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

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.

Episode Transcript

Dr. Tyler Tolbert (00:01):
My name is Dr Tyler Tolbert and I'm Dr Soren
Papi, and you're listening tothe Fix Podcast, your source for
all things implant dentistry.
Oh, and, welcome back to theFix Podcast.
So we have what I believeshould be a very familiar face
by now.
But if not, shame on you,you're going to learn today.
So right now we have DrBernardo Nunez de Sosa in with

(00:23):
us, so he's going to be yes, andthis time he's here in visual.
You can actually see the manhimself presenting, and he's a
beautiful man, so we're reallyhappy to actually have his face
on the recording today.
So welcome, bernardo, and thankyou for your patience with us
as we still try to navigateglobal time zones.
That's a very difficult thingfor us, it's true man, thanks
for the invitation for thesecond time.

Dr. Bernardo Sousa (00:44):
Actually, we had this recording.
It was one year ago or twoyears ago, I don't remember.

Dr. Soren Paape (00:48):
One year ago maybe, yeah, probably a year and
a half.

Dr. Tyler Tolbert (00:52):
Yeah, something like that.

Dr. Bernardo Sousa (00:53):
Yeah, soren was not on the conversation, it
was just between us.
Now we have a threesome, whichis also fun.
That works as well that worksas well.

Dr. Tyler Tolbert (01:06):
Yeah, yeah, so it's.
It's been a very fast year,whole lot of developments.
I definitely want to get intoall the wonderful things that
you're doing with full arch cluband all the new projects that
you have in mind as well, butfor those that don't know who
you are and don't know about allthe great things that you
brought to our industry, wouldyou mind just giving us a little
bit of background about who youare, what your training's like,
your journey to get up to thispoint, all the way back to
dental school?
Just give us that brief historyand this is something I really

(01:26):
love hearing, because Bernardohas, throughout his career and
his training and those who he'slearned from his mentors, it's
very closely intertwined withthe history of All in 4 itself.
He's really gotten to rubshoulders with such big names in
full arch and what we do, andhe's a big name himself, so I'd
really appreciate to hear that.

Dr. Bernardo Sousa (01:44):
Yeah, so where did this start?
It actually started, man, whenI was five.
In my birthday, when I was five, I said to someone that I
wanted to be a dentist, and myparents actually have this on
tape.
I think I mentioned this in thelast episode.
Yeah, and then in Portugal youdo the primary school, then you
do the high school and then yougo immediately to university.

(02:07):
We don't have the college likeyou have in the US.
So I went to dentistry and tothe Catholic University and the
only thing I really cared aboutwas the oral surgery part.
I cared so much about that thatI could not study only the
slides that we had to study forthe exams.

(02:28):
Each time I had an exam I wouldread 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 thecamera will.
Anyway, I read the book maybe 10times, man, during dental

(02:50):
school and at the end of more orless in the middle of my dental
degree I saw this interview ofPaulo Maló on the national
television and he was claimingto solving these very difficult
cases within one hour surgery,very fast for the patient, with
no grafts, no guides becausethere were no guides back in

(03:11):
those days and always withimmediate loading.
And when I heard about this thefirst time, as I said, I was
still in the dental school.
I was very intrigued becausewhat we were being taught was
maybe six implants, six to eightdouble sinus lift or bone
grafts and bone substitutes,then wait six months, nine

(03:31):
months with a removable denture,which is the worst thing in the
world, especially on top of agraft, and then wait.
He was avoiding this and I wasvery curious about his technique
.
But it's maybe in the US is thesame as it is in Portugal.
Nepotism is universal and youneed to know someone that knows,

(03:53):
someone that will pull thestrings for you if you want to
work with a big name or in avery good clinic.
And I was the first guy in myfamily to become a dentist, so I
didn't know anyone.
So I tried to pursue mypost-graduated education to
learn those things that PauloMalone was talking about.

(04:14):
So I went to the Netherlands.
I did a one-yearpost-graduation program.
It was a residency inmaxillofacial surgery.
It was awesome, but it was notabout implants.
It was big maxillofacialsurgery.
It was awesome, but it was notabout implants.
It was about it was bigmaxillofacial surgery stuff
Orthognathics, a lot oforthognathics, trauma, oncology
cases and that was not exactlywhat I was searching for.

(04:37):
Also because I could not dothese things then after that in
Portugal for legal reasons to dothis In Europe.
The legal part of maxillofacialsurgery varies a lot from
country to country.
Even if you have a degree, evenif you can do the maxillofacial
residency as a dentist in onecountry, you move to another

(04:58):
country.
The dentist that will not berecognized.
So I could not do that inPortugal and it was not.
My goal was to do thisrehabilitation with fixed teeth
very fast with minimallyinvasive stuff for the patient.
So I did a two years master'sdegree in oral rehabilitation

(05:19):
and implantology and then I wentto 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 inCuba, it's like you have one
elevator, one forceps and goahead.

(05:41):
And that was quite good, becauseyou 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.
Maybe it helps you a bit.
But it's technique, it'sunderstanding, it's 3D
visualization, it's to work likea lever.
It's not really about the tool,it's about yourself.

(06:03):
And so, yeah, meanwhile I wasalways sending my resume to Malo
Clinic, but I never got a reply.
But suddenly that reply cameand they sent me an email.
Actually, when I sent my resumethis last time, it was a night

(06:24):
out with my friends.
I was a bit tipsy when I sawthe, when I saw that they were
recruiting for a clinic that wasabout to open in Paris and I at
that point, with the rightamount of alcohol, it was like
Paris, paris can be nice.
And my argument without knowingwhat was going to happen.
And yeah and the guys.

(06:44):
They called me and I went toLisbon because I had to stay
there for one or two years to dothe whole training there.
And it's quite nice, becausethe first day nowadays, I think,
it's not like that, and becausePaulo Maló is not working at
Malo Clinic anymore.
It was a big, there was somestuff going on there.
I really don't want to go deepon that, but back in those days,

(07:06):
when I entered Malo Clinic,paulo Malo told me this Bernardo
, so what do you know aboutimplants and oral rehabilitation
?
And I said look, I did thispost-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

(07:28):
you from zero.
If you are okay with that, youstay with us.
If you want to keep insistingon those old school kind kind of
stuff, man, maybe this is notfor you.
And the guy was quite clear onthat and I enjoyed that and so,
yeah, that's what they tell you.

Dr. Tyler Tolbert (07:43):
When you start getting into like quantum
physics, they're like forgeteverything that you thought you
knew.

Dr. Soren Paape (07:48):
This is day one , you know nothing.

Dr. Tyler Tolbert (07:50):
That's pretty much how much of a revolution
that is.
Yeah, yeah and.

Dr. Bernardo Sousa (07:53):
But he was right.
And the guy was right and myfirst day working at malo clinic
was actually a quad zygo.
Can you imagine you get allthese experiences like bam?
from day zero and and yeah, sothis was my, I would say, the
biggest part of my education.

(08:13):
This was what actually changedme, changing my way of seeing
things.
My philosophy today has hasbeen very impacted from this
experience and and maybeespecially for the no bullshit
approach and something that wecan talk later on, but something
that I see nowadays a lot ofover complications, over

(08:36):
engineering of cases, whenthings can be done way more
simplistic and with the same orbetter results.
And in this kind of thinking, Ithink Paulo was way ahead, very
far ahead of anyone in theimplantology business, because
you imagine what is doing anall-on-four with tilted implants

(09:00):
, with no grafts, with exposedthreads, in 2000.
We are talking like 24 yearsago, 25 years ago yeah, it was
when he was already doing thisand I was getting these cases
there.
I was watching not only the newones, of course, but the
follow-ups and the watchingthese cases that have 15 years
follow-up, case after case aftercase.
I mean, it's, it's on thenumbers.

(09:21):
Man who has the numbers has thereason.
And so, after this, I went tothis big DSO.
I was the head surgeon of theirbusiest clinic.
I was doing revisions, revisioncases, cases that went that
failed or cases that were aboutto go into the court and they
were trying to solve things.

(09:42):
So I spent about two years onlyredoing cases and that gave me
a lot of not only endurance, butalso how can I say to find bone
when it doesn't exist anymore?
And the pterygoid part to tiltthem towards the vomer, the M
variations, the transsinus.
These things became necessaryin this time, so that's when I

(10:08):
started to Creative approaches.

Dr. Soren Paape (10:10):
Say again I said creative approaches.

Dr. Bernardo Sousa (10:12):
Yeah, yeah, yeah, more creative approaches.
The palatal approach I startedvery it was.
I would say that in 10 cases,maybe 7 or 8 were palatal
approaches.
And so, yeah, so then after awhile you start to see your own
follow ups and say this actuallyworks and maybe it works even
better in some cases in terms ofsoft tissue.

(10:34):
So, so, yeah, and then afterthis I work in several spots
getting cases, getting referrals, and then I created the full
arch club and we were historyyeah, man, the Full Arch Club
was was the first, actually thefirst Full Arch Education Center
in the world, and now there area few more, but we were the

(10:54):
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, includingthese two beautiful gentlemen
here in front of me who areamazing surgeons and who are now
doing incredible work.
You publish a lot, søren.

(11:14):
By the way, tyler is more shyto publish.
I'm a recluse, yeah, man.

Dr. Soren Paape (11:21):
I talk about a little bit on the podcast.
I try to post almost every casethat I do on my Instagram and
challenges and just show thegood cases, the beautiful ones,
and it forces me to when I'mwhen I require myself to post
them, to really like make surethat I'm doing everything as
perfect as possible.
I want all my cases to besymmetric.

(11:41):
I want efficiencies with myteam and I want to show
everybody that follows me that'spossible to do over and over
again and if you look at mycases over time, I actually
recently, just on my Instagram,went back to all the cases I did
this year and I highlightedthem.
So if you guys want to see allmy cases, you can go back and

(12:02):
see everything I've done thisyear.
I was going to do like for allof 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.
They all look basically the same, and I think that's what you
want, right?
You want all your cases to beto look the same, because you
want things to be efficient, tobe repeatable, and that's where

(12:23):
you see less complications, moreefficiencies with your team.

Dr. Bernardo Sousa (12:27):
Yeah, I actually did a video, a real,
not that long time ago that atsome point it becomes boring.
And it's true, it's always thesame.
If you have the process in yourmind, 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 untilthe end.

(12:48):
Maybe you have to do somevariation here on there.
Maybe instead of a tilteddistal implant, it's a
transsinus, maybe it's tiltedbut more anterior, or it's small
variations, but it's repeatable.
That's why I said it at somepoint it becomes boring.
I don't know if this has becomeboring for you yet, but I
promise that it will.

Dr. Tyler Tolbert (13:08):
Yeah, I think what is boring just changes
over time, right, like you starttaking on more and more trophic
cases and borderline cases andthose might start to make you
feel a little bit nervous fromtime to time, but then this
stuff used to make you nervous.

Dr. Bernardo Sousa (13:22):
you don't even think twice about Maybe.

Dr. Tyler Tolbert (13:29):
you even think twice about it, Maybe you
even feel the need to startdoing Zygos just to get out of
the boredom.
You wouldn't be.
You're not far off from that.

Dr. Bernardo Sousa (13:39):
This was a nasty one, but it was asking for
it Fair enough.

Dr. Tyler Tolbert (13:41):
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 campwith you, I remember like I just
felt so excited and a littlebit nervous about going in and
doing these like really advancedcases and a totally foreign
environment.
But the cases were incredibleand I was doing cases without

(14:02):
looking at x-rays and buildingall this confidence and getting
humbled the entire time, butlike seeing great outcomes.

Dr. Bernardo Sousa (14:08):
If you tell this to the audience man, I will
have legal problems.

Dr. Tyler Tolbert (14:12):
you cannot say oh, not at all not at all.

Dr. Bernardo Sousa (14:14):
I mean, it was beautiful work.

Dr. Tyler Tolbert (14:16):
I stand by everything that happened but but
you know you come back and nowall the cases are comparatively
very easy and you're starting toget that sort of.
They all just feel pedestrianand normal and day to day, and
you're looking for that feelingagain because you get addicted
to it.
It's like I don't know thefirst time you go skydiving or
jumping off a cliff, which youwill also do if you go do full
arch club stuff.

(14:36):
So yeah, you're looking forthat kind of challenge.
It's true, always.

Dr. Bernardo Sousa (14:39):
Yeah yeah it's true, it becomes at a
certain point.
What I found in my life waslike.
Going to work was like.
It was like going to thelibrary.
It's like I have to go therefor a while do some stuff and as
soon as I get out I haveanother plans for my day.
That was that stopped.

(14:59):
This may be maybe many peoplewon't understand what I'm saying
, but going to do a full archcase stopped being the
interesting part of my day.
I don't know if you relate withthis, but I'm saying this very
honestly.
Like, let's say, for example, Ido a lot of referral cases.

(15:22):
For example, I do a lot ofreferral cases Mostly today.
I go to some place and I do thefull arch and then I go out to
it because it's done and I don'thave more, you know,
appointments in that day.
I go, I just do that and then Ican leave, and usually my
afternoons are the exciting andthe difficult part, because I
either go running or I have a Idon't know I have a half

(15:45):
marathon to do or I gowakeboarding things that
actually scare me.
That was just a small part of myday, if this makes sense.

Dr. Soren Paape (15:55):
For sure.
I think that resonates a lotwith people that are just
getting into full arts too.
There's always this periodwhere you know you start and
you're so excited about gettingused to these cases and getting
started with these cases, andit'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 likethese are great, I know what I'm
doing, this is perfect.
And then all of a sudden youhave, like your first or first

(16:18):
couple really bad complicationsit's like you're back down
syndrome, man.

Dr. Bernardo Sousa (16:21):
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 yougo to, to work and you're
worried about the cases.

Dr. Soren Paape (16:33):
But then you slowly, as you do more and more,
you build it back up and thenit becomes a norm and you're
used to the complications andyou've seen a little bit of
everything.
And once you're back up to thetop, that's when you get to
coast right, that's when itfeels like you're at the library
.
But it does take a couple, acouple of these cycles to get
through that to get to where?
yeah, where you're confident,and Tyler and I have trained a

(16:56):
lot of doctors here in the U?
S and we've seen a lot of thesepeople, you know, get up and
they're really excited and thenall of a sudden they're down in
that pit and they just can't getout of it and they just don't.
You know they there's too muchanxiety around the cases, but
the fact of the matter is, ifyou keep challenging yourself
you know, getting going to work,doing these cases, managing
your complications then you'llfinally get to the point where

(17:18):
you feel like it's rudimentary,Exactly.

Dr. Bernardo Sousa (17:21):
And what, let me ask you?
Like, let's invert who is theinterviewer?

Dr. Tyler Tolbert (17:29):
here for a moment.

Dr. Bernardo Sousa (17:32):
If I remember correctly, when you
took the master course atdifferent times, I believe,
right, yeah, you were juststarting Full Arts, right?

Dr. Soren Paape (17:42):
We were probably, like I would sayler
was maybe a year and a half in Iwas like eight months in a year
.

Dr. Bernardo Sousa (17:49):
Okay, and then?
So we probably had 50 to 100arches under our belt, but you
fairly knew yeah, yeah, and thenafter.
Uh, I guess my question is howdid your full arch life change
after the bootcamp?
After the Full Arch Clubcurriculum, the master course
and the bootcamp Because Ifollow your cases and guys you

(18:10):
are rock stars now, from what Ican see.
And I'm curious to hear howimpactful or not it was on your
journey.

Dr. Soren Paape (18:20):
Yeah, absolutely.
Well, just a little bit ofbackground.
Just the audience is aware,tyler and I both did bernardo's
full large club master course inportugal and I don't know, you
don't, do you not offer thatanymore?
It's just all in the boot campno, we do offer.
Oh yes, it's the main courseactually yeah, yes, the master
course was was great.
Went to portugal, um got to tosee bernardo do surgeries, um

(18:42):
learned a ton.
And then we went on to thesecond course in brazil, where
we got to see Bernardo dosurgeries, learned a ton.
And then we went on to thesecond course in Brazil where we
got to do a lot more hands-onstuff.
And I would say after themaster, even just after the
master course, where we weren'tdoing it necessarily on patients
but we got to do it on modelsand see the efficiencies in your
office and the differenttechniques that you recommended
I was just taking on, I was ableto do so many more cases

(19:05):
because I was able to see theextent of what was possible with
traditional all-on-four.
I feel like a lot of people getthese cases and they're like oh,
that's a Zygo case, likethere's no way I can do that
case.
And the reality is there's a lotof these cases that can be done
that walk in your clinic andthey can be done predictably

(19:26):
using some of these workflows.
And it's a lot less trauma tothe patients when you're not
doing these quad zygos orwhatever you think that patient
needs.
And I was able to treat a tonof patients that I otherwise
thought I wasn't able to, andI've seen these patients for
follow-ups and I'd be amazed ofhow well some of these patients

(19:46):
healed that I previously thoughtthere was not a chance that
this is something that I coulddo or that anybody without like
experience doing Zygos was ableto do, and my patients were so
grateful that I could providethat service to them at.
You know the fee, because whenyou start getting into Zygos,
all of a sudden patients arepaying double what they would

(20:07):
have for a traditional all onfour and you're able to save
that those anatomical landmarksfor if something occurs five
years down the line, not at thattime.

Dr. Bernardo Sousa (20:18):
Exactly.

Dr. Soren Paape (20:19):
So that's where , that's what I think, I go to
that course.

Dr. Tyler Tolbert (20:22):
Yeah, I think for me, before the course I
probably referred out I'd say asmuch as at least five, but as
much as 10% of the people whohad terminal dentition and they
needed something due to atrophicbone or what I thought would
need zygos and things like that.
That number dropped to what Ibelieve would be less than one

(20:45):
percent at this point, in termsof what I can well, you know,
less than one percent is amazingman.
I believe that.
I mean it's a made-up statistic.

Dr. Bernardo Sousa (20:52):
I don't have yeah, sure, but we have a
feeling on.

Dr. Tyler Tolbert (20:55):
Yeah, we have a feeling on that right and so
like when I was doing justtraditional all-in-four, I felt
like I was the person that whenpatients were told no, or they
had to get all these sinus liftsand things like that, I am the
solution for those people.
Now I feel like I can be thesolution for people who have
already had all-in-four done andnow they're being told that it

(21:16):
can't be treated.

Dr. Bernardo Sousa (21:17):
Now you are entering the library, man.

Dr. Tyler Tolbert (21:20):
Yeah, that's right.
That's right.
So you're just in a different.
You're like, later on in thatprogression of the extremity of
cases and teach someone who wasalready doing all in for how to
do something next level or fixsomething.
That happened and it made mecompetent in in fixing my own
problems, right, like I used tobe just terrified if one of my
distal tilted implants uh failedbecause I was like, well,

(21:44):
that's all I know how to do, sonow I'm going to have to graft
and wait and come back and dothis all over again.
And now I know that I canrevise this competently and I
almost get excited about itbecause I'm like, okay, cool,
like I can employ this now tofix it.
So, yeah, it was just that nexttier of provider and there's
just all these more problemsthat you know how to solve and
now there's new problems too,but it's all recursive as you
continue to progress andbootcamp was absolutely the

(22:06):
biggest catalyst for me to getto that part.

Dr. Soren Paape (22:09):
Yeah, yeah yeah , I also want to point out too
that a lot of my philosophieshave changed since the master
course Before, when I thoughttraditional 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 thingslike pterygoids.
Relay those to my patients,because I see a lot of patients

(22:29):
that come from other clinicsthat are getting standard
all-on-four and maybe a coupleof those distal implants failed
and the way that those surgeonswill try to relieve that is
placing new ones, but moreanterior.
And all of a sudden you're stuckwith a prosthetic that has a
two-tooth, three-toothcantilever and it's just not a
good prosthetically drivenapproach.

(22:51):
I relay that to my patients andI say, hey, there's a lot of
other clinics here that'll dothis.
However, if you come here, wetry to do more than four
implants when we're able toplace pterygoids and create a
prosthetic that'll last you along time.
And if any of these anteriorimplants fail, we still have
that posterior support so we canrelieve those issues much

(23:14):
easier and with morepredictability.

Dr. Bernardo Sousa (23:17):
The anterior area is never a problem.
Losing one or two on theanteriors First it's so rare
that we don't even think aboutit.
I don't even remember the lasttime I lost an anterior one.
But when we do, it's so easy tosolve.
You have the nasopalatine canal.
You can tilt them towards thevomer or towards the nasal crest
.
You have so many options.

(23:39):
In the same spot, actually, youcan just put a larger one.
I mean it's never a problem.

Dr. Soren Paape (23:46):
Yeah, absolutely.

Dr. Bernardo Sousa (23:49):
But yeah, guys, you are rocking this, but
you were saying something veryinteresting, søren, because
after integration, what reallymatters is soft tissue and
cantilever.
It's the two things that willdictate the future of that
implant.
If we take out the systemicfactors of the equation.
If we take this out, it's softtissue, quality keratinized band

(24:10):
and no cantilever.
That's what we know from theliterature and that's what we
see clinically.
Like you were saying, that'swhat what will dictate if the
implants will last longer and ifwe will not have too much bone
loss because of a necessarytrauma on the implant.
And and yeah, that's it, andterry bites changed my life when
I started doing them in 2018,and Pterygoids changed my life

(24:31):
when I started doing them in2018, guys, I had to.
I was taking the panoramicx-rays and then I was looking at
the result, taking a picturewith the phone and deleting them
.
I had to hide this stuffBecause in 2018, if you put 24
millimeter implants all the wayback there here in Portugal, man

(24:53):
, people would tell I wascompletely nuts.

Dr. Soren Paape (24:56):
So I have these ones and now it's funny how
fast stuff can become the norm,right.
True, they see more and morecases, they see literature about
it and now like, if you're notdoing pterygoid implants, you're
missing out on a lot of casesthat you can solve much better
for the patients that you treat.
And it's funny because I see alot of clinics here in Denver

(25:18):
that have been around for 10years and the surgeons there
they maybe they've gottencomfortable with their standard
all in four approach.
And some of these patients cometo me because they're so
frustrated with the fact that acouple of their implants fail
and they've been in a denturefor two years because they're
just waiting for their grafts toheal.
And I'm like this is somethingI could solve tomorrow for you

(25:40):
and it's with just taking theproper education to better
yourself and I think that'simportant for your patients when
you're doing treatment likethis.
So I think I think, bernardo,before we start talking about
maybe some of these individualcases and I know that you wanted
to show some cases and stuff Ithink the audience, you should
let the audience know what theFull Arts Club concept is and

(26:03):
how it's progressed over time is, as I said, no grafts, no
guides, no zygos and no delays.

Dr. Bernardo Sousa (26:22):
So I had contact, a big contact, with
other approaches, for examplewith zygomatic implants, at some
point and I did a lot of themin the past.
But at some point I had contactwith another philosophy, which
was the custom implants, aka thesuperiosteal implants, and this

(26:49):
changed my mind to such a pointthat I started to cook an idea
and a treatment protocol thatwould allow any doctor with the
right mindset and with the rightknowledge to solve any case
without these things, withoutgrafts, without zygus, without
delays and with immediateloading.
And we have placed together abunch of techniques, which are

(27:10):
the ALON4, the ALONX,transsinusnasal Pterygoids and
the Palatal approach.
And what I found in my ownexperience is that if you only
have the Allon 4 or the standardAllon X in your tool belt, you
will solve about 60% to 70% ofall the cases.

(27:31):
If you want to go from this 60to 70% to the 95%, you need the
palatal approach.
Especially, the palatalapproach is the big, the biggest
thing that will change yourgame.
The rest, the other 5%, becausewe are on the 95% now.
The rest, you have thetransinus, the transnasal, the

(27:52):
pterygoids and the customimplants.
And I found that withcombination of these techniques
and the application of thesetechniques in the right case,
it's not to apply it because,yes, for example, when I started
teaching the transinus approachand I saw many colleagues start
to apply it without, in casesthat they were not necessary, in

(28:14):
cases that it was more thanokay to do the standard all on
four and to pterygoid, topterygoids in the back.
So this is the kind of this isthe kind of the wrong mindset
that that I try to fight, whichis why are you over complicating
when you can be morepredictable, reduce the
morbidity of your case andachieve the exact same result?

(28:35):
There is no point on doing atrans-sinus if you can do a
pterygoid, and yeah.
So we found that with all thesetechniques, man, it is
impossible that the patientcomes to your office and you
have no answer for them.
So we started, we created themaster course to teach all of
these things, started thecreated the master course to
teach all of these things.

(28:56):
I teach you all the fundamentalsof large of incisions, of flaps
, bone reduction, the techniquesthemselves, suture, medication,
follow-up.
We teach all of these and thestudents get to watch me and the
other mentor, dr Pedro, to dothis life surgery.
And then, for the colleagueswho want the ultimate experience
, like yourselves, you go to ourlife surgery boot camp in

(29:19):
brazil when you where you willhave the hardest week of your
life in oral surgery, but maybethe best as well.
And you will apply all of thesethings into patients in very
difficult cases, the cases that,according to tyler he said this
on on the interview cases youwouldn't even bother to flap.

Dr. Tyler Tolbert (29:42):
You remember saying yes, that's right, that's
right, I remember saying it.

Dr. Bernardo Sousa (29:45):
Yeah, yeah and yeah, and after the boot
camp, really honestly, I thinkpeople are ready to to tackle
everything and and that's thefeedback we have we see this in
our students.
I see this on you, for example.
You are killing all these veryhard cases that I follow on
social media and otherparticipants as well.

(30:06):
So I feel like what I feel islike 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 ofunnecessary stuff and
unnecessary grafts andunnecessary zygos.
I still see a lot ofunnecessary zygomatic implants,
to be honest, more and more.

(30:27):
But I think that in the future,things will change.
I think the custom solutionsfor patients and I'm not talking
about custom implants, I meancustom solutions in general will
be the future.
I don't think that dentalimplants will be the future.
I think the future of oralrehabilitation will be a true

(30:50):
regeneration of what is lost andnot fake stuff, not metal
screws on the mouth.
I think we will replace a lostmaxilla by another maxilla.
I think we will replace a losttooth by a real tooth.
The Japanese or the Chinese arealready doing this.
I published this news on thenewspaper.
It's on my Instagram If you gothere.

(31:11):
They were already successful onmaking a new tooth grow, and so
I think it's a matter offine-tuning now, for example,
for partial dentalism, it's amatter of fine-tuning genetics
to make the tooth with the rightshape to appear in the right
place in the right position.
If we get this right, I thinkdental implants will be obsolete

(31:32):
.
I think dental implants will beobsolete in the next 50 years
50, 5-0, not 15.
I mean 5-0.
Yeah, I was about to say hey,now we're starting to talk about
our careers, but meanwhile, wehave a lot of patients to treat,
and I do believe that thesepatients are way better treated
with the techniques that weexplore in the course compared

(31:53):
with the old school alternatives, if I can put it this way.

Dr. Tyler Tolbert (31:59):
Yeah, yeah, no, I totally agree.
How would you say, throughoutthe progression of Full Arch
Club, like you've had to teach?
I mean, you've taught so manypeople.
There's so many cases behindthis.
Would you say that thephilosophy of Full Arch Club has
changed much at all, or haveyou thrown in some more concepts
that you feel, as you've gonealong the way, that you've
learned better ways to teachpeople and you talk about soft

(32:21):
tissue as well?
What sort of things have gottenincorporated in the philosophy
as you've gone along?

Dr. Bernardo Sousa (32:25):
In the first editions of the course we were
not teaching soft tissue and Inever thought it was something
that so many people wereinterested in or that needed
that teaching.
Because for me, the soft tissuegrafting is part of my life
since the very beginning freegingival grafts, connective

(32:46):
tissue grafts and I don't know.
I've been doing that since inthe dental school actually, so
it was routine.
And then I found that manyimplantologists that can be
actually great at placing theimplants themselves, the the
soft tissue was missing and andthe colleagues started to ask

(33:06):
Bernardo, can you explain thefree gingival graft and this and
that?
And then I said, well, maybe weshould introduce a lecture on
this.
So now we have soft tissuelectures on the master course as
well In the boot camp in Brazil.
If the case needs, we do softtissue augmentation as well in a
full arch case, usually in thesame act.
So we do, for example, a fullarch in the mandible that has

(33:29):
this minimum keratinized bandand we increase with connective
tissue graft.
In the same day we also we arefinishing our protocol for soft
tissue grafting on customsuperior implants, which doesn't
exist yet and we already haveit.
How can I say it's cleared forus.

(33:50):
So when you do one sub, youalso do this in the same day and
you get the tissue from hereand you put it this way.
In this way, we will releasethis soon and but I don't think
that we have changed, like theprotocol in the implant part in
any aspect.
To be honest, tyler, I think Ithink the concept on the

(34:11):
opposite, it only gets strongerand 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 thecourse and and I also see people
that took our course and now doteaching their own course with
these principles.
So it's because it works, man,because if it didn't, yeah, it

(34:33):
has stood the test of time.

Dr. Soren Paape (34:34):
Yeah, yeah, I think soft tissue management is
something that is is overlookedquite a bit and it's very
critical.
We've talked about this on thepodcast before but the best time
to to solve these soft tissueissues and once you've seen
enough cases and you've doneenough cases, you can be pretty
certain when you place animplant and you're going to do
all of your during if thatimplant is going to have enough

(34:59):
keratinized tissue around it ornot.
And if it isn't, there's a lotof people who are like they just
want to get done with the caseand they're like all right, let
me just suture this up and sendthe patient home.
But the reality is thepatient's going to have a much
better experience if you takethat extra 10-15 minutes to lay
your pedicle flap to ensure thestability of that implant over
time.

(35:20):
And it's much easier while thatflap's already done in the
beginning of the surgery thanwaiting two years until the
patient comes in for thatfollow-up and you're sitting
there with an implant that hasmaybe endocaryogenized tissue on
the paloalto but, there'sabsolutely in the buckle and
you're starting to see some boneloss and some thread exposure
and all of a sudden you're in asituation that could have been

(35:41):
so much easily fixed in thatinitial surgery, and that's
something that we've talkedabout with, like Damon on our
podcast, and he stresses howmuch before he could do arches
in 30 minutes and he would docases in 30 minutes and now it
takes him maybe an hour to do anarch.
However, he's being much morecritical about that soft tissue

(36:04):
because he's seen thecomplications that can occur if
you're not.
And that's just part of thatprogression through full arch.
Part of our goal with thispodcast is to help people
prevent those issues prior to toseeing them in two, three years
and really focus on doing themright off the bat.
So what bernardo's saying aboutsoft tissue management is

(36:26):
critical and learning that at acourse like like full arch club,
where you can go learn palatalapproach, learn some of these
other implant techniques butthen also improve just your
traditional all in four throughsoft tissue manipulation
concepts is really critical.

Dr. Bernardo Sousa (36:42):
And I think it's so easy, man, that it's a
pity that we don't take theadvantage of having our hands on
the stuff and doing it at thespot, like you said.
And but you know what I foundwith 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 alwaysphotograph all my cases and I

(37:03):
was seeing some cases withoutcrotonized tissue that I was
absolutely sure that they hadgood tissue five years ago.
So I went to see the picturesand I was like, why did this
happen?
And you know what I realizedwith time and with talking also
with people that started when Istarted and people that were

(37:24):
able to follow their cases forso long, because it's quite
difficult to follow cases tofive years or more and everybody
was having the same issuesCases that have good tissue on
the day have good tissue on oneyear mark, maybe at two years
mark, but after that, man, youstart to lose keratinized band
and this is something that youguys, you will see more and more

(37:46):
when you go close to the fiveyear mark.
Cases that were perfect are notperfect anymore.
So the need for revision forsoft tissue is a certainty.
It is not a possibility, it's acertainty if you give it enough
time, and it's something that Ichanged in my informed consent.
Now it says that it will beneeded in the future maybe some

(38:09):
kind of soft tissue improvement,because you will lose it
naturally with time.

Dr. Soren Paape (38:17):
Yeah, absolutely.
I think that's something thathere in the US and maybe you see
it in Portugal too, but there'sa lot of clinics here and
there's a lot of peoplepracticing for large dentistry
that tell patients hey, if youcome to me, it's one surgery and
you're done, you'll be set forthe rest of your life.
And the reality is then, when arevision comes in the future,

(38:37):
it's so much harder to get thatpatient to agree to do a simple
procedure like a pedicle graft,just to increase the longevity
of that implant, because they inthe beginning they were told
hey, you, you won't needanything like this off the bat.
So I think, lowering thosepatients expectations from the
beginning and ensuring that theyunderstand that, hey, you're 45

(39:00):
years old and you're in a placewhere you need a full arch
treatment, there's a really goodchance that you're going to
need not only one revision butperhaps multiple revisions
throughout the rest of your lifeif you want this to last 40, 50
years.
And it's that clinician'sresponsibility, I think, to
learn these techniques so whenthat occurs, they're able to

(39:22):
manage those complications.
Oral surgeon.

Dr. Bernardo Sousa (39:25):
Sorry, no go ahead Go ahead.

Dr. Soren Paape (39:27):
I was just going to say every oral surgeon
that I've talked to here in theUS that I've asked them their
opinion on should you know,general dentists be doing cases
like this.
Most of them, if they're notsuper conservative with their
thinking, say you know, I don'tcare what a general dentist does
, as long as they're able tomanage those complications that

(39:48):
occur from those surgeries.
And basic soft tissuemanagement is definitely one of
those complications that anybodypracticing this style of
dentistry should be comfortablewith.

Dr. Bernardo Sousa (39:59):
Yeah, yeah, we can never promise a lifetime
results.
Look the multicenter studies,which are those who I enjoy
reading the most, because ourstudies done in a bunch of
clinics in a certain locationand they reflect better the real
world scenario, the real worldresults of the things that we do
.
And these multi-center studiesshow that the dental implants,

(40:21):
after 15 years or more, onlytwo-thirds are there.
Only two-thirds survive the 15plus year mark, which is
something that I feel like notonly patients don't know this,
but doctors don't know this aswell.
And this is the harsh reality,the things that we are doing
right now.
Man, if you have the luck, theblessing, to be able to follow

(40:45):
the case for 15 or 20 years, I'msorry to say man, but one third
of those will not be there.
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

(41:06):
us.
So, and the thing is this ifsomeone loses their teeth by
their 40s and those teeth werethere, let's say, since the
person was 10 years old, 12years old, so the teeth only
lasted 25 or 30 years how canyou expect that a metal screw

(41:28):
will last more than that.
That has no periodontalligament to absorb the forces.
Which is the biggest problem ofimplants is that they have no
shock absorbing ability andthat's why we start to lose bone
loss early bone loss becausethe stress has to go somewhere.
It goes to the crestal bone andit starts to disappear.

Dr. Soren Paape (41:49):
For sure and I think, like you said, when these
patients, you know they've lostall their teeth in 20 years, a
lot of times there's a lot ofcontributing factors that go
into the reason why thathappened, 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

(42:10):
keep my teeth clean now, oncethey have a new set of teeth in
there, a lot of times thesepatients fall back to these
habits that they've hadpreviously and there are going
to be complications that occurbecause of those.
The fact that they have theability to manage those, I think
, will really further a lot ofdentists' careers and get to a
point where they're like, oh mygosh, all these cases I've done

(42:32):
five years ago, I need to revisenow.
I'm not comfortable doing that.
If you just get some of thesebasics, it'll prolong your full
arch career and you'll have amuch happier career where you
feel like you know, where youfeel like you're going to the
library every day instead ofgoing you know, somewhere you
don't want to want to be, yeah,preventive dentistry and and the

(42:53):
complete and the revisiondentistry is going to be the
future in the short medium term.

Dr. Bernardo Sousa (42:58):
To avoid these things from happening, to
avoid people from gettingimplants in the first place,
which is something that I talk alot and you guys are on the
WhatsApp group.
I talk a lot about this Shouldthis case be a full arch?
Should this case not be a fullarch?
Can I postpone this?
Can I do something to try toavoid removing all teeth from
this person at their 30s, whichis quite dramatic?

(43:21):
Because people, we have tounderstand 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 lifeexpectancy, 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?

(43:42):
I feel like a bit of a personalfailure to doing something that
is supposed to be permanent andit's not, and I know that it's
not.
The statistics show me thatafter 15 years, only two-thirds
of the implants are there.
So I feel like we should bedoing way more in the preventive
side and to delay these thingsa lot.
But unfortunately thehealthcare is like guys, nobody

(44:06):
makes money preventing thedisease, the money is made
treating the disease and this.
We could talk a lot about this,but this is.
This changes the wholeperspective that we have on
health care is not to promotehealth, is to promote the
disease.

Dr. Soren Paape (44:23):
so it's funny.
I just this is going down adifferent rabbit hole, but I
actually had a dental cleaningthis morning and my hygienist
was talking to me about peterattia, uh, and he was.
He's one of the guys that are onthe huberman podcast a lot and
I read one of his big, one ofhis big philosophies in medical
school was was the lack ofpreventative care in the united

(44:45):
states and the sheer impact ofwhat a lot of these pharmacology
departments or, like bigbusinesses, right Pharmaceutical
companies push, and they'repushing medications that treat
these cases, when in reality, alot of the people in the United
States that have issues likediabetes or overweight or

(45:06):
whatever it is, could have beencured through preventative
measures, but instead Lifestylechange habits.

Dr. Bernardo Sousa (45:14):
Exactly yeah .

Dr. Soren Paape (45:15):
And instead are treated with drugs and they
continue some of these habits.
I'm not saying that everybody'slike that, but you know it's
very similar to oral care ifyou're in your 30s and we can
make you last another 10 yearsor even 20 years prior to
getting one of these majortreatments done.
I think it's really importantand that's something that I know
me and tyler a lot about and wereally push patients that are

(45:38):
coming in in these age groups,unless they're in a position
where they're totally not ableto be rehabilitated, but we push
them to wait before gettingthis treatment done.
The problem is the more andmore of these centers that pop
up.
I see patients that are comingin that are in their early 30s,
that have you know teeth thatare are totally fine, and

(45:59):
they're coming as a secondopinion from a clinic that said,
yeah, right that you know I'mlike, I'm like what?
like you are totally fine, likeyou do not need this done in
your situation, and the problemis they're just going to turn
around and go to the clinic thatsaid, hey, we can do this today
.
Yeah, um, so it is a majorproblem.

(46:19):
This is a major problem, youknow.
You know that in.

Dr. Bernardo Sousa (46:22):
In some countries here in europe you go
to jail if you do something likethis.
The the laws in somejurisdictions here are so strict
about about implant kind oftreatments that you lose your
license.
Man like this, if it getsproven, the people that will be
against the doctor are alsodoctors from this kind of

(46:45):
mindset the correct mindset inmy opinion that will prove,
because this and this, that thiscase should not be a full arch.
So these doctors have mutilatedthis mouse.
So the consequence is this, andit's usually either suspended
license or they banned the guyfrom practicing in this country

(47:05):
again, or you can face criminalcharges and end up in jail.

Dr. Tyler Tolbert (47:09):
It's seriously, it's no joke, it's no
joke.

Dr. Bernardo Sousa (47:11):
So I think we are a bit more conservative.
I think also, to be honest, insome places maybe too much,
maybe too much conservative andtry to save.

Dr. Tyler Tolbert (47:21):
What is not possible anymore, or at least in
the context of full archrehabilitation, does not make
sense to save and that is a fineline on the sense, yeah, for
sure, save, and but this, thereis a fine line on the sense yeah
, yeah, definitely is the otherside of the equation, because,
yeah, I don't know what theratio is but like for every

(47:41):
patient that I've seen that wastreatment planned to have all
their teeth removed and get thisdone.
There's plenty of otherpatients that I feel like this
should have been done a longtime ago and they've wasted
money and they've wasted timeand now they've got insane,
newfangled, you know treatmentin their mouth.
I mean, I've seen people thathad, you know, a mini implant
here, a standard implant here,they've got two telescopic

(48:04):
copings on their natural molarsand it's all this removable
upper snap in.
That never worked.
And you see all kinds of thingswhere people are just trying
for the sake of saving teeth,but then there's this misguided
approach towards just savewhat's there and it really ends
up costing the patient at theend of the day and they end up
getting an all-in-foureventually or they just go broke

(48:24):
or end up in a denture becausethey don't have any more to
invest.
And there's that too and so it'snot just important to know how
and when to do this well, rather, I already gave that away it's
not just important to know howto do it, but when, and there's
times where it's not gettingdone but it should, and there's
times where it's getting doneand it shouldn't so I think just
I think it's so important thateven people that don't focus

(48:45):
primarily on full arts that theyunderstand its place just in
the full array of what we can do.

Dr. Bernardo Sousa (48:50):
Yes, it's very it's.
One of the most difficultthings is to discuss this topic,
because something for me canlook like one thing from.
The easiest way to create adiscussion is to show a
panoramic x-ray to 10 doctors,because you will find 10
different treatment plans.
But I think it's very difficultto make the line where what is

(49:14):
correct, what is wise, whatstarts to be over-treatment.
It's not easy and I think moreguidelines are needed for this
for the benefit of the patient.
Maybe AI will solve the problem.
I truly believe AI will be thejudge very soon.
In most non-criminal things,even civilian things, I believe

(49:38):
AI is going to be the judge.
There is nothing that is morefair than a computer
intelligence to analyze data.

Dr. Soren Paape (49:45):
Yeah, we'll see .
I feel like the scary thing isthat 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 makethings move, and I wish that it
was a little bit simpler, but Ifeel like that, no matter what,
that's the what's going to endup happening.

(50:07):
But, I think we've.
I think we've we've gonethrough a lot of the
philosophical side of things.
I'd love to to move theconversation into into some
clinical stuff, and I know wehave some questions here for you
that we've touched onthroughout the beginning of this
episode, but I know ourlisteners really like to talk
about some of the basics, and afew questions I have for you,
bernardo, are what are somesimple things that doctors can

(50:29):
do to improve their outcomes oftheir cases over time and I know
we talked a little bit aboutsoft tissue grafting, but I'd
like to go into that a littlebit and then I'd love to hear
what are some mistakes thatyou've seen about how people
approach full arch cases and howcan they manage those and
prevent those to ensure thatthey have stability over time

(50:53):
stability over time.

Dr. Bernardo Sousa (50:54):
I think the best and the wisest and the
cheapest thing to do in thebeginning is to find a mentor
that is very good clinically butalso 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 tryto go into a course, to this
person's course, and try to talkin private.

(51:16):
Try to understand how theperson thinks, why he's choosing
this solution instead of thatsolution.
The clinical, as I said theother minutes ago, the clinical
part is the easiest to achieve.
To learn something, nowadaysyou just need to pay.
You pay for a book, you pay fora course, you pay to go to a

(51:36):
meeting and you learn.
And that's the easiest part.
I think the hardest part is themental part.
It's to try to understand, ortry to put your brain
functioning in such a way thatyou can choose the wisest
decision most of the times.

(51:56):
What should I do in this case?
What makes more sense to do inthis case for the benefit of the
patient?
In the majority of the times, Ithink this is the the difficult
thing to the most difficultthing to to understand, to learn
, because you don't buy thisknowledge.
This is something that somepeople have a natural brain for

(52:18):
implantology, for to be ahandyman, to work with screws,
with bolts to work with in anengineering brain, and this is
the hardest thing to teach.
If you don't have a goodengineering brain, you can teach
all the techniques, all thisstuff, but having the right
mindset, I think it's thecrucial part and in this regard,

(52:40):
for example, for me it stoppedmaking sense, for example, to do
a quad zygote if I can do acustom implant and preserve all
the bone of the patient.
This is the kind of mindsetthat I'm trying to explain is,
if you have two or threesolutions for the same thing,
what things are you putting onthe table to make your decision?

(53:02):
And I think that thedestruction involved should be
the first or the second for thebenefit of the patient, for
example.
Then, how long is the surgerygoing to take?
Do I need general anesthesia?
Do I not need generalanesthesia?
Is the patient going to sufferfor a long time or is it going
to be an easy post-op?
All these questions that wemake, I think, should guide the

(53:25):
decision-making process, and wereally try to put doctors to
think like this, to teach notonly techniques, but ways of
thinking about things.
But what?

Dr. Soren Paape (53:35):
was the second question Soren Sorry.
No, I agree with that.
I will.
I'm just going to give myopinion and then I'll go back to
that second question.
The you know, I get asked a lotfrom dentists who are, or maybe
you know students who are indental school who are really
trying to get into full arch andimplants and whatnot and
they're like hey, I saw that youfast tracked your path towards

(53:56):
implant dentistry.
How did you do it?
What would you recommend for me?
And my response is always thesame.
I always tell them the biggest,the most important thing is
learning those fundamentalslearning how to take teeth out,
learning how to do these things,because that's how you get
these efficiencies and when youare efficient in the case and
you understand the fundamentalsof taking teeth out and laying

(54:16):
flaps and all of these thingsthat people might overlook
because they think that it'srudimentary.
Understanding the properprotocols for doing that will
relieve a lot of these mistakesthat people run into when
they're rushing removing teethor they're rushing laying flaps
and it's causing buckle platefractures or different
occurrences during the surgery.

(54:37):
That could have easily beenmanaged just by learning those
proper fundamentals.

Dr. Bernardo Sousa (54:42):
Yeah, so that's what we spend.
You certainly sorry tointerrupt you.
The master course the first dayday, the first five, almost
five hours in the morning, isjust about fundamentals.
Even if you already know how todo Allen four, you will get
bombarded with fundamentals inthe morning how to do the flap,
where to put the blade, wherethe incision, why is the

(55:04):
incision here?
And, for example, the verticalreleasing incisions, why in this
place and not half centimeterposterior?
There is a reason foreverything that.
There is a reason.
I would say there is actually areason to do every single thing
that we do in a full arch case,that nothing is doing randomly
and absolutely agree with youthe, the fundamentals.

(55:25):
For example, here in portugal isquite common.
When you go to a dental groupit's like you want to do
implants Fine, but first youhave to take out all the
impacted teeth.
You need to prove that you knowhow to do surgery and after you
prove this, okay, maybe we willstart to give you now some
simple implants and then maybewe will give you some full arch

(55:46):
cases, but first you prove youknow your stuff in surgery.
This was the Cuba time for mewhen I was there.
It's like Bernardo, you proveyou know your stuff in surgery.
This was the Cuba time for mewhen I was there.
It's like Bernardo you have 10impacted lower molars to take
and you have two hours for allthese patients.
And we were numbing them likeone here, one there, one there,
one there and there, and then itwas like fabricating cars and

(56:09):
that's how you get good at thosethings.

Dr. Soren Paape (56:13):
No, I agree 100%.

Dr. Bernardo Sousa (56:19):
The second question Bernardo, fundamentals
is the way to go.
Before you think about, evenbefore you think about doing a
single implant.
You need to be very proficientin taking impacted teeth out, at
least in my perspective, indoing flaps, in traumatic
extractions.
You need to be very proficienton this.

(56:39):
Only after this you can startto do the the interesting part.
But the fundamentals, if youdon't have them.
That's why I always I told youin the beginning that I always
read the full Peterson book whenI was in dental school and this
changed my life reading thebook over and over and over
again, because I knew how tosolve a lot of complications and

(56:59):
I have never seen them before,but I already knew how to do how
to solve them when the timecame.

Dr. Soren Paape (57:05):
And it's all about rentals and a lot of that
stuff pairs together right likeif you start to to realize how
to solve certain issues thatoccur it.
I think it goes for differentcases and how to solve different
problems throughout the oralcavity and then everything, as
you learn more and more, meshestogether to get a clinical suite
that you can handle theselarger full arch cases yeah the

(57:27):
second question what do you?
What are some simple thingsthat people can do to improve
their outcomes for thesesurgeries over time?

Dr. Bernardo Sousa (57:36):
I think one of the hackings that you can do
on yourself is start to workwith the left hand.
This change we forced you.
Yes, this is something we do atthe master course, actually,
and then in the boot camp it'slike mandatory.
We train you to use the leftand this is something that will

(57:58):
change your life and I'm surethat everybody will understand
what I'm going to say.
Now.
If you are right-handed and youare going to place a tilted
implant on the second quadrant,some patients don't open enough.
You barely can fit your handand the contra angle and the
drill if it's a long one, it'svery complicated.
Plus, when you work with bothhands, your level of symmetry

(58:22):
it's unparallel.
So I think that one of the coolthings is start to be
ambidextrous.
I was not born ambidextrous, Itrained myself and now I write
with the left, I playinstruments and all this.
But I forced myself to learn inthe beginning and this changed
me.

Dr. Soren Paape (58:40):
We did the master course after we went the
first time.
I think one thing I said onthat was, if you are going to
Bernardo's master course, onething I'd recommend doing before
you go is start brushing yourteeth with your left hand, eat
your food with your left hand,give you a bernardo will give
you an extra pat on the back ifyou get there and you're
proficient with doing that withyour left hand and you could

(59:01):
actually feel comfortableangling an implant using that
left hand, so I agree being ableto use both hands back and
forth when you're doing thesecases It'll make things much
easier and it'll make your casesmuch more symmetric as you do
them.

Dr. Bernardo Sousa (59:16):
Yeah, Another thing that I think helps
a lot of people in thebeginning is what I was telling
before is to find a mentor andwork with the guy or shadow the
guy, because you will.
What will take you 10 years onyour own can take six months
with the right mentor and nojoke.
It's really how fast you canprogress six months with the
right mentor and no joke.
It's really how fast you canprogress and something someone
in.

Dr. Soren Paape (59:36):
Yeah, oh, go ahead.
I was just gonna say in my, inmy learning, I had a mentor my
last year of dental school and Iwas fortunate enough to be able
to work under him for an entireyear.
And so, shout out, dr G, dr heKeeley.
He was gracious enough, he hada really large oral surgery
background and for an entireyear he allowed me to do all of

(59:56):
his cases and he assisted for me.
And, man, what I learned inthat year, like you said, would
have taken me a decade afterschool and there you'd be
surprised with how many peoplejust in your local community are
willing to help teach andwilling to help you come and
shadow and before I even cut myfirst arch I was in the op for

(01:00:17):
probably over 100 cases, justseeing and watching how people
manage complications andworkflows and how efficiencies
with assistance, whatinstruments to have, and
everybody has like differentnuances that they like during
these cases and if you're ableto get a really good background
of how all of these differentthings work, you can bring
everything together and thatfirst or second case will be so

(01:00:40):
much easier for you because youknow, like you said, you read
the book over and over again.
If you're in a mentor's surgicalroom seeing it done over and
over again a lot of theseproblems that you might have
right off the bat, you'll beable to manage them so much
better.

Dr. Bernardo Sousa (01:00:56):
Yeah, another, yeah, absolutely
Another thing that I also thinkthat helps a lot and it was
something that in my life I wassearching for this always is to
try to learn something from thesource or from someone that
learned from the source.
What I mean was, for example,when I wanted to learn full arch

(01:01:17):
, 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 apoint because, especially
nowadays in social media, yousee a lot of stuff being

(01:01:40):
promoted with a lot of likes andthings like this very big hype,
things that are, for example,just not correct or could be
better, or there is no reason todo them.
If you have something that isperhaps that has a better
indication or that can be donewith more efficiency or there is
pointless to do this becauseyou are adding something without

(01:02:04):
the benefit, without anybenefit.
So I think that learning thingsfrom the source or close to the
source, I think it's a goodthing, not only in full arch,
but even in soft tissuemanagement.
We have great people that thatinvented the techniques that you
can learn from the source.
I, for example, I learned to dobone blocks with Frank Zastrow,

(01:02:27):
which became a good friend ofmine, and he has a story very
similar to mine.
He was working with ProfessorKouri, for example, and so I was
like, okay, I either learn thisfrom Fuad Kouri or I learn this
with Frank.
And then I went to Frank's andthis was always.
My life was always like this.
I always wanted to learn theclosest from the source as

(01:02:51):
possible, to hear theinformation and to acquire the
knowledge unbiased, because indentistry, there is this thing
that I don't understand why thishappened, which is everyone
wants to add a touch of his ownon something, something that has
been done for 20 years.
I will do it a little differentand call it something a little
different, for no reason, and Ithink I think learning stuff

(01:03:16):
where it was born, it'ssomething wise to do from some
for someone that is juststarting and is like clueless,
on on, on the full arch game.
I think that these are thethree things I would recommend
to doctors starting just now,and maybe a fourth one, if you
don't mind, which is to keepthis critical mind, to be critic

(01:03:38):
of what they hear, of what theyread, of what they see on
social media and especiallybeing very critic with their own
work.
I told you I always photographall my cases and the amount of
stuff, guys, guys, that Ilearned in my first years just
looking at the pictures, it'sinvaluable.

(01:04:00):
The suture details what happensif I start the suture on the
buckle versus what happens if Istart the suture on the palatal.
How to where to put theincisions on the palatal.
How to where to put theincisions.
I fill the socket with thisbone graft, but there was
something missing.
How did this turn out?
In the future, I learned somuch.
Uh, taking pictures, macropictures, not cell phone

(01:04:22):
pictures.
That's bullshit.
I mean with, with, with this, Iwill show you.

Dr. Soren Paape (01:04:30):
With a nice DSLR this was.

Dr. Bernardo Sousa (01:04:33):
I will tell you the story of this.
This is a Nikon D7100.
This I bought with my firstsalary.
My first salary was all to buythe camera and the lens More
than a decade ago.
It's still my camera and myparents were like Bernardo, your
first salary salary, you aregoing to throw all these away

(01:04:54):
into this camera.
And I told my dad this is goingto be my biggest ce investment.
If I take in proportion what Imake this month versus what it
costs, this is going to be mymost expensive C program.
And it turned out to be one ofthe best C that I took was

(01:05:17):
buying the camera.

Dr. Soren Paape (01:05:18):
Yeah, I think, proper records when you're doing
these cases.
It's invaluable to see changesover time in your patients and
you can't do it without goodimaging.
Right?
It's easy to have a patientcome back for a two-year
follow-up and you don't have apicture of the beginning and
just say, oh yeah, that looksgood, I think that's working
well.
But if, in reality, if you hada first picture, you could see,

(01:05:40):
oh wow, they actually lost threemillimeters of keratinized
tissue on the buckle of thatimplant.
What did I do in this case thatI could have done differently?
So I agree a hundred percent%and that's the main reason why I
like to, you know, post all mycases and be accountable for
those x-rays and everything,because I like to look back on
those and say, okay, what didthis case look like when I did

(01:06:01):
the surgery and what, where isit at now?
At my follow-up, did I dosomething wrong?
Was there something that I thatwas different than most of my
other cases that changed thosethings?
Are you guys already?

Dr. Bernardo Sousa (01:06:11):
taking pictures as well.

Dr. Soren Paape (01:06:14):
Yes, I don't post a lot of my surgical photos
in my Instagram because I dohave a lot of followers that are
patients and I'm trying to.
You know, there's a balancebetween doctor facing or patient
facing Instagrams and I think Iwill be leaning towards I'm
probably going to start anInstagram account just for my
clinic where I post a lot ofthose before and afters and then

(01:06:35):
I'm going to post more surgicalphotos.
But I do surgical picturesthroughout all of my cases as
well, and I think you'veprobably seen some of those,
because I post some in our FullArch 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 (01:06:51):
We have a colleague there, a Polish guy.
He posts a lot of very detailedpictures, like the implant
still in the beginning, then theimplant on the middle, then the
implant all bone level Supermacro, super macro pictures.
But I told him when he took themaster course man, if you keep
taking these pictures, you willfast forward your career super

(01:07:14):
speedy, because you see yourshit in macro ampliation.

Dr. Tyler Tolbert (01:07:20):
So, and he's getting quite proficient on that
.