The Fixed Podcast

Crossing Blades with Dr. Bernardo Nunes de Sousa: Part 1

September 03, 2024 • Fixed Podcast

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What if mastering implant dentistry could transform your career? Join us as we welcome back the incredible Dr. Bernardo Nunez de Sousa, a true innovator in the field of implant dentistry. From dreaming of becoming a dentist at just five years old to his advanced training across multiple continents, Dr. Sousa’s journey is nothing short of inspiring. He shares his deep fascination with Dr. Paulo Malo's All-on-4 technique and his adventures from Portugal to the Netherlands, and even to Cuba, where he learned invaluable lessons about technique over tools.

This episode is packed with Dr. Sousa’s personal anecdotes, including the exhilarating challenges of advanced cases and boot camps in Brazil. We discuss the evolution of full arch dentistry, moving from overwhelmingly complex cases to mastering them with finesse and confidence. You’ll hear how advanced training programs like the Full Arch Club master course can elevate your skills, making what once seemed daunting now routine. The conversation takes a deep dive into the transformative impact of innovative dental techniques and the critical role of soft tissue management in implantology, revealing the secrets to achieving long-term success in dentistry.

We also touch on the importance of preventive care, mentorship, and continuous learning to stay ahead in the field. From the nuances of soft tissue grafting to becoming ambidextrous, Dr. Sousa shares his wealth of knowledge and practical advice. The discussion underscores the significance of documenting your work and maintaining a critical mindset for continuous improvement. Whether you’re a seasoned professional or just starting in the field, this episode promises to equip you with the insights and inspiration needed to excel in implant dentistry.

Dr. Tyler Tolbert:

My name is Dr Tyler Tolbert and I'm Dr Soren Papi, and you're listening to the Fix Podcast, your source for all things implant dentistry. Oh, and, welcome back to the Fix Podcast. So we have what I believe should be a very familiar face by now. But if not, shame on you, you're going to learn today. So right now we have Dr Bernardo Nunez de Sosa in with us, so he's going to be yes, and this time he's here in visual.

Dr. Tyler Tolbert:

You can actually see the man himself presenting, and he's a beautiful man, so we're really happy to actually have his face on the recording today. So welcome, bernardo, and thank you for your patience with us as we still try to navigate global time zones. That's a very difficult thing for us, it's true man, thanks for the invitation for the second time.

Dr. Bernardo Sousa:

Actually, we had this recording. It was one year ago or two years ago, I don't remember.

Dr. Soren Paape:

One year ago maybe, yeah, probably a year and a half.

Dr. Tyler Tolbert:

Yeah, something like that.

Dr. Bernardo Sousa:

Yeah, soren was not on the conversation, it was just between us. Now we have a threesome, which is also fun. That works as well that works as well.

Dr. Tyler Tolbert:

Yeah, yeah, so it's. It's been a very fast year, whole lot of developments. I definitely want to get into all the wonderful things that you're doing with full arch club and all the new projects that you have in mind as well, but for those that don't know who you are and don't know about all the great things that you brought to our industry, would you mind just giving us a little bit of background about who you are, what your training's like, your journey to get up to this point, all the way back to dental school? Just give us that brief history and this is something I really love hearing, because Bernardo has, throughout his career and his training and those who he's learned from his mentors, it's very closely intertwined with the history of All in 4 itself. He's really gotten to rub shoulders with such big names in full arch and what we do, and he's a big name himself, so I'd really appreciate to hear that.

Dr. Bernardo Sousa:

Yeah, so where did this start? It actually started, man, when I was five. In my birthday, when I was five, I said to someone that I wanted to be a dentist, and my parents actually have this on tape. I think I mentioned this in the last episode.

Dr. Bernardo Sousa:

Yeah, and then in Portugal you do the primary school, then you do the high school and then you go immediately to university. We don't have the college like you have in the US. So I went to dentistry and to the Catholic University and the only thing I really cared about was the oral surgery part. I cared so much about that that I could not study only the slides that we had to study for the exams. Each time I had an exam I would read the whole goddamn Peterson book. I still, it's true, man. I still remember today. Actually, I have the book here. I still have. I wanted to show you then the camera will.

Dr. Bernardo Sousa:

Anyway, I read the book maybe 10 times, man, during dental school and at the end of more or less in the middle of my dental degree I saw this interview of Paulo Maló on the national television and he was claiming to solving these very difficult cases within one hour surgery, very fast for the patient, with no grafts, no guides because there were no guides back in those days and always with immediate loading. And when I heard about this the first time, as I said, I was still in the dental school. I was very intrigued because what we were being taught was maybe six implants, six to eight double sinus lift or bone grafts and bone substitutes, then wait six months, nine months with a removable denture, which is the worst thing in the world, especially on top of a graft, and then wait. He was avoiding this and I was very curious about his technique. But it's maybe in the US is the same as it is in Portugal. Nepotism is universal and you need to know someone that knows, someone that will pull the strings for you if you want to work with a big name or in a very good clinic. And I was the first guy in my family to become a dentist, so I didn't know anyone. So I tried to pursue my post-graduated education to learn those things that Paulo Malone was talking about.

Dr. Bernardo Sousa:

So I went to the Netherlands. I did a one-year post-graduation program. It was a residency in maxillofacial surgery. It was awesome, but it was not about implants. It was big maxillofacial surgery. It was awesome, but it was not about implants. It was about it was big maxillofacial surgery stuff Orthognathics, a lot of orthognathics, trauma, oncology cases and that was not exactly what I was searching for.

Dr. Bernardo Sousa:

Also because I could not do these things then after that in Portugal for legal reasons to do this In Europe. The legal part of maxillofacial surgery varies a lot from country to country. Even if you have a degree, even if you can do the maxillofacial residency as a dentist in one country, you move to another country. The dentist that will not be recognized. So I could not do that in Portugal and it was not. My goal was to do this rehabilitation with fixed teeth very fast with minimally invasive stuff for the patient. So I did a two years master's degree in oral rehabilitation and implantology and then I went to Cuba and in Cuba I stayed there about six months and man, that thing this time was so rudimentary. I don't know how it is today, but back in those days doing like a residency in surgery in Cuba, it's like you have one elevator, one forceps and go ahead.

Dr. Bernardo Sousa:

And that was quite good, because you learn that all the fancy tools we have nowadays, man, they may help you here and there, but they are not the essential, you don't really need them.

Dr. Bernardo Sousa:

Maybe it helps you a bit. But it's technique, it's understanding, it's 3D visualization, it's to work like a lever. It's not really about the tool, it's about yourself. And so, yeah, meanwhile I was always sending my resume to Malo Clinic, but I never got a reply. But suddenly that reply came and they sent me an email. Actually, when I sent my resume this last time, it was a night out with my friends. I was a bit tipsy when I saw the, when I saw that they were recruiting for a clinic that was about to open in Paris and I at that point, with the right amount of alcohol, it was like Paris, paris can be nice.

Dr. Bernardo Sousa:

And my argument without knowing what was going to happen.

Dr. Bernardo Sousa:

And yeah and the guys. They called me and I went to Lisbon because I had to stay there for one or two years to do the whole training there. And it's quite nice, because the first day nowadays, I think, it's not like that, and because Paulo Maló is not working at Malo Clinic anymore. It was a big, there was some stuff going on there.

Dr. Bernardo Sousa:

I really don't want to go deep on that, but back in those days, when I entered Malo Clinic, paulo Malo told me this Bernardo, so what do you know about implants and oral rehabilitation? And I said look, I did this post-graduation, this residency, this and that, blah, blah, blah. And he said look, from now on, if you want to stay here, you forget all of that. Forget it didn't happen, because from here we will teach you from zero. If you are okay with that, you stay with us. If you want to keep insisting on those old school kind kind of stuff, man, maybe this is not for you. And the guy was quite clear on that and I enjoyed that and so, yeah, that's what they tell you.

Dr. Tyler Tolbert:

When you start getting into like quantum physics, they're like forget everything that you thought you knew.

Dr. Soren Paape:

This is day one, you know nothing.

Dr. Tyler Tolbert:

That's pretty much how much of a revolution that is. Yeah, yeah and.

Dr. Bernardo Sousa:

But he was right. And the guy was right and my first day working at malo clinic was actually a quad zygo. Can you imagine you get all these experiences like bam?

Dr. Bernardo Sousa:

from day zero and and yeah, so this was my, I would say, the biggest part of my education. This was what actually changed me, changing my way of seeing things. My philosophy today has has been very impacted from this experience and and maybe especially for the no bullshit approach and something that we can talk later on, but something that I see nowadays a lot of over complications, over engineering of cases, when things can be done way more simplistic and with the same or better results. And in this kind of thinking, I think Paulo was way ahead, very far ahead of anyone in the implantology business, because you imagine what is doing an all-on-four with tilted implants, with no grafts, with exposed threads, in 2000. We are talking like 24 years ago, 25 years ago yeah, it was when he was already doing this and I was getting these cases there.

Dr. Bernardo Sousa:

I was watching not only the new ones, of course, but the follow-ups and the watching these cases that have 15 years follow-up, case after case after case. I mean, it's, it's on the numbers. Man who has the numbers has the reason. And so, after this, I went to this big DSO. I was the head surgeon of their busiest clinic. I was doing revisions, revision cases, cases that went that failed or cases that were about to go into the court and they were trying to solve things. So I spent about two years only redoing cases and that gave me a lot of not only endurance, but also how can I say to find bone when it doesn't exist anymore?

Dr. Bernardo Sousa:

And the pterygoid part to tilt them towards the vomer, the M variations, the transsinus. These things became necessary in this time, so that's when I started to Creative approaches.

Dr. Soren Paape:

Say again I said creative approaches.

Dr. Bernardo Sousa:

Yeah, yeah, yeah, more creative approaches. The palatal approach I started very it was. I would say that in 10 cases, maybe 7 or 8 were palatal approaches. And so, yeah, so then after a while you start to see your own follow ups and say this actually works and maybe it works even better in some cases in terms of soft tissue.

Dr. Bernardo Sousa:

So, so, yeah, and then after this I work in several spots getting cases, getting referrals, and then I created the full arch club and we were history yeah, man, the Full Arch Club was was the first, actually the first Full Arch Education Center in the world, and now there are a few more, but we were the first with these principles, with no grafts, no guides, no zygos and no delays, and and, yeah, and, we had the pleasure to teach many people, including these two beautiful gentlemen here in front of me who are amazing surgeons and who are now doing incredible work. You publish a lot, søren. By the way, tyler is more shy to publish. I'm a recluse, yeah, man.

Dr. Soren Paape:

I talk about a little bit on the podcast. I try to post almost every case that I do on my Instagram and challenges and just show the good cases, the beautiful ones, and it forces me to when I'm when I require myself to post them, to really like make sure that I'm doing everything as perfect as possible. I want all my cases to be symmetric. I want efficiencies with my team and I want to show everybody that follows me that's possible to do over and over again and if you look at my cases over time, I actually recently, just on my Instagram, went back to all the cases I did this year and I highlighted them. So if you guys want to see all my cases, you can go back and see everything I've done this year. I was going to do like for all of my cases and then I got to the beginning of this year. I was like, man, that's a lot, so we'll stick with just this year. And if you look at all of them, I mean they all are basically the same approach.

Dr. Soren Paape:

They all look basically the same, and I think that's what you want, right? You want all your cases to be to look the same, because you want things to be efficient, to be repeatable, and that's where you see less complications, more efficiencies with your team.

Dr. Bernardo Sousa:

Yeah, I actually did a video, a real, not that long time ago that at some point it becomes boring. And it's true, it's always the same. If you have the process in your mind, it's like all the cases are. It's the same thing always. It's this kind of anesthesia, this kind of incision, this kind of flap boom all the way until the end. Maybe you have to do some variation here on there. Maybe instead of a tilted distal implant, it's a transsinus, maybe it's tilted but more anterior, or it's small variations, but it's repeatable. That's why I said it at some point it becomes boring. I don't know if this has become boring for you yet, but I promise that it will.

Dr. Tyler Tolbert:

Yeah, I think what is boring just changes over time, right, like you start taking on more and more trophic cases and borderline cases and those might start to make you feel a little bit nervous from time to time, but then this stuff used to make you nervous.

Dr. Bernardo Sousa:

you don't even think twice about Maybe.

Dr. Tyler Tolbert:

you even think twice about it, Maybe you even feel the need to start doing Zygos just to get out of the boredom. You wouldn't be. You're not far off from that.

Dr. Bernardo Sousa:

This was a nasty one, but it was asking for it Fair enough.

Dr. Tyler Tolbert:

Well, it's like you're always chasing that feeling when I was down in. I'm skipping ahead a little bit, but when we were down in Brazil and we did the boot camp with you, I remember like I just felt so excited and a little bit nervous about going in and doing these like really advanced cases and a totally foreign environment. But the cases were incredible and I was doing cases without looking at x-rays and building all this confidence and getting humbled the entire time, but like seeing great outcomes.

Dr. Bernardo Sousa:

If you tell this to the audience man, I will have legal problems.

Dr. Tyler Tolbert:

you cannot say oh, not at all not at all.

Dr. Bernardo Sousa:

I mean, it was beautiful work.

Dr. Tyler Tolbert:

I stand by everything that happened but but you know you come back and now all the cases are comparatively very easy and you're starting to get that sort of. They all just feel pedestrian and normal and day to day, and you're looking for that feeling again because you get addicted to it. It's like I don't know the first time you go skydiving or jumping off a cliff, which you will also do if you go do full arch club stuff. So yeah, you're looking for that kind of challenge. It's true, always.

Dr. Bernardo Sousa:

Yeah yeah it's true, it becomes at a certain point. What I found in my life was like. Going to work was like. It was like going to the library. It's like I have to go there for a while do some stuff and as soon as I get out I have another plans for my day. That was that stopped. This may be maybe many people won't understand what I'm saying, but going to do a full arch case stopped being the interesting part of my day.

Dr. Bernardo Sousa:

I don't know if you relate with this, but I'm saying this very honestly. Like, let's say, for example, I do a lot of referral cases. For example, I do a lot of referral cases Mostly today. I go to some place and I do the full arch and then I go out to it because it's done and I don't have more, you know, appointments in that day. I go, I just do that and then I can leave, and usually my afternoons are the exciting and the difficult part, because I either go running or I have a I don't know I have a half marathon to do or I go wakeboarding things that actually scare me.

Dr. Bernardo Sousa:

That was just a small part of my day, if this makes sense.

Dr. Soren Paape:

For sure. I think that resonates a lot with people that are just getting into full arts too. There's always this period where you know you start and you're so excited about getting used to these cases and getting started with these cases, and it's like you're on this upswing where you're like, oh, you know, you maybe have a couple that go really well and you're like these are great, I know what I'm doing, this is perfect. And then all of a sudden you have, like your first or first couple really bad complications it's like you're back down syndrome, man.

Dr. Bernardo Sousa:

Yes, exactly, drop back down, yeah. And then you're down in this, you're in this pit, and it's like gruger syndrome, man, yes, exactly, you drop back down yeah, and then you're down in this, you're in this pit and it feels like a lot of anxiety when you go to, to work and you're worried about the cases.

Dr. Soren Paape:

But then you slowly, as you do more and more, you build it back up and then it becomes a norm and you're used to the complications and you've seen a little bit of everything. And once you're back up to the top, that's when you get to coast right, that's when it feels like you're at the library. But it does take a couple, a couple of these cycles to get through that to get to where?

Dr. Soren Paape:

yeah, where you're confident, and Tyler and I have trained a lot of doctors here in the U? S and we've seen a lot of these people, you know, get up and they're really excited and then all of a sudden they're down in that pit and they just can't get out of it and they just don't. You know they there's too much anxiety around the cases, but the fact of the matter is, if you keep challenging yourself you know, getting going to work, doing these cases, managing your complications then you'll finally get to the point where you feel like it's rudimentary, Exactly.

Dr. Bernardo Sousa:

And what, let me ask you? Like, let's invert who is the interviewer?

Dr. Tyler Tolbert:

here for a moment.

Dr. Bernardo Sousa:

If I remember correctly, when you took the master course at different times, I believe, right, yeah, you were just starting Full Arts, right?

Dr. Soren Paape:

We were probably, like I would sayler was maybe a year and a half in I was like eight months in a year.

Dr. Bernardo Sousa:

Okay, and then? So we probably had 50 to 100 arches under our belt, but you fairly knew yeah, yeah, and then after. Uh, I guess my question is how did your full arch life change after the bootcamp? After the Full Arch Club curriculum, the master course and the bootcamp Because I follow your cases and guys you are rock stars now, from what I can see. And I'm curious to hear how impactful or not it was on your journey.

Dr. Soren Paape:

Yeah, absolutely. Well, just a little bit of background. Just the audience is aware, tyler and I both did bernardo's full large club master course in portugal and I don't know, you don't, do you not offer that anymore? It's just all in the boot camp no, we do offer.

Dr. Soren Paape:

Oh yes, it's the main course actually yeah, yes, the master course was was great. Went to portugal, um got to to see bernardo do surgeries, um learned a ton. And then we went on to the second course in brazil, where we got to see Bernardo do surgeries, learned a ton. And then we went on to the second course in Brazil where we got to do a lot more hands-on stuff. And I would say after the master, even just after the master course, where we weren't doing it necessarily on patients but we got to do it on models and see the efficiencies in your office and the different techniques that you recommended I was just taking on, I was able to do so many more cases because I was able to see the extent of what was possible with traditional all-on-four.

Dr. Soren Paape:

I feel like a lot of people get these cases and they're like oh, that's a Zygo case, like there's no way I can do that case.

Dr. Soren Paape:

And the reality is there's a lot of these cases that can be done that walk in your clinic and they can be done predictably using some of these workflows. And it's a lot less trauma to the patients when you're not doing these quad zygos or whatever you think that patient needs. And I was able to treat a ton of patients that I otherwise thought I wasn't able to, and I've seen these patients for follow-ups and I'd be amazed of how well some of these patients healed that I previously thought there was not a chance that this is something that I could do or that anybody without like experience doing Zygos was able to do, and my patients were so grateful that I could provide that service to them at. You know the fee, because when you start getting into Zygos, all of a sudden patients are paying double what they would have for a traditional all on four and you're able to save that those anatomical landmarks for if something occurs five years down the line, not at that time.

Dr. Bernardo Sousa:

Exactly.

Dr. Soren Paape:

So that's where, that's what I think, I go to that course.

Dr. Tyler Tolbert:

Yeah, I think for me, before the course I probably referred out I'd say as much as at least five, but as much as 10% of the people who had terminal dentition and they needed something due to atrophic bone or what I thought would need zygos and things like that. That number dropped to what I believe would be less than one percent at this point, in terms of what I can well, you know, less than one percent is amazing man. I believe that. I mean it's a made-up statistic.

Dr. Bernardo Sousa:

I don't have yeah, sure, but we have a feeling on.

Dr. Tyler Tolbert:

Yeah, we have a feeling on that right and so like when I was doing just traditional all-in-four, I felt like I was the person that when patients were told no, or they had to get all these sinus lifts and things like that, I am the solution for those people. Now I feel like I can be the solution for people who have already had all-in-four done and now they're being told that it can't be treated.

Dr. Bernardo Sousa:

Now you are entering the library, man.

Dr. Tyler Tolbert:

Yeah, that's right. That's right. So you're just in a different. You're like, later on in that progression of the extremity of cases and teach someone who was already doing all in for how to do something next level or fix something. That happened and it made me competent in in fixing my own problems, right, like I used to be just terrified if one of my distal tilted implants uh failed because I was like, well, that's all I know how to do, so now I'm going to have to graft and wait and come back and do this all over again. And now I know that I can revise this competently and I almost get excited about it because I'm like, okay, cool, like I can employ this now to fix it. So, yeah, it was just that next tier of provider and there's just all these more problems that you know how to solve and now there's new problems too, but it's all recursive as you continue to progress and bootcamp was absolutely the biggest catalyst for me to get to that part.

Dr. Soren Paape:

Yeah, yeah yeah, I also want to point out too that a lot of my philosophies have changed since the master course Before, when I thought traditional all-on-four was the way to go for every case. Now I see all the advantages, prosthetically, of what you can achieve when you're doing things like pterygoids. Relay those to my patients, because I see a lot of patients that come from other clinics that are getting standard all-on-four and maybe a couple of those distal implants failed and the way that those surgeons will try to relieve that is placing new ones, but more anterior.

Dr. Soren Paape:

And all of a sudden you're stuck with a prosthetic that has a two-tooth, three-tooth cantilever and it's just not a good prosthetically driven approach. I relay that to my patients and I say, hey, there's a lot of other clinics here that'll do this. However, if you come here, we try to do more than four implants when we're able to place pterygoids and create a prosthetic that'll last you a long time. And if any of these anterior implants fail, we still have that posterior support so we can relieve those issues much easier and with more predictability.

Dr. Bernardo Sousa:

The anterior area is never a problem. Losing one or two on the anteriors First it's so rare that we don't even think about it. I don't even remember the last time I lost an anterior one. But when we do, it's so easy to solve. You have the nasopalatine canal. You can tilt them towards the vomer or towards the nasal crest. You have so many options. In the same spot, actually, you can just put a larger one. I mean it's never a problem.

Dr. Soren Paape:

Yeah, absolutely.

Dr. Bernardo Sousa:

But yeah, guys, you are rocking this, but you were saying something very interesting, søren, because after integration, what really matters is soft tissue and cantilever. It's the two things that will dictate the future of that implant. If we take out the systemic factors of the equation. If we take this out, it's soft tissue, quality keratinized band and no cantilever. That's what we know from the literature and that's what we see clinically. Like you were saying, that's what what will dictate if the implants will last longer and if we will not have too much bone loss because of a necessary trauma on the implant. And and yeah, that's it, and terry bites changed my life when I started doing them in 2018, and Pterygoids changed my life when I started doing them in 2018, guys, I had to. I was taking the panoramic x-rays and then I was looking at the result, taking a picture with the phone and deleting them. I had to hide this stuff Because in 2018, if you put 24 millimeter implants all the way back there here in Portugal, man, people would tell I was completely nuts.

Dr. Soren Paape:

So I have these ones and now it's funny how fast stuff can become the norm, right.

Dr. Soren Paape:

True, they see more and more cases, they see literature about it and now like, if you're not doing pterygoid implants, you're missing out on a lot of cases that you can solve much better for the patients that you treat.

Dr. Soren Paape:

And it's funny because I see a lot of clinics here in Denver that have been around for 10 years and the surgeons there they maybe they've gotten comfortable with their standard all in four approach. And some of these patients come to me because they're so frustrated with the fact that a couple of their implants fail and they've been in a denture for two years because they're just waiting for their grafts to heal. And I'm like this is something I could solve tomorrow for you and it's with just taking the proper education to better yourself and I think that's important for your patients when you're doing treatment like this. So I think I think, bernardo, before we start talking about maybe some of these individual cases and I know that you wanted to show some cases and stuff I think the audience, you should let the audience know what the Full Arts Club concept is and how it's progressed over time is, as I said, no grafts, no guides, no zygos and no delays.

Dr. Bernardo Sousa:

So I had contact, a big contact, with other approaches, for example with zygomatic implants, at some point and I did a lot of them in the past. But at some point I had contact with another philosophy, which was the custom implants, aka the superiosteal implants, and this changed my mind to such a point that I started to cook an idea and a treatment protocol that would allow any doctor with the right mindset and with the right knowledge to solve any case without these things, without grafts, without zygus, without delays and with immediate loading. And we have placed together a bunch of techniques, which are the ALON4, the ALONX, transsinusnasal Pterygoids and the Palatal approach. And what I found in my own experience is that if you only have the Allon 4 or the standard Allon X in your tool belt, you will solve about 60% to 70% of all the cases. If you want to go from this 60 to 70% to the 95%, you need the palatal approach. Especially, the palatal approach is the big, the biggest thing that will change your game. The rest, the other 5%, because we are on the 95% now. The rest, you have the transinus, the transnasal, the pterygoids and the custom implants.

Dr. Bernardo Sousa:

And I found that with combination of these techniques and the application of these techniques in the right case, it's not to apply it because, yes, for example, when I started teaching the transinus approach and I saw many colleagues start to apply it without, in cases that they were not necessary, in cases that it was more than okay to do the standard all on four and to pterygoid, to pterygoids in the back. So this is the kind of this is the kind of the wrong mindset that that I try to fight, which is why are you over complicating when you can be more predictable, reduce the morbidity of your case and achieve the exact same result? There is no point on doing a trans-sinus if you can do a pterygoid, and yeah. So we found that with all these techniques, man, it is impossible that the patient comes to your office and you have no answer for them. So we started, we created the master course to teach all of these things, started the created the master course to teach all of these things.

Dr. Bernardo Sousa:

I teach you all the fundamentals of large of incisions, of flaps, bone reduction, the techniques themselves, suture, medication, follow-up. We teach all of these and the students get to watch me and the other mentor, dr Pedro, to do this life surgery. And then, for the colleagues who want the ultimate experience, like yourselves, you go to our life surgery boot camp in brazil when you where you will have the hardest week of your life in oral surgery, but maybe the best as well. And you will apply all of these things into patients in very difficult cases, the cases that, according to tyler he said this on on the interview cases you wouldn't even bother to flap.

Dr. Tyler Tolbert:

You remember saying yes, that's right, that's right, I remember saying it.

Dr. Bernardo Sousa:

Yeah, yeah and yeah, and after the boot camp, really honestly, I think people are ready to to tackle everything and and that's the feedback we have we see this in our students. I see this on you, for example. You are killing all these very hard cases that I follow on social media and other participants as well. So I feel like what I feel is like I felt the need to create these things because, in my mind, the full arch was not being approached the right way. I was seeing a lot of unnecessary stuff and unnecessary grafts and unnecessary zygos. I still see a lot of unnecessary zygomatic implants, to be honest, more and more. But I think that in the future, things will change. I think the custom solutions for patients and I'm not talking about custom implants, I mean custom solutions in general will be the future.

Dr. Bernardo Sousa:

I don't think that dental implants will be the future. I think the future of oral rehabilitation will be a true regeneration of what is lost and not fake stuff, not metal screws on the mouth. I think we will replace a lost maxilla by another maxilla. I think we will replace a lost tooth by a real tooth. The Japanese or the Chinese are already doing this. I published this news on the newspaper. It's on my Instagram If you go there. They were already successful on making a new tooth grow, and so I think it's a matter of fine-tuning now, for example, for partial dentalism, it's a matter of fine-tuning genetics to make the tooth with the right shape to appear in the right place in the right position. If we get this right, I think dental implants will be obsolete. I think dental implants will be obsolete in the next 50 years 50, 5-0, not 15.

Dr. Bernardo Sousa:

I mean 5-0. Yeah, I was about to say hey, now we're starting to talk about our careers, but meanwhile, we have a lot of patients to treat, and I do believe that these patients are way better treated with the techniques that we explore in the course compared with the old school alternatives, if I can put it this way.

Dr. Tyler Tolbert:

Yeah, yeah, no, I totally agree. How would you say, throughout the progression of Full Arch Club, like you've had to teach? I mean, you've taught so many people. There's so many cases behind this. Would you say that the philosophy of Full Arch Club has changed much at all, or have you thrown in some more concepts that you feel, as you've gone along the way, that you've learned better ways to teach people and you talk about soft tissue as well? What sort of things have gotten incorporated in the philosophy as you've gone along?

Dr. Bernardo Sousa:

In the first editions of the course we were not teaching soft tissue and I never thought it was something that so many people were interested in or that needed that teaching. Because for me, the soft tissue grafting is part of my life since the very beginning free gingival grafts, connective tissue grafts and I don't know. I've been doing that since in the dental school actually, so it was routine. And then I found that many implantologists that can be actually great at placing the implants themselves, the the soft tissue was missing and and the colleagues started to ask Bernardo, can you explain the free gingival graft and this and that? And then I said, well, maybe we should introduce a lecture on this. So now we have soft tissue lectures on the master course as well In the boot camp in Brazil.

Dr. Bernardo Sousa:

If the case needs, we do soft tissue augmentation as well in a full arch case, usually in the same act. So we do, for example, a full arch in the mandible that has this minimum keratinized band and we increase with connective tissue graft. In the same day we also we are finishing our protocol for soft tissue grafting on custom superior implants, which doesn't exist yet and we already have it. How can I say it's cleared for us. So when you do one sub, you also do this in the same day and you get the tissue from here and you put it this way.

Dr. Bernardo Sousa:

In this way, we will release this soon and but I don't think that we have changed, like the protocol in the implant part in any aspect. To be honest, tyler, I think I think the concept on the opposite, it only gets stronger and with more and more evidence, and now it's not only for me, it's also from you and from all the people that have taken the course and and I also see people that took our course and now do teaching their own course with these principles. So it's because it works, man, because if it didn't, yeah, it has stood the test of time.

Dr. Soren Paape:

Yeah, yeah, I think soft tissue management is something that is is overlooked quite a bit and it's very critical.

Dr. Soren Paape:

We've talked about this on the podcast before but the best time to to solve these soft tissue issues and once you've seen enough cases and you've done enough cases, you can be pretty certain when you place an implant and you're going to do all of your during if that implant is going to have enough keratinized tissue around it or not. And if it isn't, there's a lot of people who are like they just want to get done with the case and they're like all right, let me just suture this up and send the patient home. But the reality is the patient's going to have a much better experience if you take that extra 10-15 minutes to lay your pedicle flap to ensure the stability of that implant over time.

Dr. Soren Paape:

And it's much easier while that flap's already done in the beginning of the surgery than waiting two years until the patient comes in for that follow-up and you're sitting there with an implant that has maybe endocaryogenized tissue on the paloalto but, there's absolutely in the buckle and you're starting to see some bone loss and some thread exposure and all of a sudden you're in a situation that could have been so much easily fixed in that initial surgery, and that's something that we've talked about with, like Damon on our podcast, and he stresses how much before he could do arches in 30 minutes and he would do cases in 30 minutes and now it takes him maybe an hour to do an arch.

Dr. Soren Paape:

However, he's being much more critical about that soft tissue because he's seen the complications that can occur if you're not. And that's just part of that progression through full arch. Part of our goal with this podcast is to help people prevent those issues prior to to seeing them in two, three years and really focus on doing them right off the bat. So what bernardo's saying about soft tissue management is critical and learning that at a course like like full arch club, where you can go learn palatal approach, learn some of these other implant techniques but then also improve just your traditional all in four through soft tissue manipulation concepts is really critical.

Dr. Bernardo Sousa:

And I think it's so easy, man, that it's a pity that we don't take the advantage of having our hands on the stuff and doing it at the spot, like you said. And but you know what I found with the years when I started to get to the five-year follow-ups, when I started to get my first five-year follow-ups I always photograph all my cases and I was seeing some cases without crotonized tissue that I was absolutely sure that they had good tissue five years ago. So I went to see the pictures and I was like, why did this happen? And you know what I realized with time and with talking also with people that started when I started and people that were able to follow their cases for so long, because it's quite difficult to follow cases to five years or more and everybody was having the same issues Cases that have good tissue on the day have good tissue on one year mark, maybe at two years mark, but after that, man, you start to lose keratinized band and this is something that you guys, you will see more and more when you go close to the five year mark.

Dr. Bernardo Sousa:

Cases that were perfect are not perfect anymore. So the need for revision for soft tissue is a certainty. It is not a possibility, it's a certainty if you give it enough time, and it's something that I changed in my informed consent. Now it says that it will be needed in the future maybe some kind of soft tissue improvement, because you will lose it naturally with time.

Dr. Soren Paape:

Yeah, absolutely. I think that's something that here in the US and maybe you see it in Portugal too, but there's a lot of clinics here and there's a lot of people practicing for large dentistry that tell patients hey, if you come to me, it's one surgery and you're done, you'll be set for the rest of your life. And the reality is then, when a revision comes in the future, it's so much harder to get that patient to agree to do a simple procedure like a pedicle graft, just to increase the longevity of that implant, because they in the beginning they were told hey, you, you won't need anything like this off the bat. So I think, lowering those patients expectations from the beginning and ensuring that they understand that, hey, you're 45 years old and you're in a place where you need a full arch treatment, there's a really good chance that you're going to need not only one revision but perhaps multiple revisions throughout the rest of your life if you want this to last 40, 50 years. And it's that clinician's responsibility, I think, to learn these techniques so when that occurs, they're able to manage those complications.

Dr. Soren Paape:

Oral surgeon.

Dr. Bernardo Sousa:

Sorry, no go ahead Go ahead.

Dr. Soren Paape:

I was just going to say every oral surgeon that I've talked to here in the US that I've asked them their opinion on should you know, general dentists be doing cases like this. Most of them, if they're not super conservative with their thinking, say you know, I don't care what a general dentist does, as long as they're able to manage those complications that occur from those surgeries. And basic soft tissue management is definitely one of those complications that anybody practicing this style of dentistry should be comfortable with.

Dr. Bernardo Sousa:

Yeah, yeah, we can never promise a lifetime results. Look the multicenter studies, which are those who I enjoy reading the most, because our studies done in a bunch of clinics in a certain location and they reflect better the real world scenario, the real world results of the things that we do. And these multi-center studies show that the dental implants, after 15 years or more, only two-thirds are there. Only two-thirds survive the 15 plus year mark, which is something that I feel like not only patients don't know this, but doctors don't know this as well. And this is the harsh reality, the things that we are doing right now. Man, if you have the luck, the blessing, to be able to follow the case for 15 or 20 years, I'm sorry to say man, but one third of those will not be there.

Dr. Bernardo Sousa:

General, obviously, now, yeah, we have better techniques, we have a better soft tissue, understanding and stuff, but if we talk in broadly speaking, that's what the statistics show us. So, and the thing is this if someone loses their teeth by their 40s and those teeth were there, let's say, since the person was 10 years old, 12 years old, so the teeth only lasted 25 or 30 years how can you expect that a metal screw will last more than that. That has no periodontal ligament to absorb the forces. Which is the biggest problem of implants is that they have no shock absorbing ability and that's why we start to lose bone loss early bone loss because the stress has to go somewhere. It goes to the crestal bone and it starts to disappear.

Dr. Soren Paape:

For sure and I think, like you said, when these patients, you know they've lost all their teeth in 20 years, a lot of times there's a lot of contributing factors that go into the reason why that happened, whether it's smoking, poor oral hygiene habits, whatever it is, you know, even though patients say like, hey, I'm done smoking or I'm going to keep my teeth clean now, once they have a new set of teeth in there, a lot of times these patients fall back to these habits that they've had previously and there are going to be complications that occur because of those.

Dr. Soren Paape:

The fact that they have the ability to manage those, I think, will really further a lot of dentists' careers and get to a point where they're like, oh my gosh, all these cases I've done five years ago, I need to revise now. I'm not comfortable doing that. If you just get some of these basics, it'll prolong your full arch career and you'll have a much happier career where you feel like you know, where you feel like you're going to the library every day instead of going you know, somewhere you don't want to want to be, yeah, preventive dentistry and and the complete and the revision dentistry is going to be the future in the short medium term.

Dr. Bernardo Sousa:

To avoid these things from happening, to avoid people from getting implants in the first place, which is something that I talk a lot and you guys are on the WhatsApp group. I talk a lot about this Should this case be a full arch? Should this case not be a full arch? Can I postpone this? Can I do something to try to avoid removing all teeth from this person at their 30s, which is quite dramatic? Because people, we have to understand that people that we do a full arch in their 30s, they will not die with our implants in the mouth. If they have a normal life expectancy, they will not keep those until they die. And how is this for us? Is this a failure? Is this a personal failure? What do you think?

Dr. Bernardo Sousa:

I feel like a bit of a personal failure to doing something that is supposed to be permanent and it's not, and I know that it's not. The statistics show me that after 15 years, only two-thirds of the implants are there. So I feel like we should be doing way more in the preventive side and to delay these things a lot. But unfortunately the healthcare is like guys, nobody makes money preventing the disease, the money is made treating the disease and this. We could talk a lot about this, but this is. This changes the whole perspective that we have on health care is not to promote health, is to promote the disease.

Dr. Soren Paape:

so it's funny. I just this is going down a different rabbit hole, but I actually had a dental cleaning this morning and my hygienist was talking to me about peter attia, uh, and he was.

Dr. Soren Paape:

He's one of the guys that are on the huberman podcast a lot and I read one of his big, one of his big philosophies in medical school was was the lack of preventative care in the united states and the sheer impact of what a lot of these pharmacology departments or, like big businesses, right Pharmaceutical companies push, and they're pushing medications that treat these cases, when in reality, a lot of the people in the United States that have issues like diabetes or overweight or whatever it is, could have been cured through preventative measures, but instead Lifestyle change habits.

Dr. Bernardo Sousa:

Exactly yeah.

Dr. Soren Paape:

And instead are treated with drugs and they continue some of these habits. I'm not saying that everybody's like that, but you know it's very similar to oral care if you're in your 30s and we can make you last another 10 years or even 20 years prior to getting one of these major treatments done. I think it's really important and that's something that I know me and tyler a lot about and we really push patients that are coming in in these age groups, unless they're in a position where they're totally not able to be rehabilitated, but we push them to wait before getting this treatment done. The problem is the more and more of these centers that pop up. I see patients that are coming in that are in their early 30s, that have you know teeth that are are totally fine, and they're coming as a second opinion from a clinic that said, yeah, right that you know I'm like, I'm like what?

Dr. Soren Paape:

like you are totally fine, like you do not need this done in your situation, and the problem is they're just going to turn around and go to the clinic that said, hey, we can do this today. Yeah, um, so it is a major problem. This is a major problem, you know. You know that in.

Dr. Bernardo Sousa:

In some countries here in europe you go to jail if you do something like this. The the laws in some jurisdictions here are so strict about about implant kind of treatments that you lose your license. Man like this, if it gets proven, the people that will be against the doctor are also doctors from this kind of mindset the correct mindset in my opinion that will prove, because this and this, that this case should not be a full arch. So these doctors have mutilated this mouse. So the consequence is this, and it's usually either suspended license or they banned the guy from practicing in this country again, or you can face criminal charges and end up in jail.

Dr. Tyler Tolbert:

It's seriously, it's no joke, it's no joke.

Dr. Bernardo Sousa:

So I think we are a bit more conservative. I think also, to be honest, in some places maybe too much, maybe too much conservative and try to save.

Dr. Tyler Tolbert:

What is not possible anymore, or at least in the context of full arch rehabilitation, does not make sense to save and that is a fine line on the sense, yeah, for sure, save, and but this, there is a fine line on the sense yeah, yeah, definitely is the other side of the equation, because, yeah, I don't know what the ratio is but like for every patient that I've seen that was treatment planned to have all their teeth removed and get this done. There's plenty of other patients that I feel like this should have been done a long time ago and they've wasted money and they've wasted time and now they've got insane, newfangled, you know treatment in their mouth.

Dr. Tyler Tolbert:

I mean, I've seen people that had, you know, a mini implant here, a standard implant here, they've got two telescopic copings on their natural molars and it's all this removable upper snap in. That never worked. And you see all kinds of things where people are just trying for the sake of saving teeth, but then there's this misguided approach towards just save what's there and it really ends up costing the patient at the end of the day and they end up getting an all-in-four eventually or they just go broke or end up in a denture because they don't have any more to invest.

Dr. Tyler Tolbert:

And there's that too and so it's not just important to know how and when to do this well, rather, I already gave that away it's not just important to know how to do it, but when, and there's times where it's not getting done but it should, and there's times where it's getting done and it shouldn't so I think just I think it's so important that even people that don't focus primarily on full arts that they understand its place just in the full array of what we can do.

Dr. Bernardo Sousa:

Yes, it's very it's. One of the most difficult things is to discuss this topic, because something for me can look like one thing from. The easiest way to create a discussion is to show a panoramic x-ray to 10 doctors, because you will find 10 different treatment plans. But I think it's very difficult to make the line where what is correct, what is wise, what starts to be over-treatment. It's not easy and I think more guidelines are needed for this for the benefit of the patient. Maybe AI will solve the problem. I truly believe AI will be the judge very soon. In most non-criminal things, even civilian things, I believe AI is going to be the judge. There is nothing that is more fair than a computer intelligence to analyze data.

Dr. Soren Paape:

Yeah, we'll see. I feel like the scary thing is that before we're talking about a lot of philosophical ideas, but before any of that gets into actually like make changes, there has to be some serious complications that occur to make things move, and I wish that it was a little bit simpler, but I feel like that, no matter what, that's the what's going to end up happening.

Dr. Soren Paape:

But, I think we've. I think we've we've gone through a lot of the philosophical side of things. I'd love to to move the conversation into into some clinical stuff, and I know we have some questions here for you that we've touched on throughout the beginning of this episode, but I know our listeners really like to talk about some of the basics, and a few questions I have for you, bernardo, are what are some simple things that doctors can do to improve their outcomes of their cases over time and I know we talked a little bit about soft tissue grafting, but I'd like to go into that a little bit and then I'd love to hear what are some mistakes that you've seen about how people approach full arch cases and how can they manage those and prevent those to ensure that they have stability over time stability over time.

Dr. Bernardo Sousa:

I think the best and the wisest and the cheapest thing to do in the beginning is to find a mentor that is very good clinically but also very good mentally. And if you find this mentor, try to work with the person, not for the person. Try to shadow the person or try to go into a course, to this person's course, and try to talk in private. Try to understand how the person thinks, why he's choosing this solution instead of that solution. The clinical, as I said the other minutes ago, the clinical part is the easiest to achieve. To learn something, nowadays you just need to pay. You pay for a book, you pay for a course, you pay to go to a meeting and you learn. And that's the easiest part. I think the hardest part is the mental part. It's to try to understand, or try to put your brain functioning in such a way that you can choose the wisest decision most of the times. What should I do in this case? What makes more sense to do in this case for the benefit of the patient?

Dr. Bernardo Sousa:

In the majority of the times, I think this is the the difficult thing to the most difficult thing to to understand, to learn, because you don't buy this knowledge.

Dr. Bernardo Sousa:

This is something that some people have a natural brain for implantology, for to be a handyman, to work with screws, with bolts to work with in an engineering brain, and this is the hardest thing to teach.

Dr. Bernardo Sousa:

If you don't have a good engineering brain, you can teach all the techniques, all this stuff, but having the right mindset, I think it's the crucial part and in this regard, for example, for me it stopped making sense, for example, to do a quad zygote if I can do a custom implant and preserve all the bone of the patient. This is the kind of mindset that I'm trying to explain is, if you have two or three solutions for the same thing, what things are you putting on the table to make your decision? And I think that the destruction involved should be the first or the second for the benefit of the patient, for example. Then, how long is the surgery going to take? Do I need general anesthesia? Do I not need general anesthesia? Is the patient going to suffer for a long time or is it going to be an easy post-op? All these questions that we make, I think, should guide the decision-making process, and we really try to put doctors to think like this, to teach not only techniques, but ways of thinking about things. But what?

Dr. Soren Paape:

was the second question Soren Sorry. No, I agree with that. I will. I'm just going to give my opinion and then I'll go back to that second question.

Dr. Soren Paape:

The you know, I get asked a lot from dentists who are, or maybe you know students who are in dental school who are really trying to get into full arch and implants and whatnot and they're like hey, I saw that you fast tracked your path towards implant dentistry. How did you do it? What would you recommend for me? And my response is always the same. I always tell them the biggest, the most important thing is learning those fundamentals learning how to take teeth out, learning how to do these things, because that's how you get these efficiencies and when you are efficient in the case and you understand the fundamentals of taking teeth out and laying flaps and all of these things that people might overlook because they think that it's rudimentary. Understanding the proper protocols for doing that will relieve a lot of these mistakes that people run into when they're rushing removing teeth or they're rushing laying flaps and it's causing buckle plate fractures or different occurrences during the surgery. That could have easily been managed just by learning those proper fundamentals.

Dr. Bernardo Sousa:

Yeah, so that's what we spend. You certainly sorry to interrupt you. The master course the first day day, the first five, almost five hours in the morning, is just about fundamentals. Even if you already know how to do Allen four, you will get bombarded with fundamentals in the morning how to do the flap, where to put the blade, where the incision, why is the incision here? And, for example, the vertical releasing incisions, why in this place and not half centimeter posterior? There is a reason for everything that. There is a reason. I would say there is actually a reason to do every single thing that we do in a full arch case, that nothing is doing randomly and absolutely agree with you the, the fundamentals.

Dr. Bernardo Sousa:

For example, here in portugal is quite common. When you go to a dental group it's like you want to do implants Fine, but first you have to take out all the impacted teeth. You need to prove that you know how to do surgery and after you prove this, okay, maybe we will start to give you now some simple implants and then maybe we will give you some full arch cases, but first you prove you know your stuff in surgery. This was the Cuba time for me when I was there. It's like Bernardo, you prove you know your stuff in surgery. This was the Cuba time for me when I was there. It's like Bernardo you have 10 impacted lower molars to take and you have two hours for all these patients.

Dr. Bernardo Sousa:

And we were numbing them like one here, one there, one there, one there and there, and then it was like fabricating cars and that's how you get good at those things.

Dr. Soren Paape:

No, I agree 100%.

Dr. Bernardo Sousa:

The second question Bernardo, fundamentals is the way to go. Before you think about, even before you think about doing a single implant. You need to be very proficient in taking impacted teeth out, at least in my perspective, in doing flaps, in traumatic extractions. You need to be very proficient on this. Only after this you can start to do the the interesting part. But the fundamentals, if you don't have them. That's why I always I told you in the beginning that I always read the full Peterson book when I was in dental school and this changed my life reading the book over and over and over again, because I knew how to solve a lot of complications and I have never seen them before, but I already knew how to do how to solve them when the time came.

Dr. Soren Paape:

And it's all about rentals and a lot of that stuff pairs together right like if you start to to realize how to solve certain issues that occur it. I think it goes for different cases and how to solve different problems throughout the oral cavity and then everything, as you learn more and more, meshes together to get a clinical suite that you can handle these larger full arch cases yeah the second question what do you? What are some simple things that people can do to improve their outcomes for these surgeries over time?

Dr. Bernardo Sousa:

I think one of the hackings that you can do on yourself is start to work with the left hand. This change we forced you. Yes, this is something we do at the master course, actually, and then in the boot camp it's like mandatory. We train you to use the left and this is something that will change your life and I'm sure that everybody will understand what I'm going to say. Now. If you are right-handed and you are going to place a tilted implant on the second quadrant, some patients don't open enough. You barely can fit your hand and the contra angle and the drill if it's a long one, it's very complicated. Plus, when you work with both hands, your level of symmetry it's unparallel. So I think that one of the cool things is start to be ambidextrous. I was not born ambidextrous, I trained myself and now I write with the left, I play instruments and all this. But I forced myself to learn in the beginning and this changed me.

Dr. Soren Paape:

We did the master course after we went the first time. I think one thing I said on that was, if you are going to Bernardo's master course, one thing I'd recommend doing before you go is start brushing your teeth with your left hand, eat your food with your left hand, give you a bernardo will give you an extra pat on the back if you get there and you're proficient with doing that with your left hand and you could actually feel comfortable angling an implant using that left hand, so I agree being able to use both hands back and forth when you're doing these cases It'll make things much easier and it'll make your cases much more symmetric as you do them.

Dr. Bernardo Sousa:

Yeah, Another thing that I think helps a lot of people in the beginning is what I was telling before is to find a mentor and work with the guy or shadow the guy, because you will. What will take you 10 years on your own can take six months with the right mentor and no joke. It's really how fast you can progress six months with the right mentor and no joke. It's really how fast you can progress and something someone in.

Dr. Soren Paape:

Yeah, oh, go ahead.

Dr. Soren Paape:

I was just gonna say in my, in my learning, I had a mentor my last year of dental school and I was fortunate enough to be able to work under him for an entire year.

Dr. Soren Paape:

And so, shout out, dr G, dr he Keeley. He was gracious enough, he had a really large oral surgery background and for an entire year he allowed me to do all of his cases and he assisted for me. And, man, what I learned in that year, like you said, would have taken me a decade after school and there you'd be surprised with how many people just in your local community are willing to help teach and willing to help you come and shadow and before I even cut my first arch I was in the op for probably over 100 cases, just seeing and watching how people manage complications and workflows and how efficiencies with assistance, what instruments to have, and everybody has like different nuances that they like during these cases and if you're able to get a really good background of how all of these different things work, you can bring everything together and that first or second case will be so much easier for you because you know, like you said, you read the book over and over again.

Dr. Soren Paape:

If you're in a mentor's surgical room seeing it done over and over again a lot of these problems that you might have right off the bat, you'll be able to manage them so much better.

Dr. Bernardo Sousa:

Yeah, another, yeah, absolutely Another thing that I also think that helps a lot and it was something that in my life I was searching for this always is to try to learn something from the source or from someone that learned from the source. What I mean was, for example, when I wanted to learn full arch, graftless, immediate loading, I wanted to learn with Paulo from Paulo Malo, from the source, to really drink from the first bottle that was ever created. And this changes so much to a point because, especially nowadays in social media, you see a lot of stuff being promoted with a lot of likes and things like this very big hype, things that are, for example, just not correct or could be better, or there is no reason to do them. If you have something that is perhaps that has a better indication or that can be done with more efficiency or there is pointless to do this because you are adding something without the benefit, without any benefit. So I think that learning things from the source or close to the source, I think it's a good thing, not only in full arch, but even in soft tissue management. We have great people that that invented the techniques that you can learn from the source. I, for example, I learned to do bone blocks with Frank Zastrow, which became a good friend of mine, and he has a story very similar to mine. He was working with Professor Kouri, for example, and so I was like, okay, I either learn this from Fuad Kouri or I learn this with Frank. And then I went to Frank's and this was always.

Dr. Bernardo Sousa:

My life was always like this.

Dr. Bernardo Sousa:

I always wanted to learn the closest from the source as possible, to hear the information and to acquire the knowledge unbiased, because in dentistry, there is this thing that I don't understand why this happened, which is everyone wants to add a touch of his own on something, something that has been done for 20 years. I will do it a little different and call it something a little different, for no reason, and I think I think learning stuff where it was born, it's something wise to do from some for someone that is just starting and is like clueless, on on, on the full arch game. I think that these are the three things I would recommend to doctors starting just now, and maybe a fourth one, if you don't mind, which is to keep this critical mind, to be critic of what they hear, of what they read, of what they see on social media and especially being very critic with their own work. I told you I always photograph all my cases and the amount of stuff, guys, guys, that I learned in my first years just looking at the pictures, it's invaluable.

Dr. Bernardo Sousa:

The suture details what happens if I start the suture on the buckle versus what happens if I start the suture on the palatal. How to where to put the incisions on the palatal. How to where to put the incisions. I fill the socket with this bone graft, but there was something missing. How did this turn out? In the future, I learned so much. Uh, taking pictures, macro pictures, not cell phone pictures. That's bullshit. I mean with, with, with this, I will show you.

Dr. Soren Paape:

With a nice DSLR this was.

Dr. Bernardo Sousa:

I will tell you the story of this. This is a Nikon D7100. This I bought with my first salary. My first salary was all to buy the camera and the lens More than a decade ago. It's still my camera and my parents were like Bernardo, your first salary salary, you are going to throw all these away into this camera. And I told my dad this is going to be my biggest ce investment. If I take in proportion what I make this month versus what it costs, this is going to be my most expensive C program. And it turned out to be one of the best C that I took was buying the camera.

Dr. Soren Paape:

Yeah, I think, proper records when you're doing these cases. It's invaluable to see changes over time in your patients and you can't do it without good imaging. Right? It's easy to have a patient come back for a two-year follow-up and you don't have a picture of the beginning and just say, oh yeah, that looks good, I think that's working well. But if, in reality, if you had a first picture, you could see, oh wow, they actually lost three millimeters of keratinized tissue on the buckle of that implant. What did I do in this case that I could have done differently? So I agree a hundred percent% and that's the main reason why I like to, you know, post all my cases and be accountable for those x-rays and everything, because I like to look back on those and say, okay, what did this case look like when I did the surgery and what, where is it at now? At my follow-up, did I do something wrong? Was there something that I that was different than most of my other cases that changed those things? Are you guys already?

Dr. Bernardo Sousa:

taking pictures as well.

Dr. Soren Paape:

Yes, I don't post a lot of my surgical photos in my Instagram because I do have a lot of followers that are patients and I'm trying to. You know, there's a balance between doctor facing or patient facing Instagrams and I think I will be leaning towards I'm probably going to start an Instagram account just for my clinic where I post a lot of those before and afters and then I'm going to post more surgical photos. But I do surgical pictures throughout all of my cases as well, and I think you've probably seen some of those, because I post some in our Full Arch Club group chat and I try to post surgical photos as well. So I agree 100%. I think that's super important.

Dr. Bernardo Sousa:

We have a colleague there, a Polish guy. He posts a lot of very detailed pictures, like the implant still in the beginning, then the implant on the middle, then the implant all bone level Super macro, super macro pictures. But I told him when he took the master course man, if you keep taking these pictures, you will fast forward your career super speedy, because you see your shit in macro ampliation.

Dr. Tyler Tolbert:

So, and he's getting quite proficient on that.