Robert Margeas, DDS; Adamo E. Notarantonio, DDS; Rolando Nuñez, DDS; and Marcos Vargas, BDS, DDS, MS examine the latest evidence on material performance, including esthetics, handling, wear resistance, polish retention, and long-term clinical outcomes.

Welcome to the Inside Dentistry Roundtable. I'm your host, Bob Marges. The roundtable was created to be a forum for discussion and debate on topics of interest to the oral healthcare community and the Inside Dentistry readership. On this edition, we'll be discussing advances in universal composites. We got to start by meeting our panelists. This is truly a, a melting pot of panelists. We've got a Greek me, we've got an Italian, we got a Peruvian, and we got a Venezuelan. I love it. The United Nations are here. The United Nations. I love it, and I'm gonna introduce first Adamo Noro Antonio. He graduated from State University of New York at Stony Brook School of Dental Medicine. He is an accredited fellow, and he's the past president of the AACD. A graduate and faculty member of the Koi Center, he lectures on cosmetic, restorative implant, cosmetic dentistry and has published numerous articles in dental journals. He's the co-founder along with Doctor Amanda C of the Impress Lecture Series in Charleston, South Carolina, and maintains a private practice in Huntington, New York and South Carolina. Welcome, Adamo. Thank you, sir. It's a pleasure to be here with you guys. Awesome. Our next guest, Rolando Nunez, DDS earned his degree from the Central University of Venezuela and a master's in biomaterials from the University of Alabama at Birmingham. He has over a decade of experience in aesthetic and restorative dentistry and currently serves as manager of clinical marketing at BISCO. He has lectured in over 30 countries and published numerous articles in the scientific journals in the field of adhesive dentistry. Welcome, Doctor Nunez. I'll introduce Doctor Vargas until we uh get his mic ready. He graduated from the Caetano Heridia University School of Dentistry in Lima, Peru, and then completed a two-year AEGD residency at the Eastman Dental Center in Rochester, New York. He also received his certificate and master's degree in operative dentistry from the University of Iowa where he's currently a professor in the Department of Family dentistry. My brother from another mother, Marcos from another mother, Bob Marjas. Awesome. Thank you very much, pleasure to be here. Oh, I'm really looking forward to this, and you know, before we really get started, you know, I really think we should dedicate this. Round table to one of our mentors who we recently lost, great friend, one of the smartest guys I know when it comes to adhesive dentistry, Doctor Byung, who. Absolutely amazing gentleman. Oh my God, yes, he's going to be missed by the profession tremendously. So this is for Bian. I think he'd be very proud of what we're doing and He taught us so much, so rest in peace, may his memory be eternal. So, before we get started, Marcos, you know, um, we talk about universal composites, you know, some of our viewers might not even know what really is a universal composite. Oh, what good question, Bob. Um, I was gonna ask the same thing for me, you know, let me tell you my, my, my idea and then you know we everybody can pitch in and think about it. A universal composite, my idea, it's a, it's a composite that kind of balance a lot of things. Because we need to start with the thought that there is not a perfect composite that doesn't exist. So what is a universal is a balance of a lot of the best from all worlds again, not reaching perfection, but balanced mechanical properties. Balanced handling. And the optical properties to make it somehow look aesthetics at the same time it can be used for anterior and posterior restoration. But also has some simplified shade system. Um, without being Layering type of situation that again anterior and posterior used for anterior composite anterior and posterior composite that to me in a nutshell is what a universal composite is like a potpourri of the best of every world of every world without making it perfect but uh versatile that's what my definition is. Anybody wanna you guys wanna add to that at all? I was going to just pretty much second what Marco said, you know, when you think Universal, you want it to be applicable everywhere. Obviously that's never going to be the case because it's not going to work everywhere, but I, I think it gets you. To 70, 80, maybe even 90% of situations and I think that that that's good for simplicity for keeping stuff in the office, you know, and it depends on how you practice too. I mean, if I showed you my schedule today, you'd think I'm nuts because I have two books going side by side, you know, I don't have time to layer 8 layers of composite on somebody who walks in with a with a class 4 fracture today. So for me this is the perfect circumstance for that at this moment, so. You know, and, and let's be honest, when it comes to composite, not everybody has Marcos Vargas hands, right? So they, they might struggle with it, and this may give them a better opportunity to improve aesthetics when maybe layering is not their thing, they're not that, and that's OK, you know, that's not for everybody. Um, so I think it gives you some options, not only for the anterior aesthetics, but for posterior simplicity. Keep it simple, one color, one system, then go. All right. So, um, from a product development point of view, when, when, when a universal composite is, is, is the, is the main goal, Um, Doctor Vargas just, you know, hit the nail on the head. I, I, it's gonna have physical properties to withstand, you know, the, uh, the posterior, uh, tear and wear, but also it's gonna have good optical properties and of course you want the simplicity of a shade system that allows to, you know, diminish a little bit the thought process when it comes to layering. So the way I see a universal composite is, is like your everyday workhorse that you can use in the anterior and the posterior and achieve, you know, good results and good outcome in, in, in, in most of your cases. Of course, I think that if you want to do high-end aesthetics, probably a universal composite is not gonna be the best choice, um. You want to use something a little different, but like Doctor Adamlo said, layering is not for everyone. High anesthetics with composite work is not for everyone, so I think universal composites can be an interesting workhorse to have in, in the office for good clinical outcome. Yeah, I, I totally agree with that too, and you know, um, on that Rolanda, I wanna ask you too, you know what advancements do you think in the modern universal composite most differentiate them from like the previous generations and you being a researcher and. Um, working in that field, what has changed the most, do you think, from the previous generations of universals? Lesser shades, more shades? I, I, yeah, I think that, you know, you have the, um, the, the filler technology is, is, is always something that every company is trying to. Improve and trying to experiment, you know, either to achieve higher strength or to achieve higher aesthetics or to achieve higher polishability. It all depends on what you're looking for, but shading systems is what seems to be one of the largest, uh, biggest issues when it comes to You know, um, placing a composite specifically in the aesthetic region, so what you have is offerings from different companies with simplified shading systems, whether it's something that they, you know, they categorize it as, you know, light, uh, medium, and dark, you know. And those three options should theoretically encompass most of the shades in the Vita shade guide. Whether it's true or not, that's the goal, you know, so you have different options. You got products like Omnichroma, one shade, one syringe does it all. That's, that's, you know, interesting, you know, it doesn't work in every case, but it works in a lot of cases. It's an interesting product, so I think in the shading. Um, trying to get the most amount of shades in the least amount of syringes and offerings is what, uh, is driving the universal composite, uh, research. Marcos, do you want to add to that at all, or you know, I agree again with Orlando here too. Um, I think I like to think about, yeah, these materials as stronger materials than in the past. But at the same time, they can hit a much broader range of clinical situations. That kind of a, in a nutshell, to me, it is a universal composite. It's a stronger and uh you can use it in much broader clinical situation. Um, I think to me that's the biggest advantage over the years. Yeah, and actually I, I wanna even get a little more specific to that because I just used one today on a case where I did some edge bonding and a couple diastomas on a younger young man, I think he's 21, 22 today, and I was able to do it in one universal shade and, and I don't know how you guys feel, but for me back in the day. A diastoma closure edge bonding was a lot harder when we didn't have those because if it sometimes straight enamel was too achromatic and it got gray, forget about the achromatics like a like a milky white or whatever, you couldn't use that for edge bonding because you'd see a gray stripe, but even the, the enamel, some of them were a little too translucent. I feel like the. Universals have a combination of that. Achromatic chromatic enamel color with a little body in it so that blend when you have a diasma space I don't see that delineation like I used to in the past if I picked the the wrong composite I feel like I can get away with more with a universal than I could back in the day. Yeah, hey, Marcos, you know, in, in which clinical situations do you find universal composites most effective, and do you, do you see any limitations? Because I know you've worked with a lot of single shade composites and you've worked with maybe a three shade composite. What, you know, where would you say? They're most effective and, and what are the limitations? Well, I think more effective, you know, without limitations might be posterior restoration because you don't have the aesthetic requirements, and these materials, I, in my opinion, they're very strong enough to withhold a medium to a small size plus one plus twos. So I think that's the ideal, you know, this is pretty much one single shade, you know, hits it all. For the anterior, I think the discussion changes a little bit because it changes into the field of aesthetics and part of that is what are we trying to imitate? Like if you have a tooth that is fairly monochromatic, these materials will fit perfectly. Small class 3 is diastema like uh Adamo just said, they blend perfectly. Now, when you have an imitate a class 4 with a contralateral 2. That is has a lot of translucency halo characterization that is something that aesthetically a universal composite is never going to match. In those situations you have to layer and get it to the beauty of a normal tooth. Now again, in Adamo say this before when you're in a busy practice. It's, it's almost impossible to layer because layer takes two things a lot of practice, a steep learning curve, and time. So for most practitioner this doesn't happen, doesn't exist. The insurance company pay you a certain amount of money for a Class 4 that buys you a certain amount of time in the chair. When you wanna extend that time to layering, all of a sudden it's not productive. I believe we have to think about it in my point of view as an educator. I need to educate these students to work in private practice in an environment that is normal or let's say medium range that you. That you charge you live through insurance charge certain amount of money all of a sudden a patient comes with these aesthetic requirements and it's very difficult for a general practitioner to do this aesthetic cases to the fine degree. Yeah. I agree. Rolando, you wanna add to that at all? You know which clinical situations are most effective and limitations? When, when we were developing um our universal composite um you know option offering, um, we focused on strength and from a clinical perspective. The posterior region was something that we wanted to, like, we wanted, uh, we would like for our users to, um, have a preference of, you know, using our composite quantum in the posterior region because of its handling and because of the, the possibilities of creating something that looks nice enough and it's very strong, but I've, I've, I've had the I, I've given this composite for people that do high-end aesthetics to try and, and they, they. It's not that they don't like it, they feel it, it, it's not there, you know, to do some interesting cool layers and effects, even though we did try to incorporate certain shades like bleach shades and incisor shades, it's not there, but that's not the main purpose of the material, you know, so I agree with, with Doctor Vargas. When he said, well, when you got a layer, this may not be your first option. When you want to mimic something that has halo and translucency and opalescence and all these things, yeah, a universal composite is, is, is, is not going to be enough, OK? And that's OK. It's, it's part of the game, it's part of the limitations, and it is what it is. But as an insurance-based practice, that composite works very, very well because it's good enough, it handles well polished, and for the everyday person who's not, you know, getting 500 to $600 a tooth, that's the kind of composite you want to use. Yeah, yeah, and Adamo, you know what factors have the greatest impact on achieving aesthetic outcomes with universal composites? Are you using it more toward the posterior, using it for small restorations? You know what factors would you say have the greatest impact or procedures? 100% for posteriors, right? And I think whatever system you're going to. Decide on is, is really gonna be personal and handleability and how you like it in, in a class 2 because I'll tell you, I like my composite in a class 2 to feel different than I like it for my anterior stuff. So that's a whole, that's a whole another discussion in itself. So I think posteriors is a no-brainer. Like I said, I, I think in the past, uh, it was a little trickier, but now I think these universal. are taking such a good chameleon effect with not just 11 system like Rolando mentioned before, but you're giving me light, medium, dark. I think you hit a lot more success in the anterior and in the same places that I mentioned before, diasthmas, a little edge bonding, rounding a corner, even adding a, a, a, a little bit of, of width to a tooth with the composite in the past, it was hard with just One layer because it was usually you picked enamel, it was gray. If it was Denton, it was too opaque. But these universals have a good balance, in my opinion. So, I've been using them more and more in the front, to be completely honest, but in specific cases. Class 4s, it doesn't hide the fracture well enough for me and my hands. That's just me. Uh, but for diastomas, for edge bonding, I, I love them. I think they're great. You guys wanna add to that at all? No, I, I agree 100% with, uh, with what Adamo said, you know, again, high aesthetics, it doesn't get you there for, I would say 70, 80% of the cases and 90%, 95% from the dentist, absolutely 100% for me as a private practitioner, I'm looking literally at handling. I don't want it to be sticky. I want to be able to polish it fast and, and like how do the handling characteristics, um, Rolando, even, even with the composite you guys developed, you looked at the characteristics of polish retention, wear resistance, and shade. How do you feel about that all in one type of composite, being able to achieve it, and you feel pretty comfortable achieving that? Well, you know, uh, it's interesting that you ask that because, um, We have machines that measure things, you know, um, we can measure fracture toughness, we can measure wear resistance, we can measure. Flexural strength, compressive strength, right, and we have numbers and we can compare that to other products or to other types of materials. And that's important because it gives you a very good idea of physical behavior, but when it comes to handling, it's very, very personal, and you know, we at Bisco, we we've created our, you know, the company has grown based on adhesive dentistry, right? So if If, if Doctor Sa for example, would have told you, Doctor Barges, uh, Doctor Barges, I'm giving you this bonding agent. It's in a bottle, it's a black bottle. You put one drop in the mixing well and then you place it on the tooth and you're like, yes sir, I believe what you're saying. I'm going to do it. That is a non-tangible, um, how do I say it, experience. It's a drop of adhesive on a mixing well. But when I give you a syringe of composite, now you're gonna feel it in your hand. It's very tangible. So for us has been very difficult. To find what a sweet spot is. There is no such thing. It's a moving target. You cannot, you know, hone in and say, oh, I'm gonna get this handling because what you like, Adamo may not like. Then Doctor Vargas is going to throw it out the window, right? Because everybody's got a different. Opinion, you know, so it's very difficult. We, our composite doesn't stick to the instrument. That's a fact. We have a machine that measures that, but what I don't have is a machine that mimics Doctor Vargas' hands. I don't have that. So it's very difficult to create something that everybody would like. And Marcos, you, you talked in the past about handling and polishment. I mean, what, how important is it to you of handling polishability, wear resistance, fracture toughness? If you're looking at a universal, is there any of those particularly you say I have to have this? Well, I think you have to have a strength, you know, there's no doubt about it, you have to have a strength, cause you're using it as an anterior and a posterior, and a posterior, pretty much, it needs to be a strength, you know, for the posterior of the mouth. At the same time, I think, Polish retention should be up there because especially when you're close to the Geneva, you know, you don't keep the polish, then bacteria is going to get trapped and how composites fail. Now, or even flipping the equation, we can look at how composites fail. And they in the literature say for two reasons they fail recurrent decay, oh, polish rotation is important because as in trap plaque, and the other uh factor why composite fail is fracture, and that's directly related with strength, fractural strength and fractured toughness. So those two characteristics to me are the most important that I will definitely need to have in a composite that I will use as a universal. Abdominal, yeah, see, you guys are too smart for me, right, because I, I don't really know what fracture resistance means, tough strength. So this is how I roll. I get a composite and I say, Rolando, is this good? Did you test it? He goes, yeah. Use it. OK. But then he's right. When it comes in my hands, I might be like, actually, this stuff sucks. I don't like the way it feels. I don't like the way it handles. So I throw it in the garbage and then I find another one and I say, I'm not smart enough to figure this out. Rolando, does this work? And he texts me back, yes or no. So, Yeah, I trust Rolando because, not because he's my friend, but because he does this day and he knows all the data and all the tests and that's fine. But the limiting factor is gonna be, and I get, every time I post a class 4 composite on Instagram, I get 1000 DMs. What composite did you use? And you know what I write back? I will physically send you the carpool that I used on this particular case and there's no way you're gonna figure it out because Seriously, like you have to, you might hate it because the reason I picked the composite I like in the anterior is very simple. I like the way it handles. Every company makes very pretty composite now, especially the ones that focus on anterior aesthetics. So for me, it's, I got to be able to manipulate it fast because I got 30 minutes to do to fix a class 4 that a kid fell on their face. Yeah, I totally agree with that. And let me tell you one thing. You have to trust the company that's making the material and I will say this about Bisco Bianca over the years had sacrificed profitability and income for one reason. He did not want to bring a one bottle universal adhesive out until it was ready to be made. And you know what, Rolando, that actually cost him profit. Because other people brought it out and you know what, you wanna work with manufacturers who, who have made products that have tested at the time for sure, you know, it's so interesting that you say that because today we were having a discussion with a couple of people that we just hired who were explaining the timeline. Of, of the Visco's adhesive development starting with Alban 2 all the way to Alban Universal and we got there was a gap where Visco didn't do anything when it came to new products which were the 7th generation and the 6th generations and the question was why didn't we have anything he said because you know the doctors are say we don't, we don't know enough. We need to learn first and then we come up with something that actually works. Now, Adamo said something, I want to be really quick, um, about how he uses things and whatnot. Um, I saw a dear friend ranting about composite on social media two days ago. A dear friend from, um, from New York. Talking about how composite people criticize the composite because they don't last long and they actually last longer and whatnot and so forth, you know. I'm not gonna name names here. I will, I don't. He said it, I didn't say it. Now, I wanted to write something on that post, but then I watched it again and I totally get where he's coming from. However, Here, here we have, uh, information, you know, data from the NIH, National Institute of Health, right? The NIH, and this is, this is, this is in writing, OK, the NIH establishes that the average. Clinical performance of a composite in the posterior region. It's 5.7 years. Now, hear me out. Average. Average 5.7 years. And the two reasons why a composite fails is because like Dr. Vargas said, You have secondary carries. And you have fracture of the material. That's it. Now, you may argue that compo my composites last 20 years. Yours and I have to believe that if you're a fellow of the American Academy of Cosmetic Dentistry, or you are a professor or former professor of the University of Iowa, specifically the restorative operative dentistry department and head of the operative dentistry graduate program. You must be a little bit above average. You're not average. So when you criticize this thing about, oh, it, it should last longer, yes, it should, but it's not. Is it poor bonding? Is it poor material selection? Is it not using a rubber dam? Is it not using a proper matrix system? A combination, all of the above, whatever, but it is a fact that composites are not lasting as long as they should. But and I want to make this clear, I'm not saying that composites suck, which is what Abdamo criticize when people say composites, they stink. I don't know if I should have said suck here in this recording, but, OK, great. So I understand where he's coming from. Composites don't suck. But there is a technique, uh, sensitivity to them because not every operator is as good as others, so they should last longer, but they're not, unfortunately, you know what I'm saying, so I just wanted to put that out there because I thought your rent was awesome. I loved it. Adamo, Adamo, on that note, being a fellow of the AACD, what do you think contributes most to the long-term success of composite restorations? I mean, in your opinion, is it though, is it your technique? Is it isolation? Is it all the above, the adhesive? What do you think contributes to long-term success and And we'll end it with that question. I'm gonna tell you there's two answers, and they have nothing to do with bonding or rubber dam or anything like that. I think those all help obviously, but I'm gonna tell you I've seen composites that I did 18 years ago that are still in the mouth in the anterior, and let me tell you something, I didn't know Rolando then, and that means I didn't know how to bond because I didn't know what the hell I was doing. I just read directions. That's all. I read the bottles and that was it. So, well, at least you read the bottles. I did that. Well, if these people read the bottle, the IFU, yeah, and I remember years ago Gary Alex, when I told him what I was using to bond veneers in this very office that I'm at right now, he told me my stuff would be gone out in 4 years minimum. And they're 20 years plus. So where was I heading to? I think the two reasons are one, and this was my point on my rant the other day, because what people, when they say composite chips, if they take a patient, they put a composite on their chips, OK? Then they go, well, we gotta do porcelain. So they put the porcelain and the porcelain does not chip, but where did they just put the risk? They took the risk off the composite and they put it on the opposing tooth, because if your occlusion's off, you're done. OK, so when your occlusion's off, the composite's gonna break. When your occlusion's off, your porcelain might not break, but your opposing tooth is gonna wear, OK? And then number 2, and I learned this trick many years ago in Gary Alex's office. I watched him do a smile design and take photos, and the last photo he took of the patient, he said, Please put your hands on your lap. And he took a picture of their fingers and I looked at him, I go, what are you doing? He goes, he's a nail biter. And I'm gonna keep it in my record because she comes back with broken veneers. Guess what? I'm gonna recharge it for him. So, what about habits? I had a kid come in here 22 years. I did a class 4 when he was 6. And my partner saw him and said, how did that stay in your mouth? He goes, Doctor Adamo scared the crap out of me and told me, don't ever bite into a bagel or an apple, so I've been cutting up my food for 22 years. So your answer is, I think if you're an average bonder and understand occlusion and then your patient doesn't screw it up, your composite should last. It should. But we missed that side, and that's what annoys me about social media. It chips, it chips. OK, so just don't fix the problem of occlusion or a bad habit, and let's just switch the porcelain, porcelain and destroy the other art. So that was my rant the other day. I wish you chimed in. We would have done a live. It would have been amazing, bro. No, dude, and, you know, don't get me wrong, but I'm going to repeat it again. You're not average. You're not. Neither is Doctor Vargas, neither is Doctor Vargas, and it has nothing to do with you thinking you're so, no, no, no, I'm telling you, I'm watching from the outside. You guys are not average. You are not average. So you can't talk about the longevity of a composite. It doesn't make any sense. Well, I did. In closing, do you have anything, anything more you'd like to say, Marcus, about this topic, or? Well, no, just for closing, I would say that, you know, just going to the long term success, the composite is only part of it. I agree with Adamo. There are so many things, right? The adhesive technique, isolation, polymeritation. We haven't talked about like curing the conservation of the prep that how conservatives your prep, the smaller versus bigger occlusive management. Damo, I'm with you there and also the patient factors carries risk, oral hygiene, function, diet, occlusal forces. So there are so many variables why the longevity is affected. So the material is just a small part of all these, all these. So it's not in the composite, it's just so many other factors that, that, that, but again I always think about what do they fail. How you fix it fixes the things that make him fail, right? And is. When we talk about composites, is make it stronger and making polish the polishability or that luster last longer. That's kind of my final, my final words here, Bob, and thank you for having me here. Oh, you're welcome. Rolando, anything else to say before we end? No, no, no, I think that, you know, um, I am, I'm not a clinician, so I, I can't really have an opinion on the clinical work done by me, but I do agree with, uh, with you guys that there's so many variables that will have an impact and we as a manufacturer can only control. Um, the testing of properties, but we don't have a way to simulate what happens in somebody's mouth with so many things going on, right? So I want to express that um we can only go so far when it comes to product development and then we just hope that Um, you guys do the rest, you know, but we try to put a good product in your hands, and, but that's as far as we can go. Yeah, Rolando, you know what, your composites, I've never seen one of your composite fails, my friend. Oh, I appreciate that, Doctor Barnes. It's good to know. I said because you're above average and the capacity. No, you just, no, you just say that you never put a composite, so I've never seen one of you fail. Hey, Adamo, I promise you you'd be able to get back to your last patient, and that's the last word on this edition of the roundtable. If you have further questions or comments regarding universal composites, please send them to my attention at roundtable@connection.com. Thanks for joining us. We'll see you on the next edition of the Inside Dentistry Roundtable.