The Fixed Podcast

Crossing Blades with Dr. Bernardo Nunes de Sousa: Part 2

September 16, 2024 • Fixed Podcast

Share episode

Unlock the secrets of advanced implant dentistry with our special guest, Dr. Bernardo Nunes de Sousa, as we navigate the intricate world of dental implants. Bernardo shares his invaluable insights on the evolution of custom subperiosteal implants and their revolutionary benefits for super atrophic cases. Discover why these custom solutions are becoming the preferred choice over traditional zygomatic implants, particularly in challenging scenarios, and the critical role of detailed dental records and photography in managing complications and tracking case progress.

Ever wondered about the difference between the Branemark method and other implant placement techniques? Join us as we dissect the nuances between customized implants and traditional methods, emphasizing the preservation of the maxilla's bony architecture. Bernardo explains how leveraging the maxilla's natural buttresses ensures the stability of customized implants and how this compares to the more invasive zygomatic implants. We'll also touch on the practical workflow from a clinician's perspective and discuss the current landscape of customized implant availability in the United States.

Finally, gear up for a deep dive into advanced surgical techniques that can make or break complex dental procedures, particularly sinus lifts. With Bernardos step-by-step guidance on tissue management, you'll learn the essential skills for ensuring optimal healing and stability. Don't miss the discussion on extending incisions and utilizing the tuberosity area for thin palatal tissues. We wrap up with a heartfelt conversation on mentorship and the importance of motivation in the dental field, featuring Dr. Bernardo's admiration for the host's impactful work. This episode is a must-listen for anyone looking to elevate their implant dentistry practice.

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, okay great.

Dr. Soren Paape:

So yeah, I mean, I think those are invaluable topics that you know photography, proper records and everything. They go a super long way for people who are trying to manage their complications over time and just see how their cases progress over time, to manage their complications over time and just see how their cases progress over time. I know that a lot of people are super interested in custom implants and subperiosteals and I know that you know you're a big front leader in the custom implants, at least the new age ones, right?

Dr. Bernardo De Sousa:

We've seen.

Dr. Soren Paape:

I was at course in Portugal when Picos came and showed all of his mandibular subperiosteal implants that he's done over the past you know 30 years and in the follow-ups of those and how wonderful they are and I think that you know the seeing a lot of these zygocases and stuff. It's really important to bring in subperiosteals in the maxilla because it does offer another you know, I guess you could say lifespan for patients who.

Dr. Soren Paape:

I feel like there's the full arch lifespan right, and then if we can eliminate that zygomatic lifespan and instead have a subperiosteal lifespan, and then maybe zygomatic zygomatic in the future, or if you have, you know, all-on-fours that turned into zygomatic and all of a sudden those zygomatic are failing, I feel like a lot of patients are in a situation where they're stuck with a really shitty denture then for the rest of their life. So you know, incorporating some periosteals, then go ahead.

Dr. Bernardo De Sousa:

Yeah, this is the reality, man.

Dr. Bernardo De Sousa:

There are countless patients that had failed quad zygos that there are on obturator prosthesis at this moment and that nobody knows about this reality. This is what is under the iceberg, you know, because nowadays the industry is pushing Zygus with such power that doctors almost feel like they are surgical inapt if they don't do quads every day. And the reality is that the need for a quad or for a sub is less than 1% of the cases. That's the first thing we have to keep in mind, because with all the other techniques you can go to 99% of those cases, which is the overwhelming majority of what is of the full arch population.

Dr. Bernardo De Sousa:

The quad zygote problem is not a problem of the implant, it's not a problem of techniques, it's not a problem of the doctor that places them. It's a problem of anatomy. We have the sinus in the middle and we need to create these big slots to place this short implant, because the zygote is a short implant. The implantable part of the zygote is quite small, it's 10, 11, 13 millimeters only, but it has a very big arm. But the implant is also it's actually a short one and the destruction that is necessary to place to do a quad is something that is so big and so irreversible that it is even difficult to do a sub after you lose a quad. It's difficult, the destruction that is left, the big autosinus communication that you have, the zygoma that gets destroyed. It's very difficult to approach a case like this and I think that we should consider the custom superiosteal implants, because I said the other day this on social media and the majority of people understood what I was saying, but there is always a small percentage that wants to test the words.

Dr. Bernardo De Sousa:

But this is true the superior osseous surgery, guys, is a minimally invasive surgery, because we have to think the minimally invasive concept always depends on the expected outcome. You understand what I'm saying. We cannot expect to solve a super atrophic case with a single implant. It's not going to solve the case right. So we need to understand what is on the table. A supratrophic case either goes for a quadzygote or for a superiosteal implant. So, for the two options that are on the table, when I say that this is the minimally invasive one, it's compared with the other solution that achieves the same result. So in this sense, yes, it's a minimally invasive solution compared with the quad, because the quad we know the destruction that is required just to place the implant. So, yes, I do believe that is something very promising the fact that these customized nowadays without having to open a flap like it was on the old days that were two surgeries were necessary, one just for the impression of the bone and then another one for the placement.

Dr. Bernardo De Sousa:

Now we don't need to do that first one. We use the CBCT scan. It's a surgery that takes about one hour. We use the CBCT scan. It's a surgery that takes about one hour. Most of my surgeries actually and you know this, you have seen this take local anesthesia only, and we always we are absolutely positive that this patient is going to have fixed teeth today. It's not something that we aspire to, it's a certainty in this approach.

Dr. Bernardo De Sousa:

So when we think, when I think about you know the pros and the cons. The only cons that I see is that first you need a few weeks to produce the implant. You know you cannot just appear in the office and boom and do it. No, you need to take the scan, you need to design the implant, to print it and all these things and and and the price. It's more expensive than buying a couple of zygomatic implants.

Dr. Bernardo De Sousa:

But besides these two things, I think the pros are way more than the cons and that's why, when I started with this kind of technology, I said to myself OK, now I'm on a crossroads.

Dr. Bernardo De Sousa:

Do I continue with the zygos or do I go into this journey, pioneering approach, roads do I continue with the zygos or do I go into this journey, pioneering approach, and and try to maybe change a little bit the way these, these very complicated cases, are going to be done in the future? And you know, we took a leap of faith, but it was not real faith, you know. I mean, we studied all the concepts. I read the lincoln books, you know I I spoke with people that did the old ones back in the days. I spoke with Mike Picos as well. His follow-ups are amazing on the other ones. And I think this new technology has evolved so much and there's so many nuances that make this work better than the other ones that it will be. You know, having these available here, for example, in Portugal, having these available and not using would be an heresy, you know.

Dr. Tyler Tolbert:

I mean, why should I destroy the, the midface, when I can keep all the remaining bone and still do, uh, immediate loading so that's something that I want to speak to there, because we're talking about the minimally evasive, you know, concept as it relates to to the outcome zygote. Right, of course, yes, as a. In comparing zygos versus customized implants, you made the point that with the way that zygos are being done today, it can be very difficult to then rehab them with a customized implant afterward. Aren't as versed in, zygos or customized right?

Dr. Tyler Tolbert:

Is that right now what is a very popular modality with zygomatic placement, whereas traditionally it used to be an intra sinus approach that would start transpalatally, very palatal, to where we are normally placing traditional implants, and then it would transverse the sinus exclusively, and then, of course, the superior border of the of the sinuses is going to be the inferior aspect of the zygote, and so there's not as much, there's not necessarily any instruction to the sort of outer maxillary wall that forms the sinus. But now what we're seeing a lot of is this, you know, extra sinus approach. So they're doing slot preparation along the wall of the sinus, and this has a lot to do with the classification of the case. Right, you can talk about different.

Dr. Bernardo De Sousa:

Yeah, but actually, Tyler, the Brandmark approach, the first one was the more conservative, you know it was way more conservative.

Dr. Tyler Tolbert:

Yeah, in this sense right, it was more dangerous. This is counterintuitive.

Dr. Bernardo De Sousa:

It was more dangerous and the palatal exit the prosthetic exit was worse, terrible, terrible, much worse. But if I was a patient back in those days, you know, and I had the option to do the external approach or the internal approach with Brandmark, I would prefer the internal approach in my mouth Because it's way more conservative.

Dr. Tyler Tolbert:

Right, right it is. It goes through a space that's already empty and you still have the bony architecture of the maxilla. So I think that's kind of this sort of counterintuitive nuance to you know, what we consider minimally invasive is the way we're doing. The extra sinus approach is actually more destructive to bony architecture. That could be used for a customized implant. So I think that's a very interesting nuance that you bring up for sure.

Dr. Bernardo De Sousa:

Yeah, yeah, yeah, yeah, yeah. I love to do everything I can to preserve, even in trans sinus, for example. You, you know if I have a clear sinus.

Dr. Soren Paape:

I will not open the wall, you know. I will keep the wall of the sinus intact.

Dr. Bernardo De Sousa:

Create a window there, because when you create a window, you are opening the possibility of having a oral sinus communication, you are opening the possibility of the failure of the graft and, and once that happens it's difficult to create, very difficult to create a new sinus window. And you know this is the cascade of destruction, the ladder of destruction. You start destroying and the correction is always a bit more destructive than what it already was, and things start to escalate very quickly and start to go to to to the point of no return. You know, and this is what I really keep in mind at all the times when I do a treatment plan and I would advise anyone to do the same is to see how irreversible is the stuff that you are doing today? Or is there, is there any alternative that is more reversible for this patient? Because, remember, your implants will not last until the patient dies. Two-thirds are there, one-third is lost after 15 years. So yeah.

Dr. Soren Paape:

Bernardo, what are the work?

Dr. Tyler Tolbert:

For those that aren't as Sorry, I just wanted to make sure. So for those that aren't as familiar with the concept of customized implants, versus, you know, like a subperiosteal design. So can we talk about, you know, the design of these customized implants as it relates to the anatomy, as it uses the bony architecture. How is it anchored? How is that anchorage, working differently than a zygote? How does that? Then, translate to a prosthetic success as well.

Dr. Bernardo De Sousa:

So the anchorage point of the custom implant is the same exact basis of the fractures of the maxilla, the Lefortfort one, principles that we know for more than 100 years. This is really not something new. We know that the strongest parts that we have is the three but main buttresses right, the zygomatic batteries, the puriform and the pterygoid buttresses is the main three main buttresses that we have on the mid face. That's exactly where this implant is anchored. We have two very long implants here on the zygote. They are 22mm implants, micro implants, they are narrower. We have a bunch of micro implants here all along the canine pillar and we have one on the palatal side. But most of the implant is anchored.

Dr. Bernardo De Sousa:

The most important part is the zygomatic anchorage and the piriform buttress anchorage. This is what keeps the implant so solid that you see this actually in a real patient or even if you try this on a model, you screw all the screws and you try to move, you try to bend it and it is rock solid. You can't move this. The micro movement here is zero, contrary to the zygomatic implants, which often they don't have a micro. They have a macro, sometimes right there at the moment of the surgery because the arm is so long and it's such a big area unsupported that the implant actually bends. You can see it, you know, and actually there was a paper published that I put on I just put on the WhatsApp group a few weeks ago a clinical lab study comparing the bending of the zygote depending on the length and the bending of the custom superiosteal implant. And the bending of the zygote often goes to pass the threshold. The bending, the deformation on the custom implant is always within the acceptable range, so it doesn't fracture. So it's a different approach.

Dr. Soren Paape:

Can you talk about the process for workflow as far as records fabrication and then like surgical placement with the prosthetic.

Dr. Bernardo De Sousa:

Yeah, it's super simple from a doctor's point of view. You have the CT scan of your patient, you just send it to the lab. They will design it. You either change something that you feel like it should be a little different. I always make a change here or there. You know I have done so many that I think I know from experience that I prefer to be like this or like that, but they are minor, to be honest, minor stuff. And then they will send it to you and you just book the surgery. From a doctor's perspective, it is the easiest thing on the world what about?

Dr. Soren Paape:

what about? I think the biggest question that we're gonna get and and you know you're talking about all these pros with the customized implants and people are gonna be are gonna ask well, how do I get them right? So what is the? What's the timeline looking like in the united states? Can you give us some? My understanding is that they're not approved quite yet, but I think for the last year we've been told they're coming, so do you?

Dr. Bernardo De Sousa:

have any insider info about you have to. Let me make a disclaimer, because I believe that most of the world thinks I have something to do with the company and I don't. I have zero shares on the company. I wish I had, you should, but really I don't work. I have zero shares on the company.

Dr. Soren Paape:

I wish I had you should.

Dr. Bernardo De Sousa:

But really I don't work for the company, I have no royalties in anything, so I really don't know, and I know that this process with the FDA is taking a bit too long and it should have been approved by now a long time ago. But as far as I know and this is unofficial information it's going to be very soon. I cannot compromise on anything because, again, I'm they are being, they are telling it's very close for two years now and actually in our last conversation, tyler, it was just about to be approved and our last conversation was like one year and a half ago, but I don't know, man, maybe if you have some contacts on FDA, they will clarify this a little better, because I don't know if it's on the company side or if it's on the FDA side.

Dr. Tyler Tolbert:

Once. You guys have been working with these customized implants for much longer than anybody in the US has right, anybody that's placed them in the U? S have done it on sort of an experimental, provisionary basis. You know we talk a lot about the backend of Zygos and, and you know something about and not just zygos but implants in general with everything exploding is that you know we can get implants to torque out, we can even get them to integrate, and then we can screw in teeth and we're not actually going to see the consequences of overlooking certain things for years. Right, it might be five years before you find out that something wasn't really done properly to begin with.

Dr. Tyler Tolbert:

So what do some of these long-term follow-ups or these customized implants look like? How long have they been in function? What sort of complications are we seeing? And, ultimately, how do we undo it if something has gone wrong? How easy are these to remove? What do rehabs for customized implants look? Like if you've had the opportunity to see that.

Dr. Bernardo De Sousa:

That's a great question because we started with the concept as soon as it appeared in 2017. But we have to understand that the implants that we were placing in 2017 are way different from the implants that we are placing now in 2024. The design is different. A lot of things have changed. The micro implants, micro screws, are different and some anatomical places that we are placing the screws are also different. So we had all this journey with the company, you know, improving the things that we were seeing that could be improved. So the last version of the implant is from 2022. So when we compare, you know, to talk about follow-ups, we have to talk about the same object. It's a bit unfair to compare the different kind of designs, you know. But yeah, but the last design is from 2022. I can tell you that the ones that I did in 2017, they I have a 100 success rate. I never removed any and they never failed.

Dr. Bernardo De Sousa:

The most common complication is the exposure, which is also the most common complication is the exposure, which is also the most common complication of the zygote is also the exposure. And they actually expose in the same area. You know, they always expose in the buccal arm, the arm that goes along the crest. You know that goes and turns around the crest. The same as with zygos. I would say that the percentage of exposure is quite similar. At least it is what I see in my zygo cases. You know I was having some exposures here and there. The more vertically atrophic was the case, the more likely I was having this. And yeah, so my success rate as of today and as far as I know, is 100% because they are all in function and functioning well. And I know about some fractures. I have seen two in the older designs and the problem of those fractures was almost I would say that all the fractures that I know about was a passivity problem. So it was.

Dr. Tyler Tolbert:

On the bone.

Dr. Bernardo De Sousa:

Yes, they were not about was a passivity problem. So it was. Yes, they were not. It was a problem with the placement, not a problem with the implant itself, so to say. And that's why they are segmented now, because can you imagine how difficult it is to place such a big structure? It's like a butterfly, you know, from zygo to zygote. We we had to place it at once, so imagine you have to place one side first and then place the other. It was very difficult to place the the first one. Now it's way easier and it's the passivity that you are able to achieve. It's way easier to achieve and, and yes, it, like we spoke, it's a minimally invasive surgery fix the teeth and the patients love it.

Dr. Bernardo De Sousa:

Most of the times we do it. I know this may sound strange, but we do it with local anesthesia and, yeah, we are having great success on this and we are receiving patients from all around the world. I've treated Australian patients, I've treated US patients, european patients patients I've treated US patients, european patients and typically the kind of patient that has lost implant treatments before or that heard so many times your case is not doable that once they knew that this was available, they came and they fly here and they got fixed at it in the same day. And I also don't think it's fair. You know, I don't want to put this bad image on the zygos because I don't think that way. You know, I think zygomatic implants are the best, the second best solution for this type of cases and I also used them before for this type of cases and I also used them before. I think that they have helped enormous amount of people that were completely hopeless.

Dr. Bernardo De Sousa:

I think that the zygomatic surgery is one of the most beautiful zygomatic surgeries that you can do. It's very exciting, it's nice to do Doing it right, it's beautiful to do it right, the right way. But, as I said, for us it's just a bit too destructive and we have other options. But I totally understand in countries where this is not available, you know the kind of the need to go and to use zygomatic inputs because you have to solve the cases somehow and that's what you have, that's what you use. But yeah, that's our perspective Since we started with this. I don't see us turning back. At least I will need to see many complications, which I haven't seen yet with these implants.

Dr. Tyler Tolbert:

And is it routine as well, with relation to the exposure that you're seeing in that issue, in that position, that you're also seeing it with Zygos too? Are you guys doing buccal fat pads and multilayer closure to try to insulate against that too?

Dr. Bernardo De Sousa:

That's a great question.

Dr. Bernardo De Sousa:

We were talking before about fundamentals and this is a fundamentals question, because the buccal fat pad guys people need to put this in the mind.

Dr. Bernardo De Sousa:

Once you use it, it's gone, poof, it's gone, it's not going to appear anymore. Then the patients look like this asymmetric, you know, if you only use on one side and if you have a problem, if you lose a zygote and you need to close a communication later on, you have no buckle fat pad anymore. So we avoid using the buccal fat pad. You know, as the devil avoids the cross, the first option that we always go for is for a rotated pedicle flap. You can get a huge coverage with the well, depends on the part, depends on the patient, but most of the times you can suture a two centimeter hole in the crest, a communication with the sinus, with a rotated pedicle flap. And that's how I think we should go Again, for the same exact reason for fundamentals, for principles, for going for something that is reversible, first right and I do this on the palatal side. I know it will grow back and I still have the buccal fat pad if things go south and if I still need to go there in the future.

Dr. Tyler Tolbert:

Right, right, so can we talk a little bit too about the rotated pedicle flap. So can you explain what that is, what your general approach is for that and for people that aren't doing zygos or whatever the case may be if they see an oral-atrial communication, or there's deficient tissue how can they utilize that?

Dr. Bernardo De Sousa:

Yeah, it's the easiest thing in the world. Imagine you have your flap wide open right on the buccal and on the palatal side and you have the bone totally exposed on the maxilla. You look at the palatal tissue in one of the sides, you grab it and you see how thick that is right. You see the thickness, the full thickness of that palatal tissue. If you cut that in half, you will separate. In one side you have the mucosa, in the other side you will have all connective tissue and fat. You also see fat. That part that you separated, it's the, it's almost done. You just need to cut on the bottom to release it, right? Does this make sense? Am I explaining more or less right?

Dr. Bernardo De Sousa:

so it will just stay attached on the posterior part for irrigation, right, because all the rest, the rest. I will send you some.

Dr. Tyler Tolbert:

Yes, we'll put that in this.

Dr. Bernardo De Sousa:

I have those slides so I will send you these pictures. But it's so easy Just separate the part in half and then you cut the borders so you have it mobile. Just attach it on distal and then you rotate it over your defect. You suture it either to the bone or to the buccal tissue with a mattress or something to keep it stable, and then you continue to do your thing. Naturally, you close, naturally, everything is normal. It's the easiest thing to do.

Dr. Tyler Tolbert:

Yeah, that's a great hack. I've had my first ordinal communication after like an indirect sinus lift, and I remembered about this and I had not actually used it before and I was like, oh man, okay, let's seat the patient. And then I'm going to be in my office for a second and I'm looking up YouTube videos. I'm like, all right, exactly how do I do this again?

Dr. Bernardo De Sousa:

And it really isn't bad and it's it solved the problem Like it was nothing. I think that's one of those fundamental toolkits that you definitely want to have for whenever you have those complications, or to prevent them if you have a deficiency. The trick is, there is only one trick, which is you have to you start with your blade separating the two halfs where the defect is, because you have to go way more anterior, so you have tissue to rotate posterior right yeah, so you have to start next to the defect or just slightly distal to to the defect, but you have to extend a lot.

Dr. Tyler Tolbert:

You know anteriorly, anterior because you need to wrap around so you can swing it yeah, yeah and that's the, the, the only.

Dr. Soren Paape:

Thing but how?

Dr. Tyler Tolbert:

did it turn out. Well, right, oh, beautifully, beautifully, Very well, very well, it healed over, and you know, then I just had to figure out what I was going to do after that, but yeah, Now, sorry to interrupt.

Dr. Bernardo De Sousa:

For example it's interesting you ask this Now. This is in our lecture, this is on the master course. Good, step by step, how to do this technique, because again, doctors ask for it and it's such a precious move to solve so many complications.

Dr. Tyler Tolbert:

Yeah, it is no. What I was going to say is so let's say you go to do that and every so often I'll see someone actually has a very thin palatal tissue. I mean, it can happen from time to time. You know what happens if you're just not really able to split the difference on that, you're not able to get the connective tissue out. Is there a full thickness version of this that you can do? That's going to be a bitch to heal, or like what do you do if the tissue is too thin there?

Dr. Tyler Tolbert:

you go to the tuber that's the second best, for sure you go to the tuber yeah, okay the.

Dr. Bernardo De Sousa:

The only disadvantage on going to to the tuber is that you have a flap, that is, that you have a free flap right. It's not connected to any. It's transplanted.

Dr. Bernardo De Sousa:

It's a transplant. I did many of them in the beginning when I was afraid of the greater palatine. You know, I was going to the tuber and I started having a few necrosis here and there and I was like, okay, maybe I should lose the fear of the greater pelotin. That's another thing. Doctors starting now have to understand that the bleeding from the greater pelotin may look like a lot to you but from a surgeon perspective it's peanuts, it's nothing, that's not a serious bleeding. You know, and I will give you, tell you this story very quickly In the last boot camp we had a student that with the flap elevator, when he was raising the flap on the tuberosity, he was making so much strength with the arm that it slipped from the crest and cut the greater pelotin at the origin.

Dr. Bernardo De Sousa:

You know and you know, the guy was a bit in panic and his colleague was also in panic and we were like, trying to be very pedagogical with the situation, he's like, okay, guys, this is a bit of bleeding, but it's not that serious. Okay, it's not that much. If you see a serious bleeding in maxillofacial surgery, if you see a lift 4.1 or a lift 4.2, man, I have dealt with those kinds of bleedings. This is not one of those. This is anesthesia compression, most of the times. In five minutes it's completely gone if you do the right maneuvers I think we chatted too on.

Dr. Soren Paape:

I posted something a couple weeks ago about how you know maybe not life-saving, but a great tool to have in your toolkit is just some sort of electrocouter unit.

Dr. Bernardo De Sousa:

Right, if you can get a bovie you know everyone should have, yeah, and if you're unfamiliar you can use Bovi pens.

Dr. Soren Paape:

There's disposable Bovi pens for like anywhere from like 10 to 20 bucks a piece. You can even get Bovi pens with exchangeable tips that are around $100. And you can just get different tips but just spending that $100 to have something that can cauterize that bleed in your operatory is A simple monopolar.

Dr. Bernardo De Sousa:

one is more than enough, or even the pen.

Dr. Soren Paape:

Yeah, and if you have questions about which one I've used before, you can reach out to me. I'm happy to answer them. But there'll be just one less thing that you need to worry about, because if you do have a bleed that doesn't you can't get it to stop with compression or with epinephrine or whatever. You have a bovie will definitely solve that issue for you.

Dr. Bernardo De Sousa:

Yeah and losing. And it's actually quite pedagogical, you know, to hit the greater pelotin one time or two times or three times, because you start to, you know, not worry so much when these things happen. And sometimes, on the taking a graft from the palate, the connective tissue graft or even a free gingival graft, sometimes it happens, start squirting, but you keep your cool, you do what you you are supposed to do and it will always stop. As a friend of mine told me many years ago, a maxillofacial surgeon, when I was in the residency, all bleeding eventually stops. What's coming, eventually it always stops.

Dr. Soren Paape:

It's self-resolving the way that I like to handle, you know, because I've gotten especially doing pterygoids. If you're back in the pterygoid region and you reflect a lot, sometimes you'll get a little bit of bleeding from that greater palatine coming from under the flap. And the way I like to solve that is, you know one, I don't want to sit there and spend 10, 20 minutes of my surgery just compressing it. I just grab my hemostat clamp the tissue right there and it goes away. And I keep working with the hemostat clamp there and you know when you remove it, it stopped.

Dr. Soren Paape:

Yep, yep, and by the you know, 15, 10, 15 minutes later. You know you've been doing something else that you know you need. Take the hemostat out and you're good to go, and that way you're not sitting there, you know, wasting your precious surgical time where the patient's under anesthesia. You know you can think if you have an anesthesiologist there, I mean you're paying a good couple hundred bucks for every 15 minutes. Maybe not quite that much, but you know that time is critical.

Dr. Bernardo De Sousa:

And that's, that's another. Sorry to interrupt, that's another lecture we introduced in the bootcamp in Brazil. First day is how to deal with heavy bleeding, for example. It's another thing that we were changing and improving because we saw people panic a bit and I understand, I also panicked in my first ones, but it's really not something that that big. You know, I panicked in my first ones, but it's really not something that big. It's big for dentists. It's not big when you are used to other kinds of bleeding. I remember in the Netherlands I saw a guy that was in a fight with someone that had an axe. Can you imagine Fighting someone with an axe? The guy had a major cut. This was the most serious thing I saw in my life, you know, and still solvable, yeah.

Dr. Soren Paape:

You know, one thing I wanted to mention that I forgot to say before and I'm it's. It's kind of a question for you too, bernardo, when you're doing a rotated pedicle flaps. Another pro, in my understanding, is, compared to a buckle fat pad is a lot of times that connective tissue regenerates so you're able to re, you know, not right away, but once it heals up, especially in. You know, I see a lot of patients that have palatal tissue, that is, it's thick, it's really thick and a lot of surgery, you know much.

Dr. Soren Paape:

It's too much. You need to thin it out. But if you're able to, instead of thinning it, you can use that to wrap around the implant to preserve keratinized tissue. That's always a solution to come back to again to use if you need to down the line.

Dr. Bernardo De Sousa:

Yeah, yeah, exactly. I think I mentioned this before. That's one of the pros of using the palatal tissue is it regenerates not fully. Actually, a friend of mine did a study exactly on how many cubic millimeters it regenerates after one year it was. He found out that it was not fully, but it was about 85 90 if I remember correctly.

Dr. Bernardo De Sousa:

So it's almost everything and and, yeah, one year later you have it there again. So, yeah, it's, it's like an infinite pool of good tissue for you. You know that keeps coming back, keep keeps spawning Is this the right word Like the Pokemon's when they spawn, spawn.

Dr. Tyler Tolbert:

Spawning. Okay, then you edit this Respawn. It's a renewable energy source.

Dr. Bernardo De Sousa:

Oh no, that's staying in Respawn. I like that.

Dr. Soren Paape:

Yeah.

Dr. Tyler Tolbert:

It respawn.

Dr. Bernardo De Sousa:

Connective tissue respawns.

Dr. Tyler Tolbert:

Yes, yes, absolutely that's good.

Dr. Soren Paape:

Well, hey, bernardo, you know we went over so much in this episode and I've actually, if you're watching this on YouTube, you've probably watched Bernardo's sun setting behind him throughout the episode. So you know we really appreciate all of your time on this episode and this will be one that gets cut up into a few episodes because it's been a journey throughout. But you know we really appreciate all of your time and I think that anybody who's looking to up their full arch game and get you know prosthetics that have no cantilever and are looking for solutions to bleeds and looking for ways that they can take on more patients without going through larger approaches like zygomatic implants and stuff, it is critical to check out the Full Arch Club. Additionally, you know I don't think that you're able to get in.

Dr. Soren Paape:

I had questions too, like hey, how do I get into Bernardo's WhatsApp group? And it's go to the master course, go to the bootcamp, and you'll get access to a lot of clinicians some of the best clinicians in the world who are able to answer some of these questions that you have immediately. You know, I think everybody in that group is very transparent with you. Know, I'm in a surgery, I have this issue. What do you recommend and you get a lot of responses from wonderful clinicians throughout the world just by having access to that group. So I think it's a wonderful CE to take if you're looking to get into. You know more advanced cases and again, we really appreciate your time. Today you can follow Bernardo. What's your Instagram, bernardo? Just so people can look through your stuff and see the Full Arts Club.

Dr. Bernardo De Sousa:

So we have two Instagrams for you Bernardo N Souza, which is mine, and the Full Arts Club Instagram as well. And, as we were talking in off before this goes to air, we are at the moment preparing courses that have never been done until today, not only to help you become the best surgeon possible, but also that you become the best person operating. I will not disclose more information now, but, to be something radically different from what has been done until now, we are also going to launch soft tissue only stuff, because a lot of doctors are asking, and they ask on the group and on the WhatsApp group as well. So we are preparing what I believe to be the most complete full arch soft tissue course for doctors, where you learn all the techniques that you need in the Full Arch game, with a bonus. I think I can say that it also involves soft tissue, but it stresses your nerves. So I will not disclose everything now.

Dr. Tyler Tolbert:

The more you tell me, the more questions I have. It's not actually making it easier so it's going to be fun.

Dr. Bernardo De Sousa:

So, yeah, keep tuned and also on the website, because all if a course exists better than asking me or the manager or anyone is to see on the website if it exists, is there? So, fullarchclubcom, when I when I have to know where I have to fly for a course or something, I go to my website because I don't know.

Dr. Soren Paape:

So it's my calendar well, hey, thanks so much. And again, you can always find tyler and I at my instagrams dr soren poppy tyler's is dr tyler trobert, and then you can reach both of us at the fixed Podcast Instagram. Again, if you're listening to this on Spotify or whatever platform you use, we always have these videos on YouTube as well, where you can see all of our faces, and we try to incorporate as many panos and stuff into the videos as possible. So definitely take a look at those. And again, thank you for your time, bernardo.

Dr. Bernardo De Sousa:

Thank you very much. It's the second interview that we do and I feel like a bit of a death for you too.

Dr. Bernardo De Sousa:

You know because I saw you in the very beginning and now two, two years later, it's really, honestly, it's impressive the way you two are growing, and and other guys from the boot camp as well, and your new project with the clinics. And you remember we talked about the brain. You guys have the right brain, okay, and this is, as I said, the clinical part is the easiest to learn. But having the right brain is something difficult to teach and if you are born with it, use it wisely and you are born with it, and I'm really proud of the things that you are accomplishing, not only in the clinic, but also with the podcast previously with the other one and now with the Fixed podcast and I think you deserve everything good that is going to happen to you because you work hard, you are smart and you apply your smartness into doing good things to people. So keep doing what you are doing, into doing good things to people. So keep doing what you're doing. It's really motivating to me to have contributed with something to this.

Dr. Soren Paape:

Well, hey, thanks so much, Bernardo. That means a lot coming from you and you've always been a wonderful mentor to us and we really appreciate it. So thanks so much everyone for listening and tune in next time for the Fix podcast.