacity and then for me the final test is contouring and
polishing when i put a lustre on this how does it look and those three things really help me say
okay this can be a go-to composite Right. Now I do want to ask you about the warming because I was
going to, you mentioned it, I was going to ask you about it. It's getting more popular now for
dentists to use warmers. Is that what you call them? Warmers? I don't know what you call them.
Yeah. Composite warmers. Sure. Warmers. Because it actually does change the viscosity favorably so
that you get better adaptation. But then it also. When it starts to cool,
you start to get more viscous. So there's a learning curve there. So tell us about what your
experience is going from not using a warmer to going to using a warmer and what should dentists be
looking out for? Yeah, this is really a fascinating subject for me because I've really been puzzled
by why so many doctors haven't adapted warmers. And, you know,
honestly, Dr. Klein, we get stuck in the way we do things.
going to stay there as long as possible and be dragged to a new product for fear of obsolescence.
You know what I mean? It's like, oh my God. First of all, that's human nature. And second of all,
if a dentist is doing something for years successfully, you can't blame them for saying,
you know what? I've been doing this for 10, 15 years. I've had... few failures. And this is working
great in my hands. Why do I need to switch? Yeah. So I'll give you an example. The old hybrid
composites, the first ones out, were super soft and creamy. Why? They were filled around 60%,
maybe 65%. They were also fairly translucent because they didn't have a lot of glass in them. They
shrunk quite a bit. They didn't polish well, and they never held a luster. But with that said,
Dennis would say, but I love how it handles. And they're like, okay, great. So what happened was
companies started producing composites that were by all regards, superior,
better filler content, less shrinkage, all these things improved, except Dennis would say,
I don't like the handling. So I'm a kind of sciencey guy. I'm like, okay, wait, you're telling me
I've got half the shrinkage, better, twice the strength, better wear characteristics.
I got to figure a way to use this stuff. So I always equate composites to cheese,
okay? So if you ask the average Janice, you got brie, you got gouda, you got cheddar,
and you got Parmigiano-Reggiano. Which one do you want to put in a tooth at room temperature?
And they'll all tell you, give me brie. Some will say, well, maybe gouda, but none of them say
sharp cheddar or Parmigiano. They want the gooey stuff. They want the gooey stuff. Well, the
reality is... composites, and I don't care who manufactures them, are better than old composites,
just technically. The problem is most of them are like a sharp cheddar. And some of them get even
up to the Parmigiano-Reggiano, where they're so stiff doctors say, no way. The reason I've
employed composite warming is I can take a product that tends to be fairly rigid and get it to
behave like a Gouda or Brie by adjusting its temperature. Not only that,
and this is back to basic chemistry, when you heat up something from room temperature to 155
degrees, that heat actually helps drive monomer conversion forward.
So there's lots of studies now saying a dentist who places a composite that's warm cures
immediately within two minutes, which is a long time between increments. You reap the benefit of
greater monomer conversion, greater depth of cure, greater hardness. So there's a ton of science to
support composite warming. But put the science aside, I like it because I can change the handling
of a composite. Now, in the past, did you use flowables to get down in the box in adaptation with
the stiffer composites in the past? Yeah, because you almost had to. They were too stiff and you
could never... You could never ensure based on their filler content and their rigidity that you
would get full adaptation. So we put in a flowable,
still a reasonable technique for dentists who haven't changed. But what I noticed with Grandiosa4U
is I've tried it first without warming. I'm like, wow, this is really quite soft. This responds
well without a warmer. But there are times like you describe in a box form where I may say, you
know, I'd like it a little softer. Great. I'll just heat it up. So I'll change my game with the
same material based on, you know, how I want the material to respond. Class fives.
I like it softer than in, say, you know, an anterior. I don't want it to slump. So.
You can change it up with composite warming, but this material handles so well, you may not need
to. Yeah, what kind of warmer do you... There's a company called,
I think, Adent that sells it. Yeah, Adent is the composite warmer I have.
Oh, that's the one you have. Yeah, and they manufacture for a lot of other companies and private
label to those companies, but it's called the Calcet composite warmer. Okay, and they're universal
warmers. So if you get that, you can use... any composite anything you can warm up flowable you can
warm flowable in it as well. So some people like a really runny flowable and it almost ensures
adaptation. So there's some advantages to doing that for sure. Now, just curious,
as far as your adhesive technique, talk about isolation real quick. How do you isolate a tooth? And
be honest, if you don't use a rubber dam, that's fine. Tell us how you do it. And do you use the
selective etch technique with a universal adhesive or what kind of technique do you use?
Yeah. So fair question. And I'll tell you this, preface this with saying I was a professor and
chair at a dental school for 15 years and a tenured faculty member for 30 years.
With that said, I can proudly say I do not use a rubber dam. I'm not an endodontist.
I'm a general dentist. What I do use is a product called an isolate. An isolate does.
miraculous things for restorative dentistry it holds the tongue away it holds the cheek away it
props the patient open it evacuates saliva and it keeps the field illuminated yeah and they have
isovac they have isovac too that doesn't have a lot if you don't need the light doesn't have the
light but yeah it's a brilliant product and really i can faithfully say that i've i perform at the
same level i did with a rubber dam as i do with an ice light or maybe even better because As that
patient's constantly being evacuated of saliva, everything dries up in their mouth. I mean, it's
quite a dry field. And what I noticed, not in endo, because endo you seal differently, but in
restorative dentistry, what would happen with most of my students is they'd have a rubber dam on.
And when they first put it on, it was pretty darn dry. By the end, when they're getting to the
point where they're going to fill, things are leaking like a sieve. And you're like, okay, this is
not serving its purpose as well as it should. So I look for alternatives. Um,
and, uh, we actually introduced isolate at the university. Yeah, no,
it's a very good product. I had a podcast with Dr. Nate Lawson and he uses it. He uses rubber
dam too, but he also uses isolate. Okay. So isolation is very important with adhesion and also
composites. So it's, I mean, we're talking about, Oh, absolutely. You have to be, you know. I joke
around. I say, listen, doctors, I don't care what you isolate with. You could use a tennis ball if
you can get it in the mouth. That works for you. That's absorbent too. You've got to have a dry
field. Right. Make sure if you're going to use a tennis ball, use a heavy duty tennis ball for hard
courts. Yes, exactly. Right. We can talk to the tennis players out there. So that's interesting. So
adhesive protocol, before you're putting your composite in, you're using a sectional matrix?
band with the two separate. And then, you know, Gemma speaking, I don't have one bonding technique.
I don't fall into a camp, meaning I'm not a total etcher, I'm not a self etcher or a selective
etcher. I consider myself a smart etcher. And what I mean by that is I'll employ all three of those
techniques in different clinical situations. So if I'm repairing the incisal edge. on an anterior
tooth that's only an enamel, give me total etch. If I'm on a combination restoration,
say a class five, I'll selective etch those. If I'm restoring root carries with composite,
I'll self etch those. So I think a universal adhesive is where I kind of land because it gives me
the versatility to do different etching techniques. Right, right. It's all substrate. It's all
substrate driven. Yeah, exactly. Yeah. I think that's just a smart way to go. Absolutely. But I
think it's important for our listeners to understand that over etching the dentin is not helpful in
many ways, especially if you're using a universal adhesive because you're going to lose that.
capability of bonding to the inorganic material that you wipe out when you over etch the dentin.
You need that mineralization there. Absolutely. Yeah, for the MD. I wanted to make one other
comment on the shades, the five shades in Grandiosa for you. And this is important to recognize.
So the market has gone to composites with fewer shades, right?
But what a lot of companies have done, and they won't tell you this, is they produce this new, say,
six-shade system. What they have done is not re-engineer anything. What they do is they go to
their most common SKUs and say, hey, guess what? We sell the most of A2, followed by A3,
followed by A1, followed by B1, and some other obscure. And they create a kit out of their five
best-selling composites and say, we now have a limited shade kit. Well, that is not what VOCO did
with Grandioso 4U. They're saying, no, no, no, that's not what we're going to do. We're going to
actually engineer this so we can faithfully say that an A1 matches A1,
C1, D2, and B1. And that cluster shade matching is how they covered the 16 shades.
So it's not just pulling off your favorite SKU and repackaging. No, that's a very good point. Very
good point. It's re-engineering. So, you know, and I call out companies. I'm like, okay, how is
this different than, say, your 17-shade system? And they say it's not.
You're selectively choosing which shade that you need. Correct. I'm like, well, in that case, I
should just buy the shades I use most commonly. I mean, the reality is you have your finger on the
pulse, Dr. Geissberger, when it comes to these products. as an evaluator you work with the
manufacturers and that's how yeah they have all the intellectual property i mean voca worked for a
decade on learning how to cluster these shades 10 years yeah it's remarkable and they've done a
really good job this to me is kind of the answer to some of the things we've been looking for and
without providing false promises yeah I mean, the key thing is the manufacturers heard it from the
clinicians. They need to reduce their inventory, they need to simplify procedures, and they need to
achieve the aesthetics that their patients want and all the priorities that you outlined before,
what you find that's really important in a material. I know when this Grandioso for You came out,
because I know the people over at VOCO, they're great people and they have a great research
department. I mean, it's... really top-notch and they care they don't put products out until they
have years of positive evaluations and they actually take the feedback from people like you very
seriously and adjust their chemistry and then they send it back to you and say hey is this any
better you know that kind of thing and over the years they've perfected it so That's something that
dentists don't know when they're buying something. And they also should be careful about buying on
price. VOCO is reasonable on price, but never buy a composite because it's on sale. I mean,
that's... Yeah, you got to be really careful. Anywise, pound foolish. It'll bite you in the long
run. Absolutely. Well, listen, Dr. Geissberger, I really appreciate your input. It's always very...
And that's what we're looking for in this podcast program. And I hope our listeners got something
out of this. I can't see how they didn't get something out of it unless they were not paying
attention, right? I mean, it's a lot of good stuff here. All right, listen, have a great evening
and thanks so much for your time. Thank you.