The One-Composite Question: Can a Universal Material Really Do It All?

You'll see these veneer cases sometimes. People with those lower anterior veneers, they look too thick to me. The incisal edges look a little thick. The emergence profiles aren't what I want them to be. We end up with more of a convex surface, and I just don't like that. I would much rather whiten the lower anterior teeth, or all the lower teeth, and do a little finessing with some composite. The cases that I showed, I did one with incisal edges, and I also did one with diastema closure. It just blends beautifully. It's really simple to do. I can do it in a very short amount of time. Welcome to Austin, Texas, and welcome to the Phil Klein Dental Podcast. Today, we're tackling a question every restorative dentist has asked at some point. Can one composite really do it all? For decades, we've accepted trade-offs. Great polish, but limited strength. Strong posterior composites with compromised aesthetics and complicated shade systems. But composite technology has come a long way. According to our guest, Dr. Susan McMahon, we've reached a point where a single universal composite can handle virtually every direct restorative case. And on top of that, deliver stellar results. I'm talking polishability, polish retention, aesthetics, low shrinkage, and coverage of all your aesthetic needs with just five shades. And with all that, Dr. McMahon uses this same universal composite for posterior teeth. where she gets strength and a 4mm depth of cure. Not bad. So if you're looking to simplify your restorative workflow without compromising outcomes, this is an episode you won't want to miss. As I mentioned, our guest today is Dr. Susan McMahon. She's a graduate of the University of Pittsburgh School of Dental Medicine and leads the largest cosmetic dental practice in Western Pennsylvania. She frequently lectures across the United States and abroad and has been voted by her peers as a top Pittsburgh dentist every year for over two decades. 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. McMahon, it's great to have you on the show. Hello, Dr. Phil. Thanks for having me here. You know, I always enjoy talking dentistry with you. Yeah, absolutely. My pleasure. Our pleasure. And before we get started, I do want to commend you, if I may, on the excellent... job you did on the webinar you presented on vivalearning.com in the middle of January of this year. And in that presentation, you walked through four clinical cases that truly showcased what can be achieved with today's newest universal composite materials, which is today's topic. And for those of you listening out there, if you're interested, the title is Universal Simplicity, Mastering Anterior and Posterior Restorations with Universal Composites. And you can watch that webinar on vivalearning.com. Search McMahon, M-C-M-A-H-O-N, and you'll see it on the search results page. And like I said, Dr. McMahon, you did a great job bringing real-world clinical insight into how next-generation universal composites, no pun intended, are reshaping direct restorative dentistry in a big way. So today we'll begin with this. From a clinician's perspective, what would the ideal... universal composite resin look like when it comes to filler loading, resin chemistry, optical properties? And why have those factors traditionally been so hard to balance in one material? I think the best thing that's been happening in dentistry recently is this trending towards simplicity and fewer and fewer products to do more and more procedures. And I'm a big fan of the universal composites. And what's that supposed to look like? Well, I want it to do everything, right? I want to be able to use a single product on my posterior restorations. And posteriorly, we're looking for several things. We want wear resistance. We want high filler particle matter in there. And we want radiopacity. So we want to be able to build posterior restorations that last a long time, that hold up to the occlusion, and that also adapt well to the cavity. walls and don't have polymerization shrinkage issues. Yeah. Now with the additional filler and less resin, you'll pretty much by default get less polymerization shrinkage, right? Because if you have less resin, you get less shrinkage. And that's what some of these new universal composites, one particular we're going to be talking about, which is Grandioso 4U. And we'll get to that in a minute. But the truth of the matter is for years, we've been told that we need different composites for anterior aesthetics. and posterior strength, which includes bulk fill efficiency. So when you're working in the back of the mouth, you want something that you could bulk fill for obvious reasons. Four millimeters would be probably what you're looking for minimally. And you want that strength, which you get with that additional filler. But where it fell short was that anterior aesthetic capability. But now it seems like we finally reached a point where a single universal composite can realistically handle the majority of direct restorative cases. Do you think we're at that point yet? I absolutely think we're there. Right. So before you had your posterior composite that did those things you need the posterior to do, but you couldn't use it in the anterior because the optics weren't right, the finish wasn't great, or if it finished well, it didn't hold its finish, it would look great for... six weeks and then you'd see the patient again and you think what happened to my shine it's gone and um so you really there was no products that you could use in both places so you had to stock posteriors and anteriors and i was you know i was a big fan of the person that had like 15 different shades of anterior composite and i wanted to do all the layering and you just don't need to do that anymore you can get beautiful beautiful results with the composites these universal composites so what do you attribute that to In particular, this new material that you talked about on the webinar, which really, according to VOCO, and I know the people over there, they have a great R&D department. They're a very reputable company. They have this universal composite that's 91% filled, which is more than we've seen in any. what we call a universal composite. I think typically, what is it, 85%, 80 to 85 is what we're talking about. This is kind of a unique distribution of particles, a combination of microfill, nanofill, pre-polymerized particles. It's got everything in there, different shapes. So it seems to me that they've found this secret sauce that has that high fill, but also handles really well. And you've used it. So and i'm not i'm an endodontist retired. So I have not used it Tell us your experience with it and and what is it that's working for you? You're right that it handles well. Sometimes when you hear that high filler content, you think, oh, this is going to be tough to work with. It's not going to be creamy like I want it to be. It's not going to be able to be sculptable for posterior anatomy and for the anatomy I want in the interior, but it's really a beautiful handling material. And I think that what all those particles are doing is getting this optical property that allows it to be translucent when you're So you can get a four millimeter cure out of it. And then as it's polymerizing, it gets a little opacity to it. And those particles are reflecting light and reflecting color and shade off the tooth that you're putting it in and the other teeth around it and truly giving it like that chameleon effect. And we hear that a lot, chameleon and camouflage effect. And you don't always see it with these universal composites. But with the Grandiosa for you, you can actually see it. And if you want to check out the webinar, you can see it pre-polymerized in a tooth and then post-polymerized. And you can see where you can actually see a little translucency at an incisal edge and then more opacity as you're getting toward the body of the tooth. And as we're talking about some of the cases you showed in that webinar, and we talked offline about this, Dr. McMahon, I found it interesting how you were pretty much set on doing indirect in the aesthetic zone in the upper, but going with direct restorative for the lower anteriors rather than putting veneers on the lower anteriors. That might be something routinely done by a general dentist, but share with us the conversation we had. Right. So we do a lot of veneers in our practice. Favorite thing to do is if necessary, we'll do indirect upper anterior. And if I can, I will do some composite bondings, a little bit of direct restoration on the lower anterior for a couple of reasons. I, you know, we definitely have people that want veneers upper and lower and we'll do those cases. But if I'm able to preserve that tooth structure on the lower anterior, I always want to do that. Those teeth are little, those incisors are little. I don't love prepping them. I don't love prepping lower canines if I don't have. to and you know sometimes you'll see these veneer cases sometimes people with those lower anterior veneers they look they look too thick to me they look the incisal edges look a little thick the emergence profiles aren't what I want them to be we end up with like a more of a convex surface and I just don't like that I would much rather whiten the lower anterior teeth all the lower teeth, and do a little finessing with some composite. Like the cases that I showed, I did one with incisal edges. And I also did one with diastema closure. And all a single shade of the Grandioso 4U. I think I did them all with the A1 shade. And different color teeth. It just blends beautifully. It's really simple to do. I can do it in a very short amount of time. Yeah, what was the learning curve for you on that? I mean, I know you've been practicing a little while. That's generous. Thanks a little while. But dentists are a little bit reluctant sometimes to spend a lot of chair time manually fussing around with direct restorative. Now, some love it. And they do it all the time. And it's like anything else. If you do it all the time and you have confidence and you're artistic, it's no big deal. But some of us don't have this brilliant artistic ability. We're good, but it gets a little frustrating when you have to freehand it. It's a skill set that's totally teachable and learnable and repeatable. It's a very easy procedure. We do something called a five minute finish. I think that's on Viva Learning to our five minute finish webinar, how to finish, you know, with one disc, a couple of universal spin brushes. And you can get with this, this material, especially a beautiful, beautiful shine. It's going to last a long time. It really rivals micro fills, but. The simplicity is that you're doing it with one shade of composite. You're doing it with matrix bands that are very simple to use. And it's absolutely repeatable and can be done by any dentist, I think. Yeah. And I think in that webinar that I talked about, you show these cases step by step with really nice photography, which a lot of times we don't see. which I'd love to see more of on Viva Learning in the webinars because you're doing the cases. And, you know, a lot of times the KOL will jump from the pre-op to three steps in and then the final. And then the audience is going, wow, that looks great. How did you get there? You really showed it step by step and you move very quickly through it. And it was really well done. And you even had a happy picture with your patient at the end, especially the diastema closing patient. I guess people could find that on social media. I know you post some of these. So you mentioned shade matching, and I want to talk about that for a second because that's very tied into inventory, right? Because if you have a lot of shades, you have a lot of inventory. Inventory can be frustrating for the dentist and cause inefficiencies in the operatory. But these universal composites, or at least the one that you're currently using Grandioso for you, has a cluster shade system. Tell us about that and tell us how that really helps. minimize inventory and keep things running really fast and smooth in the office yeah i don't know if there's a secondary market for expired composite but if you know of one please let me know because i have drawers full of it right we have all i never can get to the end of my composite um before now because it would expire and before i could get to it right because there was just so much of it you never used all of the ends so with universal shade matching um I think, you know, these five shades of composite basically cover the entire 14 Vita Shade Guide. So when I look at it, I look at somebody's tooth. Are they light, medium, or dark? And dark to me is going to be probably in that range of somewhere around the A3.5, A4 range. If they're a lot darker than that, if you're looking at like really deep seas, then you're probably looking at tinting something. The Grandioso for you also has a bleach shade that I do a lot of work with because we whiten everybody's teeth. The bleach shade works for anybody that's light. So I look at somebody's tooth. are they medium are they light or are they darker and if they're light i'm picking the a1 if they're medium i'm picking the a2 and if they're dark i'm picking the a3 and it blends it really blends um you know i also used it on some class 5 restorations and i'm always frustrated when i see those when you see that class 5 and it looks um it's it always looks a little uh translucent even with the opaque shades or if you put an opaque shade in there it looks too bright um so the a3 grandioso for you bam it just it really nailed it it it it was opaque enough, opacious enough, but at the same time blended with that enamel in a really nice way. So, you know, you don't, you don't even have to, I think you could do 95% of what you wanted to do with an A1 from the Grandioso for you and only get into the deeper stuff. If you're really working with a lot of color or you're not doing a lot of whitening in our office. Everybody's whitening their teeth. Yeah, I was going to actually ask you that. Is it something you do routinely where you whiten the teeth before you put the veneers on? And obviously you do. And by the way, this is such a major contrast to the way it was in the past when they actually sold shade matching equipment. I mean, it was like $2,000 for this machine that would scan your tooth and it would give you different levels of different results. at different parts of you know the incisal third you know the the cervical third the body of the tooth it was insane i mean i don't know how dentists could even do that and make a living with all the time that they put into making these things look good so dentistry is changing very quickly and it's certainly getting i i think it's getting easier is it not i mean with digital workflow or you're rolling your eyes to some extent is it not i mean what Patients are still challenging. I'm not saying that's changed. But with the digital workflow, I mean, just think about the intraoral scanner. That's got to make things a lot easier than doing trays and washes and impressions, right? Oh, without a doubt. I think the ramp up is a little steeper. So you can... You can do cases that might have taken you five years of experience, 10 years of experience before. You can do that faster with technology, with help from the outside dental community, with these new products that say you don't have. to match you don't have to figure out what shade this is and everybody's not good with shade right everybody is not um you know feeling comfortable like looking at it and guessing how much layering can i do and i do remember that remember these sales that come with shade guides and on the back of the shade guide would be a recipe as to how you got that which three shades you had to use to layer to get the shade tab color on the front. And that was, you know, we don't have that kind of time in dentistry anymore, I think. I don't think we ever had the kind of time. I think basically those kinds of artistic renditions of direct restorative were done almost performatively on stage when KOLs would present. You know, that's what they were looking at. Like how to make the audience feel like, man, I'm a terrible dentist because I can never do that. But it's nice to look at it. I'm glad he's having fun, but I'm not doing that in my practice. I mean, that's basically what 90% of the audience were thinking, right? That's what I used to think. And you're a superstar now. You're the key opinion leader I'm talking about. But you've gone the other way. You're the KOL that actually connects to the general dentist out there who wants to do really good dentistry, but needs to understand the practicality of operatory time and overhead. And the patient wants to get out too. They don't want to spend their whole life in the dental practice. And if they're really happy with what you're doing, Dr. McMahon, then that's good, right? If it's biologically sound and the patient's extremely happy, what more do you want to do? Right. I always want to do something and I always try to teach things that I do that are practical, but give you really beautiful results that are simple, but give you great results that you can be proud of. Dentistry that you're proud of. And it looks like I always consider this a success if it looks like I was never there. That's what makes me feel good. Yeah. And when you did the webinar, you showed a picture of you and your patient, the gentleman that you did the diastoma closing on. And you look. as happy as he did. And it was his teeth. That's a good thing, right? It's a great thing, right? To feel good about what you do? Yeah. That's a great thing. Yeah. So, I mean, you found the, like I use the word secret sauce, I mean, not only for the patient, but for your satisfaction that you're getting when you get up every day. So workflow simplification versus clinical compromise, there's often skepticism around materials that promise simplified workflows i guess we're so we have so many black eyes and scars if you've been around a while in dentistry i'm not talking about the dentist that just got out six months ago but if you've been practicing for a while you know that sometimes companies over promise things from your experience dr mcmahon can a highly filled universal composite One that we're talking about here is 91% filler. I mean, back in the day, if you said that, they would say you couldn't even put a shovel through it, right? It's so thick. Can that material truly replace both traditional layering composites and bulk fills without compromising aesthetics or performance? I guess time will tell, but... Certainly since I've been using this, I have had great results aesthetically and I feel really good clinically with it. Like I feel like I'm putting in a really long lasting restoration. posterior and anterior and i've been really pleased with the results um i've been about i guess my oldest ones are maybe like eight months and so we've been through a recall and the shine is this looks like the same day as i put it in the mouth so i'm pleased with that so far and i think i think we have to trust um you know sort of trust our companies too like you had mentioned that voco has been producing really high quality composite material. And even in this Grandioso family for a decade, I've been using Grandioso for a decade. And so I feel really comfortable moving to their next gen. And when I see results like this, it's the one I reach for. I do want to ask you about 3D printing today because we've done some podcast episodes in the past about 3D printing. And I remember when you first got your 3D printer. You were excited about it. I asked you how long it took you to get comfortable with it. How is that going now in your practice? Is it becoming something you're not as excited about, or is it something that's completely irreplaceable and invaluable to your workflow and what you're doing as far as production? I think I'm definitely in the irreplaceable and invaluable category with the printer. We are using our printers every day. I don't know how many I had when I last talked to you, but I've got three operating full-time in my office now. we do just yesterday we printed a prototype for an all on x case so implants went in we do a quick scan you know it's all been pre-planned right but we do a quick scan 45 minutes later i have a prototype ready to go in our patient's mouth optic laser a little bit cure it a little bit and she left with a beautiful restoration um so you built a whole provisional all-on-four provisional by printing it 100% by printing it. So we scan it. For us, that goes to the lab, which is all pre-planned. They take that scan, match it up, layer it on top of their previous design work, and then send it right back to us 10 minutes later in an STL file, and then we print from there. So the collaboration, that's what I'm hearing more and more is what you're saying, and it's right on target. The collaboration between the dentist and the laboratory digitally has become so critically important that that's, first of all, you have to be working with the right laboratory, right? They have to have all the digital understanding and equipment that will fulfill what you're looking to do in your office. seeing patients and doing all the great things you're doing and deferring that workload to your laboratory. But at the same time, you get the efficiency and expediency by having a printer in your office because now the STL file comes back to you. But all the stuff you're not really keen on doing, you have a laboratory that's very sophisticated and very capable of providing you what you're looking for. Right. I don't have the skill set to digitally design an entire case like that. I know functionally what I want it to look like. I know aesthetically what I want it to look like. But I do not have the time nor the inclination to sit at my computer with ExoCAD and design that. So I work with someone to help me do that. So they walked out with a provisional all on four. And that provisional not only benefits the patient in such a big way, but... gives you time to evaluate the case. How long do you typically leave the patient in the provisional stage? We'll keep her in the provisional probably three and a half months, and then we'll fine tune it from that prototype. I'll scan that prototype, and then we'll... Designed the zirconia right off of that prototype that's been in her mouth, that the occlusion has been fine-tuned and the aesthetics are fine-tuned. Although it looked pretty great coming right out of the printer, I've got to say, because of all the prep work. And probably delivered about three and a half months. That's amazing, amazing. And the more you scan, the more digital information that lab gets. Now they're doing facial scanning, which covers the movements of the jaw if you opt into the jaw tracker part of it. So you take it from one extreme to the other and it fills in the gaps. You know, you don't have to do a face bow transfer anymore and an articulator. Do you have a facial scanner at this point or not yet? I have a ray face, a facial acquisition scanner, but I don't have the motion scanner. Jaw tracking, I think it's called. Jaw tracking scan. Yeah, that's relatively new. The next time I talk to you, you'll have one. Probably. Sorry about that. Yeah, so it's easy. for me to say sitting behind a microphone to say this is a great time to practice dentistry because I'm not out there in the operatory like you are but it seems to me that compared to the way things were even 10 years ago it seems to me that this is just an exciting time to be out there because what you could do digitally and how fast you can do it and how how reliable it's getting and now these new materials like we're talking about here we never thought we could get a material that could do one one material can do all this I don't think you thought that a couple of years ago, right? Oh, no. We would have scoffed at it. It'll never hold up. I'm always going to use my micro fill in the anterior. You know, if you want to be the rock star kind of beautiful dentistry. And I am using this in anterior cases and thrilled with it. Right. So the number one dental practice in Pittsburgh for how many years in a row you've got that award? A couple. A couple, yeah. A few. A few decades. If you're using a new composite that's considered a universal composite for everything and it's working out as well as you're seeing in your webinar, I mean, that's very impressive. And I'm really happy that it simplifies life. It makes it easy for you and it makes it easy for your staff. And it certainly makes it better for inventory where you won't have to be selling it on the secondary market, all your expired stuff. Yeah. That's good. Thank you so much for joining us. We appreciate your time, Dr. McMahon. Hopefully, we'll get you on again soon. Have a great evening. Thank you so much. I appreciate you, Dr. Phil.