September 16, 2024 • 39 mins
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.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
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,okay great.
Dr. Soren Paape (00:10):
So yeah, I mean , I think those are invaluable
topics that you know photography, proper records and everything.
They go a super long way forpeople who are trying to manage
their complications over timeand just see how their cases
progress over time, to managetheir complications over time
and just see how their casesprogress over time.
I know that a lot of people aresuper interested in custom
(00:32):
implants and subperiosteals andI know that you know you're a
big front leader in the customimplants, at least the new age
ones, right?
Dr. Bernardo De Sousa (00:36):
We've seen.
Dr. Soren Paape (00:37):
I was at course in Portugal when Picos came and
showed all of his mandibularsubperiosteal implants that he's
done over the past you know 30years and in the follow-ups of
those and how wonderful they areand I think that you know the
seeing a lot of these zygocasesand stuff.
It's really important to bringin subperiosteals in the maxilla
(00:58):
because it does offer anotheryou know, I guess you could say
lifespan for patients who.
I feel like there's the fullarch lifespan right, and then if
we can eliminate that zygomaticlifespan and instead have a
subperiosteal lifespan, and thenmaybe zygomatic zygomatic in
the future, or if you have, youknow, all-on-fours that turned
(01:19):
into zygomatic and all of asudden those zygomatic are
failing, I feel like a lot ofpatients are in a situation
where they're stuck with areally shitty denture then for
the rest of their life.
So you know, incorporating someperiosteals, then go ahead.
Dr. Bernardo De Sousa (01:32):
Yeah, this is the reality, man.
There are countless patientsthat had failed quad zygos that
there are on obturatorprosthesis at this moment and
that nobody knows about thisreality.
This is what is under theiceberg, you know, because
nowadays the industry is pushingZygus with such power that
(01:57):
doctors almost feel like theyare surgical inapt if they don't
do quads every day.
And the reality is that theneed for a quad or for a sub is
less than 1% of the cases.
That's the first thing we haveto keep in mind, because with
all the other techniques you cango to 99% of those cases, which
(02:21):
is the overwhelming majority ofwhat is of the full arch
population.
The quad zygote problem is not aproblem 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 middleand we need to create these big
(02:43):
slots to place this shortimplant, because the zygote is a
short implant.
The implantable part of thezygote is quite small, it's 10,
11, 13 millimeters only, but ithas a very big arm.
But the implant is also it'sactually a short one and the
destruction that is necessary toplace to do a quad is something
(03:06):
that is so big and soirreversible that it is even
difficult to do a sub after youlose a quad.
It's difficult, the destructionthat is left, the big autosinus
communication that you have,the zygoma that gets destroyed.
It's very difficult to approacha case like this and I think
(03:27):
that we should consider thecustom superiosteal implants,
because I said the other daythis on social media and the
majority of people understoodwhat I was saying, but there is
always a small percentage thatwants to test the words.
But this is true the superiorosseous surgery, guys, is a
(03:49):
minimally invasive surgery,because we have to think the
minimally invasive conceptalways depends on the expected
outcome.
You understand what I'm saying.
We cannot expect to solve asuper atrophic case with a
single implant.
It's not going to solve thecase right.
(04:09):
So we need to understand whatis on the table.
A supratrophic case either goesfor a quadzygote or for a
superiosteal implant.
So, for the two options thatare on the table, when I say
that this is the minimallyinvasive one, it's compared with
the other solution thatachieves the same result.
So in this sense, yes, it's aminimally invasive solution
(04:32):
compared with the quad, becausethe quad we know the destruction
that is required just to placethe implant.
So, yes, I do believe that issomething very promising the
fact that these customizednowadays without having to open
a flap like it was on the olddays that were two surgeries
(04:53):
were necessary, one just for theimpression of the bone and then
another one for the placement.
Now we don't need to do thatfirst one.
We use the CBCT scan.
It's a surgery that takes aboutone hour.
We use the CBCT scan.
It's a surgery that takes aboutone hour.
Most of my surgeries actuallyand you know this, you have seen
this take local anesthesia only, and we always we are
(05:14):
absolutely positive that thispatient is going to have fixed
teeth today.
It's not something that weaspire to, it's a certainty in
this approach.
So when we think, when I thinkabout you know the pros and the
cons.
The only cons that I see isthat first you need a few weeks
to produce the implant.
You know you cannot just appearin the office and boom and do
(05:34):
it.
No, you need to take the scan,you need to design the implant,
to print it and all these thingsand and and the price.
It's more expensive than buyinga couple of zygomatic implants.
But besides these two things, Ithink the pros are way more than
the cons and that's why, when Istarted with this kind of
(05:55):
technology, I said to myself OK,now I'm on a crossroads.
Do I continue with the zygos ordo I go into this journey,
pioneering approach, roads do Icontinue with the zygos or do I
go into this journey, pioneeringapproach, and and try to maybe
change a little bit the waythese, these very complicated
cases, are going to be done inthe future?
And you know, we took a leap offaith, but it was not real
(06:16):
faith, you know.
I mean, we studied all theconcepts.
I read the lincoln books, youknow I I spoke with people that
did the old ones back in thedays.
I spoke with Mike Picos as well.
His follow-ups are amazing onthe other ones.
And I think this new technologyhas evolved so much and there's
so many nuances that make thiswork better than the other ones
(06:40):
that it will be.
You know, having theseavailable here, for example, in
Portugal, having these availableand not using would be an
heresy, you know.
Dr. Tyler Tolbert (06:49):
I mean, why should I destroy the, the
midface, when I can keep all theremaining bone and still do, uh
, immediate loading so that'ssomething that I want to speak
to there, because we're talkingabout the minimally evasive, you
know, concept as it relates toto the outcome zygote.
Right, of course, yes, as a.
(07:09):
In comparing zygos versuscustomized implants, you made
the point that with the way thatzygos are being done today, it
can be very difficult to thenrehab them with a customized
implant afterward.
Aren't as versed in, zygos orcustomized right?
Is that right now what is a verypopular modality with zygomatic
placement, whereastraditionally it used to be an
intra sinus approach that wouldstart transpalatally, very
(07:32):
palatal, to where we arenormally placing traditional
implants, and then it wouldtransverse the sinus exclusively
, and then, of course, thesuperior border of the of the
sinuses is going to be theinferior aspect of the zygote,
and so there's not as much,there's not necessarily any
instruction to the sort of outermaxillary wall that forms the
sinus.
But now what we're seeing a lotof is this, you know, extra
(07:54):
sinus approach.
So they're doing slotpreparation along the wall of
the sinus, and this has a lot todo with the classification of
the case.
Right, you can talk aboutdifferent.
Dr. Bernardo De Sousa (08:03):
Yeah, but actually, Tyler, the Brandmark
approach, the first one was themore conservative, you know it
was way more conservative.
Dr. Tyler Tolbert (08:11):
Yeah, in this sense right, it was more
dangerous.
This is counterintuitive.
Dr. Bernardo De Sousa (08:14):
It was more dangerous and the palatal
exit the prosthetic exit wasworse, terrible, terrible, much
worse.
But if I was a patient back inthose days, you know, and I had
the option to do the externalapproach or the internal
approach with Brandmark, I wouldprefer the internal approach in
my mouth Because it's way moreconservative.
Dr. Tyler Tolbert (08:36):
Right, right it is.
It goes through a space that'salready empty and you still have
the bony architecture of themaxilla.
So I think that's kind of thissort of counterintuitive nuance
to you know, what we considerminimally invasive is the way
we're doing.
The extra sinus approach isactually more destructive to
bony architecture.
That could be used for acustomized implant.
So I think that's a veryinteresting nuance that you
bring up for sure.
Dr. Bernardo De Sousa (08:57):
Yeah, yeah, yeah, yeah, yeah.
I love to do everything I canto preserve, even in trans sinus
, for example.
You, you know if I have a clearsinus.
Dr. Soren Paape (09:07):
I will not open the wall, you know.
I will keep the wall of thesinus intact.
Dr. Bernardo De Sousa (09:08):
Create a window there, because when you
create a window, you are openingthe possibility of having a
oral sinus communication, youare opening the possibility of
the failure of the graft and,and once that happens it's
difficult to create, verydifficult to create a new sinus
window.
And you know this is thecascade of destruction, the
ladder of destruction.
You start destroying and thecorrection is always a bit more
(09:31):
destructive than what it alreadywas, and things start to
escalate very quickly and startto go to to to the point of no
return.
You know, and this is what Ireally keep in mind at all the
times when I do a treatment planand I would advise anyone to do
the same is to see howirreversible is the stuff that
(09:52):
you are doing today?
Or is there, is there anyalternative that is more
reversible for this patient?
Because, remember, yourimplants will not last until the
patient dies.
Two-thirds are there, one-thirdis lost after 15 years.
So yeah.
Dr. Soren Paape (10:09):
Bernardo, what are the work?
Dr. Tyler Tolbert (10:11):
For those that aren't as Sorry, I just
wanted to make sure.
So for those that aren't asfamiliar with the concept of
customized implants, versus, youknow, like a subperiosteal
design.
So can we talk about, you know,the design of these customized
implants as it relates to theanatomy, as it uses the bony
architecture.
How is it anchored?
How is that anchorage, workingdifferently than a zygote?
(10:32):
How does that?
Then, translate to a prostheticsuccess as well.
Dr. Bernardo De Sousa (10:35):
So the anchorage point of the custom
implant is the same exact basisof the fractures of the maxilla,
the Lefortfort one, principlesthat we know for more than 100
years.
This is really not somethingnew.
We know that the strongestparts that we have is the three
but main buttresses right, thezygomatic batteries, the
(10:57):
puriform and the pterygoidbuttresses is the main three
main buttresses that we have onthe mid face.
That's exactly where thisimplant is anchored.
We have two very long implantshere on the zygote.
They are 22mm implants, microimplants, they are narrower.
We have a bunch of microimplants here all along the
(11:21):
canine pillar and we have one onthe palatal side.
But most of the implant isanchored.
The most important part is thezygomatic anchorage and the
piriform buttress anchorage.
This is what keeps the implantso solid that you see this
actually in a real patient oreven if you try this on a model,
(11:42):
you screw all the screws andyou 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'thave a micro.
They have a macro, sometimesright there at the moment of the
surgery because the arm is solong and it's such a big area
(12:07):
unsupported that the implantactually bends.
You can see it, you know, andactually there was a paper
published that I put on I justput on the WhatsApp group a few
weeks ago a clinical lab studycomparing the bending of the
zygote depending on the lengthand the bending of the custom
(12:28):
superiosteal implant.
And the bending of the zygoteoften goes to pass the threshold
.
The bending, the deformation onthe custom implant is always
within the acceptable range, soit doesn't fracture.
So it's a different approach.
Dr. Soren Paape (12:46):
Can you talk about the process for workflow
as far as records fabricationand then like surgical placement
with the prosthetic.
Dr. Bernardo De Sousa (12:55):
Yeah, it's super simple from a
doctor's point of view.
You have the CT scan of yourpatient, you just send it to the
lab.
They will design it.
You either change somethingthat you feel like it should be
a little different.
I always make a change here orthere.
You know I have done so manythat I think I know from
experience that I prefer to belike this or like that, but they
are minor, to be honest, minorstuff.
(13:17):
And then they will send it toyou and you just book the
surgery.
From a doctor's perspective, itis the easiest thing on the
world what about?
Dr. Soren Paape (13:26):
what about?
I think the biggest questionthat we're gonna get and and you
know you're talking about allthese pros with the customized
implants and people are gonna beare gonna ask well, how do I
get them right?
So what is the?
What's the timeline lookinglike in the united states?
Can you give us some?
My understanding is thatthey're not approved quite yet,
but I think for the last yearwe've been told they're coming,
(13:52):
so do you?
Dr. Bernardo De Sousa (13:52):
have any insider info about you have to.
Let me make a disclaimer,because I believe that most of
the world thinks I havesomething to do with the company
and I don't.
I have zero shares on thecompany.
I wish I had, you should, butreally I don't work.
I have zero shares on thecompany.
Dr. Soren Paape (14:05):
I wish I had you should.
Dr. Bernardo De Sousa (14:06):
But really I don't work for the
company, I have no royalties inanything, so I really don't know
, and I know that this processwith the FDA is taking a bit too
long and it should have beenapproved by now a long time ago.
But as far as I know and thisis unofficial information it's
(14:26):
going to be very soon.
I cannot compromise on anythingbecause, again, I'm they are
being, they are telling it'svery close for two years now and
actually in our lastconversation, tyler, it was just
about to be approved and ourlast conversation was like one
year and a half ago, but I don'tknow, man, maybe if you have
(14:48):
some contacts on FDA, they willclarify this a little better,
because I don't know if it's onthe company side or if it's on
the FDA side.
Dr. Tyler Tolbert (15:00):
Once.
You guys have been working withthese customized implants for
much longer than anybody in theUS has right, anybody that's
placed them in the U?
S have done it on sort of anexperimental, provisionary basis
.
You know we talk a lot aboutthe backend of Zygos and, and
you know something about and notjust zygos but implants in
general with everythingexploding is that you know we
can get implants to torque out,we can even get them to
(15:21):
integrate, and then we can screwin teeth and we're not actually
going to see the consequencesof overlooking certain things
for years.
Right, it might be five yearsbefore you find out that
something wasn't really doneproperly to begin with.
So what do some of theselong-term follow-ups or these
customized implants look like?
How long have they been infunction?
What sort of complications arewe seeing?
And, ultimately, how do we undoit if something has gone wrong?
(15:42):
How easy are these to remove?
What do rehabs for customizedimplants look?
Like if you've had theopportunity to see that.
Dr. Bernardo De Sousa (15:49):
That's a great question because we
started with the concept as soonas it appeared in 2017.
But we have to understand thatthe implants that we were
placing in 2017 are waydifferent from the implants that
we are placing now in 2024.
The design is different.
A lot of things have changed.
(16:10):
The micro implants, microscrews, are different and some
anatomical places that we areplacing the screws are also
different.
So we had all this journey withthe company, you know,
improving the things that wewere seeing that could be
improved.
So the last version of theimplant is from 2022.
So when we compare, you know,to talk about follow-ups, we
(16:34):
have to talk about the sameobject.
It's a bit unfair to comparethe different kind of designs,
you know.
But yeah, but the last designis from 2022.
I can tell you that the onesthat I did in 2017, they I have
a 100 success rate.
I never removed any and theynever failed.
(16:56):
The most common complication isthe exposure, which is also the
most common complication is theexposure, which is also the most
common complication of thezygote is also the exposure.
And they actually expose in thesame area.
You know, they always expose inthe buccal arm, the arm that
goes along the crest.
You know that goes and turnsaround the crest.
(17:18):
The same as with zygos.
I would say that the percentageof exposure is quite similar.
At least it is what I see in myzygo cases.
You know I was having someexposures here and there.
The more vertically atrophicwas the case, the more likely I
was having this.
And yeah, so my success rate asof today and as far as I know,
(17:40):
is 100% because they are all infunction and functioning well.
And I know about some fractures.
I have seen two in the olderdesigns and the problem of those
fractures was almost I wouldsay that all the fractures that
I know about was a passivityproblem.
So it was.
Dr. Tyler Tolbert (17:59):
On the bone.
Dr. Bernardo De Sousa (17:59):
Yes, they were not about was a passivity
problem.
So it was.
Yes, they were not.
It was a problem with theplacement, not a problem with
the implant itself, so to say.
And that's why they aresegmented now, because can you
imagine how difficult it is toplace 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
(18:22):
side first and then place theother.
It was very difficult to placethe the first one.
Now it's way easier and it'sthe passivity that you are able
to achieve.
It's way easier to achieve and,and yes, it, like we spoke,
it's a minimally invasivesurgery fix the teeth and the
patients love it.
(18:42):
Most of the times we do it.
I know this may sound strange,but we do it with local
anesthesia and, yeah, we arehaving great success on this and
we are receiving patients fromall around the world.
I've treated Australianpatients, I've treated US
patients, european patientspatients I've treated US
(19:04):
patients, european patients andtypically the kind of patient
that has lost implant treatmentsbefore or that heard so many
times your case is not doablethat once they knew that this
was available, they came andthey fly here and they got fixed
at it in the same day.
And I also don't think it'sfair.
You know, I don't want to putthis bad image on the zygos
(19:27):
because I don't think that way.
You know, I think zygomaticimplants are the best, the
second best solution for thistype of cases and I also used
them before for this type ofcases and I also used them
before.
I think that they have helpedenormous amount of people that
were completely hopeless.
I think that the zygomaticsurgery is one of the most
(19:49):
beautiful zygomatic surgeriesthat you can do.
It's very exciting, it's niceto do Doing it right, it's
beautiful to do it right, theright way.
But, as I said, for us it'sjust a bit too destructive and
(20:11):
we have other options.
But I totally understand incountries where this is not
available, you know the kind ofthe need to go and to use
zygomatic inputs because youhave to solve the cases somehow
and that's what you have, that'swhat you use.
But yeah, that's ourperspective Since we started
with this.
I don't see us turning back.
At least I will need to seemany complications, which I
haven't seen yet with theseimplants.
Dr. Tyler Tolbert (20:34):
And is it routine as well, with relation
to the exposure that you'reseeing in that issue, in that
position, that you're alsoseeing it with Zygos too?
Are you guys doing buccal fatpads and multilayer closure to
try to insulate against that too?
Dr. Bernardo De Sousa (20:47):
That's a great question.
We were talking before aboutfundamentals and this is a
fundamentals question, becausethe buccal fat pad guys people
need to put this in the mind.
Once you use it, it's gone, poof, it's gone, it's not going to
appear anymore.
Then the patients look likethis asymmetric, you know, if
you only use on one side and ifyou have a problem, if you lose
(21:10):
a zygote and you need to close acommunication later on, you
have no buckle fat pad anymore.
So we avoid using the buccalfat pad.
You know, as the devil avoidsthe cross, the first option that
we always go for is for arotated pedicle flap.
You can get a huge coveragewith the well, depends on the
(21:31):
part, depends on the patient,but most of the times you can
suture a two centimeter hole inthe crest, a communication with
the sinus, with a rotatedpedicle flap.
And that's how I think weshould 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
(21:54):
palatal side.
I know it will grow back and Istill have the buccal fat pad if
things go south and if I stillneed to go there in the future.
Dr. Tyler Tolbert (22:04):
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 thataren't doing zygos or whatever
the case may be if they see anoral-atrial communication, or
there's deficient tissue how canthey utilize that?
Dr. Bernardo De Sousa (22:20):
Yeah, it's the easiest thing in the
world.
Imagine you have your flap wideopen right on the buccal and on
the palatal side and you havethe bone totally exposed on the
maxilla.
You look at the palatal tissuein one of the sides, you grab it
and you see how thick that isright.
You see the thickness, the fullthickness of that palatal
(22:42):
tissue.
If you cut that in half, youwill separate.
In one side you have the mucosa, in the other side you will
have all connective tissue andfat.
You also see fat.
That part that you separated,it's the, it's almost done.
You just need to cut on thebottom to release it, right?
(23:05):
Does this make sense?
Am I explaining more or lessright?
so it will just stay attached onthe posterior part for
irrigation, right, because allthe rest, the rest.
I will send you some.
Dr. Tyler Tolbert (23:21):
Yes, we'll put that in this.
Dr. Bernardo De Sousa (23:23):
I have those slides so I will send you
these pictures.
But it's so easy Just separatethe part in half and then you
cut the borders so you have itmobile.
Just attach it on distal andthen you rotate it over your
defect.
You suture it either to thebone or to the buccal tissue
(23:44):
with a mattress or something tokeep 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 (23:55):
Yeah, that's a great hack.
I've had my first ordinalcommunication after like an
indirect sinus lift, and Iremembered about this and I had
not actually used it before andI was like, oh man, okay, let's
seat the patient.
And then I'm going to be in myoffice for a second and I'm
looking up YouTube videos.
I'm like, all right, exactlyhow do I do this again?
Dr. Bernardo De Sousa (24:22):
And it really isn't bad and it's it
solved the problem Like it wasnothing.
I think that's one of thosefundamental toolkits that you
definitely want to have forwhenever you have those
complications, or to preventthem if you have a deficiency.
The trick is, there is only onetrick, which is you have to you
start with your bladeseparating the two halfs where
the defect is, because you haveto go way more anterior, so you
have tissue to rotate posteriorright yeah, so you have to start
next to the defect or justslightly distal to to the defect
(24:46):
, but you have to extend a lot.
Dr. Tyler Tolbert (24:48):
You know anteriorly, anterior because you
need to wrap around so you canswing it yeah, yeah and that's
the, the, the only.
Dr. Soren Paape (24:56):
Thing but how?
Dr. Tyler Tolbert (24:56):
did it turn out.
Well, right, oh, beautifully,beautifully, Very well, very
well, it healed over, and youknow, then I just had to figure
out what I was going to do afterthat, but yeah, Now, sorry to
interrupt.
Dr. Bernardo De Sousa (25:08):
For example it's interesting you ask
this Now.
This is in our lecture, this ison the master course.
Good, step by step, how to dothis technique, because again,
doctors ask for it and it's sucha precious move to solve so
many complications.
Dr. Tyler Tolbert (25:24):
Yeah, it is no.
What I was going to say is solet's say you go to do that and
every so often I'll see someoneactually has a very thin palatal
tissue.
I mean, it can happen from timeto time.
You know what happens if you'rejust not really able to split
the difference on that, you'renot able to get the connective
tissue out.
Is there a full thicknessversion of this that you can do?
That's going to be a bitch toheal, or like what do you do if
the tissue is too thin there?
(25:44):
you go to the tuber that's thesecond best, for sure you go to
the tuber yeah, okay the.
Dr. Bernardo De Sousa (25:51):
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.
It's a transplant.
I did many of them in thebeginning when I was afraid of
the greater palatine.
(26:12):
You know, I was going to thetuber and I started having a few
necrosis here and there and Iwas like, okay, maybe I should
lose the fear of the greaterpelotin.
That's another thing.
Doctors starting now have tounderstand that the bleeding
from the greater pelotin maylook like a lot to you but from
(26:34):
a surgeon perspective it'speanuts, 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 astudent that with the flap
elevator, when he was raisingthe flap on the tuberosity, he
was making so much strength withthe arm that it slipped from
(26:56):
the crest and cut the greaterpelotin at the origin.
You know and you know, the guywas a bit in panic and his
colleague was also in panic andwe were like, trying to be very
pedagogical with the situation,he's like, okay, guys, this is a
bit of bleeding, but it's notthat serious.
Okay, it's not that much.
(27:17):
If you see a serious bleedingin 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 completelygone if you do the right
(27:39):
maneuvers I think we chatted tooon.
Dr. Soren Paape (27:42):
I posted something a couple weeks ago
about how you know maybe notlife-saving, but a great tool to
have in your toolkit is justsome sort of electrocouter unit.
Dr. Bernardo De Sousa (27:52):
Right, if you can get a bovie you know
everyone should have, yeah, andif you're unfamiliar you can use
Bovi pens.
Dr. Soren Paape (28:00):
There's disposable Bovi pens for like
anywhere from like 10 to 20bucks a piece.
You can even get Bovi pens withexchangeable tips that are
around $100.
And you can just get differenttips but just spending that $100
to have something that cancauterize that bleed in your
operatory is A simple monopolar.
Dr. Bernardo De Sousa (28:20):
one is more than enough, or even the
pen.
Dr. Soren Paape (28:23):
Yeah, and if you have questions about which
one I've used before, you canreach out to me.
I'm happy to answer them.
But there'll be just one lessthing that you need to worry
about, because if you do have ableed that doesn't you can't get
it to stop with compression orwith epinephrine or whatever.
You have a bovie willdefinitely solve that issue for
you.
Dr. Bernardo De Sousa (28:43):
Yeah and losing.
And it's actually quitepedagogical, you know, to hit
the greater pelotin one time ortwo times or three times,
because you start to, you know,not worry so much when these
things happen.
And sometimes, on the taking agraft from the palate, the
connective tissue graft or evena free gingival graft, sometimes
it happens, start squirting,but you keep your cool, you do
(29:05):
what you you are supposed to doand it will always stop.
As a friend of mine told memany years ago, a maxillofacial
surgeon, when I was in theresidency, all bleeding
eventually stops.
What's coming, eventually italways stops.
Dr. Soren Paape (29:22):
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 pterygoidregion and you reflect a lot,
sometimes you'll get a littlebit of bleeding from that
greater palatine coming fromunder the flap.
And the way I like to solvethat is, you know one, I don't
want to sit there and spend 10,20 minutes of my surgery just
(29:43):
compressing it.
I just grab my hemostat clampthe tissue right there and it
goes away.
And I keep working with thehemostat clamp there and you
know when you remove it, itstopped.
Yep, yep, and by the you know,15, 10, 15 minutes later.
You know you've been doingsomething else that you know you
need.
Take the hemostat out andyou're good to go, and that way
you're not sitting there, youknow, wasting your precious
(30:05):
surgical time where thepatient's under anesthesia.
You know you can think if youhave an anesthesiologist there,
I mean you're paying a goodcouple hundred bucks for every
15 minutes.
Maybe not quite that much, butyou know that time is critical.
Dr. Bernardo De Sousa (30:18):
And that's, that's another.
Sorry to interrupt, that'sanother lecture we introduced in
the bootcamp in Brazil.
First day is how to deal withheavy bleeding, for example.
It's another thing that we werechanging and improving because
we saw people panic a bit and Iunderstand, I also panicked in
my first ones, but it's reallynot something that that big.
You know, I panicked in myfirst ones, but it's really not
(30:39):
something that big.
It's big for dentists.
It's not big when you are usedto other kinds of bleeding.
I remember in the Netherlands Isaw a guy that was in a fight
with someone that had an axe.
Can you imagine Fightingsomeone with an axe?
The guy had a major cut.
This was the most serious thingI saw in my life, you know, and
(31:03):
still solvable, yeah.
Dr. Soren Paape (31:05):
You know, one thing I wanted to mention that I
forgot to say before and I'mit's.
It's kind of a question for youtoo, bernardo, when you're
doing a rotated pedicle flaps.
Another pro, in myunderstanding, is, compared to a
buckle fat pad is a lot oftimes that connective tissue
regenerates so you're able to re, you know, not right away, but
(31:26):
once it heals up, especially in.
You know, I see a lot ofpatients that have palatal
tissue, that is, it's thick,it's really thick and a lot of
surgery, you know much.
It's too much.
You need to thin it out.
But if you're able to, insteadof thinning it, you can use that
to wrap around the implant topreserve keratinized tissue.
That's always a solution tocome back to again to use if you
(31:46):
need to down the line.
Dr. Bernardo De Sousa (31:47):
Yeah, yeah, exactly.
I think I mentioned this before.
That's one of the pros of usingthe palatal tissue is it
regenerates not fully.
Actually, a friend of mine dida study exactly on how many
cubic millimeters it regeneratesafter one year it was.
He found out that it was notfully, but it was about 85 90 if
(32:12):
I remember correctly.
So it's almost everything andand, yeah, one year later you
have it there again.
So, yeah, it's, it's like aninfinite pool of good tissue for
you.
You know that keeps coming back, keep keeps spawning Is this
the right word Like thePokemon's when they spawn, spawn
.
Dr. Tyler Tolbert (32:30):
Spawning.
Okay, then you edit thisRespawn.
It's a renewable energy source.
Dr. Bernardo De Sousa (32:35):
Oh no, that's staying in Respawn.
I like that.
Dr. Soren Paape (32:38):
Yeah.
Dr. Tyler Tolbert (32:39):
It respawn.
Dr. Bernardo De Sous (32:39):
Connective tissue respawns.
Dr. Tyler Tolbert (32:41):
Yes, yes, absolutely that's good.
Dr. Soren Paape (32:43):
Well, hey, bernardo, you know we went over
so much in this episode and I'veactually, if you're watching
this on YouTube, you've probablywatched Bernardo's sun setting
behind him throughout theepisode.
So you know we reallyappreciate all of your time on
this episode and this will beone that gets cut up into a few
episodes because it's been ajourney throughout.
But you know we reallyappreciate all of your time and
(33:06):
I think that anybody who'slooking to up their full arch
game and get you knowprosthetics that have no
cantilever and are looking forsolutions to bleeds and looking
for ways that they can take onmore patients without going
through larger approaches likezygomatic implants and stuff, it
is critical to check out theFull Arch Club.
Additionally, you know I don'tthink that you're able to get in
(33:28):
.
I had questions too, like hey,how do I get into Bernardo's
WhatsApp group?
And it's go to the mastercourse, go to the bootcamp, and
you'll get access to a lot ofclinicians some of the best
clinicians in the world who areable to answer some of these
questions that you haveimmediately.
You know, I think everybody inthat group is very transparent
with you.
Know, I'm in a surgery, I havethis issue.
What do you recommend and youget a lot of responses from
(33:50):
wonderful clinicians throughoutthe world just by having access
to that group.
So I think it's a wonderful CEto take if you're looking to get
into.
You know more advanced casesand again, we really appreciate
your time.
Today you can follow Bernardo.
What's your Instagram, bernardo?
Just so people can look throughyour stuff and see the Full
Arts Club.
Dr. Bernardo De Sousa (34:09):
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 offbefore this goes to air, we are
at the moment preparing coursesthat have never been done until
today, not only to help youbecome the best surgeon possible
(34:33):
, but also that you become thebest person operating.
I will not disclose moreinformation now, but, to be
something radically differentfrom what has been done until
now, we are also going to launchsoft tissue only stuff, because
(34:53):
a lot of doctors are asking,and they ask on the group and on
the WhatsApp group as well.
So we are preparing what Ibelieve to be the most complete
full arch soft tissue course fordoctors, where you learn all
the techniques that you need inthe Full Arch game, with a bonus
.
I think I can say that it alsoinvolves soft tissue, but it
(35:18):
stresses your nerves.
So I will not discloseeverything now.
Dr. Tyler Tolbert (35:22):
The more you tell me, the more questions I
have.
It's not actually making iteasier so it's going to be fun.
Dr. Bernardo De Sousa (35:30):
So, yeah, keep tuned and also on the
website, because all if a courseexists better than asking me or
the manager or anyone is to seeon the website if it exists, is
there?
So, fullarchclubcom, when Iwhen I have to know where I have
to fly for a course orsomething, I go to my website
because I don't know.
Dr. Soren Paape (35:52):
So it's my calendar well, hey, thanks so
much.
And again, you can always findtyler and I at my instagrams dr
soren poppy tyler's is dr tylertrobert, and then you can reach
both of us at the fixed PodcastInstagram.
Again, if you're listening tothis on Spotify or whatever
platform you use, we always havethese videos on YouTube as well
(36:12):
, where you can see all of ourfaces, and we try to incorporate
as many panos and stuff intothe videos as possible.
So definitely take a look atthose.
And again, thank you for yourtime, bernardo.
Dr. Bernardo De Sousa (36:22):
Thank you very much.
It's the second interview thatwe do and I feel like a bit of a
death for you too.
You know because I saw you inthe very beginning and now two,
two years later, it's really,honestly, it's impressive the
way you two are growing, and andother guys from the boot camp
(36:44):
as well, and your new projectwith the clinics.
And you remember we talkedabout the brain.
You guys have the right brain,okay, and this is, as I said,
the clinical part is the easiestto learn.
But having the right brain issomething difficult to teach and
if you are born with it, use itwisely and you are born with it
, and I'm really proud of thethings that you are
(37:07):
accomplishing, not only in theclinic, but also with the
podcast previously with theother one and now with the Fixed
podcast and I think you deserveeverything good that is going
to happen to you because youwork hard, you are smart and you
apply your smartness into doinggood things to people.
So keep doing what you aredoing, into doing good things to
people.
So keep doing what you're doing.
It's really motivating to me tohave contributed with something
(37:31):
to this.
Dr. Soren Paape (37:34):
Well, hey, thanks so much, Bernardo.
That means a lot coming fromyou and you've always been a
wonderful mentor to us and wereally appreciate it.
So thanks so much everyone forlistening and tune in next time
for the Fix podcast.
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,okay great.
Dr. Soren Paape (00:10):
So yeah, I mean , I think those are invaluable
topics that you know photography, proper records and everything.
They go a super long way forpeople who are trying to manage
their complications over timeand just see how their cases
progress over time, to managetheir complications over time
and just see how their casesprogress over time.
I know that a lot of people aresuper interested in custom
(00:32):
implants and subperiosteals andI know that you know you're a
big front leader in the customimplants, at least the new age
ones, right?
Dr. Bernardo De Sousa (00:36):
We've seen.
Dr. Soren Paape (00:37):
I was at course in Portugal when Picos came and
showed all of his mandibularsubperiosteal implants that he's
done over the past you know 30years and in the follow-ups of
those and how wonderful they areand I think that you know the
seeing a lot of these zygocasesand stuff.
It's really important to bringin subperiosteals in the maxilla
(00:58):
because it does offer anotheryou know, I guess you could say
lifespan for patients who.
I feel like there's the fullarch lifespan right, and then if
we can eliminate that zygomaticlifespan and instead have a
subperiosteal lifespan, and thenmaybe zygomatic zygomatic in
the future, or if you have, youknow, all-on-fours that turned
(01:19):
into zygomatic and all of asudden those zygomatic are
failing, I feel like a lot ofpatients are in a situation
where they're stuck with areally shitty denture then for
the rest of their life.
So you know, incorporating someperiosteals, then go ahead.
Dr. Bernardo De Sousa (01:32):
Yeah, this is the reality, man.
There are countless patientsthat had failed quad zygos that
there are on obturatorprosthesis at this moment and
that nobody knows about thisreality.
This is what is under theiceberg, you know, because
nowadays the industry is pushingZygus with such power that
(01:57):
doctors almost feel like theyare surgical inapt if they don't
do quads every day.
And the reality is that theneed for a quad or for a sub is
less than 1% of the cases.
That's the first thing we haveto keep in mind, because with
all the other techniques you cango to 99% of those cases, which
(02:21):
is the overwhelming majority ofwhat is of the full arch
population.
The quad zygote problem is not aproblem 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 middleand we need to create these big
(02:43):
slots to place this shortimplant, because the zygote is a
short implant.
The implantable part of thezygote is quite small, it's 10,
11, 13 millimeters only, but ithas a very big arm.
But the implant is also it'sactually a short one and the
destruction that is necessary toplace to do a quad is something
(03:06):
that is so big and soirreversible that it is even
difficult to do a sub after youlose a quad.
It's difficult, the destructionthat is left, the big autosinus
communication that you have,the zygoma that gets destroyed.
It's very difficult to approacha case like this and I think
(03:27):
that we should consider thecustom superiosteal implants,
because I said the other daythis on social media and the
majority of people understoodwhat I was saying, but there is
always a small percentage thatwants to test the words.
But this is true the superiorosseous surgery, guys, is a
(03:49):
minimally invasive surgery,because we have to think the
minimally invasive conceptalways depends on the expected
outcome.
You understand what I'm saying.
We cannot expect to solve asuper atrophic case with a
single implant.
It's not going to solve thecase right.
(04:09):
So we need to understand whatis on the table.
A supratrophic case either goesfor a quadzygote or for a
superiosteal implant.
So, for the two options thatare on the table, when I say
that this is the minimallyinvasive one, it's compared with
the other solution thatachieves the same result.
So in this sense, yes, it's aminimally invasive solution
(04:32):
compared with the quad, becausethe quad we know the destruction
that is required just to placethe implant.
So, yes, I do believe that issomething very promising the
fact that these customizednowadays without having to open
a flap like it was on the olddays that were two surgeries
(04:53):
were necessary, one just for theimpression of the bone and then
another one for the placement.
Now we don't need to do thatfirst one.
We use the CBCT scan.
It's a surgery that takes aboutone hour.
We use the CBCT scan.
It's a surgery that takes aboutone hour.
Most of my surgeries actuallyand you know this, you have seen
this take local anesthesia only, and we always we are
(05:14):
absolutely positive that thispatient is going to have fixed
teeth today.
It's not something that weaspire to, it's a certainty in
this approach.
So when we think, when I thinkabout you know the pros and the
cons.
The only cons that I see isthat first you need a few weeks
to produce the implant.
You know you cannot just appearin the office and boom and do
(05:34):
it.
No, you need to take the scan,you need to design the implant,
to print it and all these thingsand and and the price.
It's more expensive than buyinga couple of zygomatic implants.
But besides these two things, Ithink the pros are way more than
the cons and that's why, when Istarted with this kind of
(05:55):
technology, I said to myself OK,now I'm on a crossroads.
Do I continue with the zygos ordo I go into this journey,
pioneering approach, roads do Icontinue with the zygos or do I
go into this journey, pioneeringapproach, and and try to maybe
change a little bit the waythese, these very complicated
cases, are going to be done inthe future?
And you know, we took a leap offaith, but it was not real
(06:16):
faith, you know.
I mean, we studied all theconcepts.
I read the lincoln books, youknow I I spoke with people that
did the old ones back in thedays.
I spoke with Mike Picos as well.
His follow-ups are amazing onthe other ones.
And I think this new technologyhas evolved so much and there's
so many nuances that make thiswork better than the other ones
(06:40):
that it will be.
You know, having theseavailable here, for example, in
Portugal, having these availableand not using would be an
heresy, you know.
Dr. Tyler Tolbert (06:49):
I mean, why should I destroy the, the
midface, when I can keep all theremaining bone and still do, uh
, immediate loading so that'ssomething that I want to speak
to there, because we're talkingabout the minimally evasive, you
know, concept as it relates toto the outcome zygote.
Right, of course, yes, as a.
(07:09):
In comparing zygos versuscustomized implants, you made
the point that with the way thatzygos are being done today, it
can be very difficult to thenrehab them with a customized
implant afterward.
Aren't as versed in, zygos orcustomized right?
Is that right now what is a verypopular modality with zygomatic
placement, whereastraditionally it used to be an
intra sinus approach that wouldstart transpalatally, very
(07:32):
palatal, to where we arenormally placing traditional
implants, and then it wouldtransverse the sinus exclusively
, and then, of course, thesuperior border of the of the
sinuses is going to be theinferior aspect of the zygote,
and so there's not as much,there's not necessarily any
instruction to the sort of outermaxillary wall that forms the
sinus.
But now what we're seeing a lotof is this, you know, extra
(07:54):
sinus approach.
So they're doing slotpreparation along the wall of
the sinus, and this has a lot todo with the classification of
the case.
Right, you can talk aboutdifferent.
Dr. Bernardo De Sousa (08:03):
Yeah, but actually, Tyler, the Brandmark
approach, the first one was themore conservative, you know it
was way more conservative.
Dr. Tyler Tolbert (08:11):
Yeah, in this sense right, it was more
dangerous.
This is counterintuitive.
Dr. Bernardo De Sousa (08:14):
It was more dangerous and the palatal
exit the prosthetic exit wasworse, terrible, terrible, much
worse.
But if I was a patient back inthose days, you know, and I had
the option to do the externalapproach or the internal
approach with Brandmark, I wouldprefer the internal approach in
my mouth Because it's way moreconservative.
Dr. Tyler Tolbert (08:36):
Right, right it is.
It goes through a space that'salready empty and you still have
the bony architecture of themaxilla.
So I think that's kind of thissort of counterintuitive nuance
to you know, what we considerminimally invasive is the way
we're doing.
The extra sinus approach isactually more destructive to
bony architecture.
That could be used for acustomized implant.
So I think that's a veryinteresting nuance that you
bring up for sure.
Dr. Bernardo De Sousa (08:57):
Yeah, yeah, yeah, yeah, yeah.
I love to do everything I canto preserve, even in trans sinus
, for example.
You, you know if I have a clearsinus.
Dr. Soren Paape (09:07):
I will not open the wall, you know.
I will keep the wall of thesinus intact.
Dr. Bernardo De Sousa (09:08):
Create a window there, because when you
create a window, you are openingthe possibility of having a
oral sinus communication, youare opening the possibility of
the failure of the graft and,and once that happens it's
difficult to create, verydifficult to create a new sinus
window.
And you know this is thecascade of destruction, the
ladder of destruction.
You start destroying and thecorrection is always a bit more
(09:31):
destructive than what it alreadywas, and things start to
escalate very quickly and startto go to to to the point of no
return.
You know, and this is what Ireally keep in mind at all the
times when I do a treatment planand I would advise anyone to do
the same is to see howirreversible is the stuff that
(09:52):
you are doing today?
Or is there, is there anyalternative that is more
reversible for this patient?
Because, remember, yourimplants will not last until the
patient dies.
Two-thirds are there, one-thirdis lost after 15 years.
So yeah.
Dr. Soren Paape (10:09):
Bernardo, what are the work?
Dr. Tyler Tolbert (10:11):
For those that aren't as Sorry, I just
wanted to make sure.
So for those that aren't asfamiliar with the concept of
customized implants, versus, youknow, like a subperiosteal
design.
So can we talk about, you know,the design of these customized
implants as it relates to theanatomy, as it uses the bony
architecture.
How is it anchored?
How is that anchorage, workingdifferently than a zygote?
(10:32):
How does that?
Then, translate to a prostheticsuccess as well.
Dr. Bernardo De Sousa (10:35):
So the anchorage point of the custom
implant is the same exact basisof the fractures of the maxilla,
the Lefortfort one, principlesthat we know for more than 100
years.
This is really not somethingnew.
We know that the strongestparts that we have is the three
but main buttresses right, thezygomatic batteries, the
(10:57):
puriform and the pterygoidbuttresses is the main three
main buttresses that we have onthe mid face.
That's exactly where thisimplant is anchored.
We have two very long implantshere on the zygote.
They are 22mm implants, microimplants, they are narrower.
We have a bunch of microimplants here all along the
(11:21):
canine pillar and we have one onthe palatal side.
But most of the implant isanchored.
The most important part is thezygomatic anchorage and the
piriform buttress anchorage.
This is what keeps the implantso solid that you see this
actually in a real patient oreven if you try this on a model,
(11:42):
you screw all the screws andyou 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'thave a micro.
They have a macro, sometimesright there at the moment of the
surgery because the arm is solong and it's such a big area
(12:07):
unsupported that the implantactually bends.
You can see it, you know, andactually there was a paper
published that I put on I justput on the WhatsApp group a few
weeks ago a clinical lab studycomparing the bending of the
zygote depending on the lengthand the bending of the custom
(12:28):
superiosteal implant.
And the bending of the zygoteoften goes to pass the threshold
.
The bending, the deformation onthe custom implant is always
within the acceptable range, soit doesn't fracture.
So it's a different approach.
Dr. Soren Paape (12:46):
Can you talk about the process for workflow
as far as records fabricationand then like surgical placement
with the prosthetic.
Dr. Bernardo De Sousa (12:55):
Yeah, it's super simple from a
doctor's point of view.
You have the CT scan of yourpatient, you just send it to the
lab.
They will design it.
You either change somethingthat you feel like it should be
a little different.
I always make a change here orthere.
You know I have done so manythat I think I know from
experience that I prefer to belike this or like that, but they
are minor, to be honest, minorstuff.
(13:17):
And then they will send it toyou and you just book the
surgery.
From a doctor's perspective, itis the easiest thing on the
world what about?
Dr. Soren Paape (13:26):
what about?
I think the biggest questionthat we're gonna get and and you
know you're talking about allthese pros with the customized
implants and people are gonna beare gonna ask well, how do I
get them right?
So what is the?
What's the timeline lookinglike in the united states?
Can you give us some?
My understanding is thatthey're not approved quite yet,
but I think for the last yearwe've been told they're coming,
(13:52):
so do you?
Dr. Bernardo De Sousa (13:52):
have any insider info about you have to.
Let me make a disclaimer,because I believe that most of
the world thinks I havesomething to do with the company
and I don't.
I have zero shares on thecompany.
I wish I had, you should, butreally I don't work.
I have zero shares on thecompany.
Dr. Soren Paape (14:05):
I wish I had you should.
Dr. Bernardo De Sousa (14:06):
But really I don't work for the
company, I have no royalties inanything, so I really don't know
, and I know that this processwith the FDA is taking a bit too
long and it should have beenapproved by now a long time ago.
But as far as I know and thisis unofficial information it's
(14:26):
going to be very soon.
I cannot compromise on anythingbecause, again, I'm they are
being, they are telling it'svery close for two years now and
actually in our lastconversation, tyler, it was just
about to be approved and ourlast conversation was like one
year and a half ago, but I don'tknow, man, maybe if you have
(14:48):
some contacts on FDA, they willclarify this a little better,
because I don't know if it's onthe company side or if it's on
the FDA side.
Dr. Tyler Tolbert (15:00):
Once.
You guys have been working withthese customized implants for
much longer than anybody in theUS has right, anybody that's
placed them in the U?
S have done it on sort of anexperimental, provisionary basis
.
You know we talk a lot aboutthe backend of Zygos and, and
you know something about and notjust zygos but implants in
general with everythingexploding is that you know we
can get implants to torque out,we can even get them to
(15:21):
integrate, and then we can screwin teeth and we're not actually
going to see the consequencesof overlooking certain things
for years.
Right, it might be five yearsbefore you find out that
something wasn't really doneproperly to begin with.
So what do some of theselong-term follow-ups or these
customized implants look like?
How long have they been infunction?
What sort of complications arewe seeing?
And, ultimately, how do we undoit if something has gone wrong?
(15:42):
How easy are these to remove?
What do rehabs for customizedimplants look?
Like if you've had theopportunity to see that.
Dr. Bernardo De Sousa (15:49):
That's a great question because we
started with the concept as soonas it appeared in 2017.
But we have to understand thatthe implants that we were
placing in 2017 are waydifferent from the implants that
we are placing now in 2024.
The design is different.
A lot of things have changed.
(16:10):
The micro implants, microscrews, are different and some
anatomical places that we areplacing the screws are also
different.
So we had all this journey withthe company, you know,
improving the things that wewere seeing that could be
improved.
So the last version of theimplant is from 2022.
So when we compare, you know,to talk about follow-ups, we
(16:34):
have to talk about the sameobject.
It's a bit unfair to comparethe different kind of designs,
you know.
But yeah, but the last designis from 2022.
I can tell you that the onesthat I did in 2017, they I have
a 100 success rate.
I never removed any and theynever failed.
(16:56):
The most common complication isthe exposure, which is also the
most common complication is theexposure, which is also the most
common complication of thezygote is also the exposure.
And they actually expose in thesame area.
You know, they always expose inthe buccal arm, the arm that
goes along the crest.
You know that goes and turnsaround the crest.
(17:18):
The same as with zygos.
I would say that the percentageof exposure is quite similar.
At least it is what I see in myzygo cases.
You know I was having someexposures here and there.
The more vertically atrophicwas the case, the more likely I
was having this.
And yeah, so my success rate asof today and as far as I know,
(17:40):
is 100% because they are all infunction and functioning well.
And I know about some fractures.
I have seen two in the olderdesigns and the problem of those
fractures was almost I wouldsay that all the fractures that
I know about was a passivityproblem.
So it was.
Dr. Tyler Tolbert (17:59):
On the bone.
Dr. Bernardo De Sousa (17:59):
Yes, they were not about was a passivity
problem.
So it was.
Yes, they were not.
It was a problem with theplacement, not a problem with
the implant itself, so to say.
And that's why they aresegmented now, because can you
imagine how difficult it is toplace 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
(18:22):
side first and then place theother.
It was very difficult to placethe the first one.
Now it's way easier and it'sthe passivity that you are able
to achieve.
It's way easier to achieve and,and yes, it, like we spoke,
it's a minimally invasivesurgery fix the teeth and the
patients love it.
(18:42):
Most of the times we do it.
I know this may sound strange,but we do it with local
anesthesia and, yeah, we arehaving great success on this and
we are receiving patients fromall around the world.
I've treated Australianpatients, I've treated US
patients, european patientspatients I've treated US
(19:04):
patients, european patients andtypically the kind of patient
that has lost implant treatmentsbefore or that heard so many
times your case is not doablethat once they knew that this
was available, they came andthey fly here and they got fixed
at it in the same day.
And I also don't think it'sfair.
You know, I don't want to putthis bad image on the zygos
(19:27):
because I don't think that way.
You know, I think zygomaticimplants are the best, the
second best solution for thistype of cases and I also used
them before for this type ofcases and I also used them
before.
I think that they have helpedenormous amount of people that
were completely hopeless.
I think that the zygomaticsurgery is one of the most
(19:49):
beautiful zygomatic surgeriesthat you can do.
It's very exciting, it's niceto do Doing it right, it's
beautiful to do it right, theright way.
But, as I said, for us it'sjust a bit too destructive and
(20:11):
we have other options.
But I totally understand incountries where this is not
available, you know the kind ofthe need to go and to use
zygomatic inputs because youhave to solve the cases somehow
and that's what you have, that'swhat you use.
But yeah, that's ourperspective Since we started
with this.
I don't see us turning back.
At least I will need to seemany complications, which I
haven't seen yet with theseimplants.
Dr. Tyler Tolbert (20:34):
And is it routine as well, with relation
to the exposure that you'reseeing in that issue, in that
position, that you're alsoseeing it with Zygos too?
Are you guys doing buccal fatpads and multilayer closure to
try to insulate against that too?
Dr. Bernardo De Sousa (20:47):
That's a great question.
We were talking before aboutfundamentals and this is a
fundamentals question, becausethe buccal fat pad guys people
need to put this in the mind.
Once you use it, it's gone, poof, it's gone, it's not going to
appear anymore.
Then the patients look likethis asymmetric, you know, if
you only use on one side and ifyou have a problem, if you lose
(21:10):
a zygote and you need to close acommunication later on, you
have no buckle fat pad anymore.
So we avoid using the buccalfat pad.
You know, as the devil avoidsthe cross, the first option that
we always go for is for arotated pedicle flap.
You can get a huge coveragewith the well, depends on the
(21:31):
part, depends on the patient,but most of the times you can
suture a two centimeter hole inthe crest, a communication with
the sinus, with a rotatedpedicle flap.
And that's how I think weshould 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
(21:54):
palatal side.
I know it will grow back and Istill have the buccal fat pad if
things go south and if I stillneed to go there in the future.
Dr. Tyler Tolbert (22:04):
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 thataren't doing zygos or whatever
the case may be if they see anoral-atrial communication, or
there's deficient tissue how canthey utilize that?
Dr. Bernardo De Sousa (22:20):
Yeah, it's the easiest thing in the
world.
Imagine you have your flap wideopen right on the buccal and on
the palatal side and you havethe bone totally exposed on the
maxilla.
You look at the palatal tissuein one of the sides, you grab it
and you see how thick that isright.
You see the thickness, the fullthickness of that palatal
(22:42):
tissue.
If you cut that in half, youwill separate.
In one side you have the mucosa, in the other side you will
have all connective tissue andfat.
You also see fat.
That part that you separated,it's the, it's almost done.
You just need to cut on thebottom to release it, right?
(23:05):
Does this make sense?
Am I explaining more or lessright?
so it will just stay attached onthe posterior part for
irrigation, right, because allthe rest, the rest.
I will send you some.
Dr. Tyler Tolbert (23:21):
Yes, we'll put that in this.
Dr. Bernardo De Sousa (23:23):
I have those slides so I will send you
these pictures.
But it's so easy Just separatethe part in half and then you
cut the borders so you have itmobile.
Just attach it on distal andthen you rotate it over your
defect.
You suture it either to thebone or to the buccal tissue
(23:44):
with a mattress or something tokeep 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 (23:55):
Yeah, that's a great hack.
I've had my first ordinalcommunication after like an
indirect sinus lift, and Iremembered about this and I had
not actually used it before andI was like, oh man, okay, let's
seat the patient.
And then I'm going to be in myoffice for a second and I'm
looking up YouTube videos.
I'm like, all right, exactlyhow do I do this again?
Dr. Bernardo De Sousa (24:22):
And it really isn't bad and it's it
solved the problem Like it wasnothing.
I think that's one of thosefundamental toolkits that you
definitely want to have forwhenever you have those
complications, or to preventthem if you have a deficiency.
The trick is, there is only onetrick, which is you have to you
start with your bladeseparating the two halfs where
the defect is, because you haveto go way more anterior, so you
have tissue to rotate posteriorright yeah, so you have to start
next to the defect or justslightly distal to to the defect
(24:46):
, but you have to extend a lot.
Dr. Tyler Tolbert (24:48):
You know anteriorly, anterior because you
need to wrap around so you canswing it yeah, yeah and that's
the, the, the only.
Dr. Soren Paape (24:56):
Thing but how?
Dr. Tyler Tolbert (24:56):
did it turn out.
Well, right, oh, beautifully,beautifully, Very well, very
well, it healed over, and youknow, then I just had to figure
out what I was going to do afterthat, but yeah, Now, sorry to
interrupt.
Dr. Bernardo De Sousa (25:08):
For example it's interesting you ask
this Now.
This is in our lecture, this ison the master course.
Good, step by step, how to dothis technique, because again,
doctors ask for it and it's sucha precious move to solve so
many complications.
Dr. Tyler Tolbert (25:24):
Yeah, it is no.
What I was going to say is solet's say you go to do that and
every so often I'll see someoneactually has a very thin palatal
tissue.
I mean, it can happen from timeto time.
You know what happens if you'rejust not really able to split
the difference on that, you'renot able to get the connective
tissue out.
Is there a full thicknessversion of this that you can do?
That's going to be a bitch toheal, or like what do you do if
the tissue is too thin there?
(25:44):
you go to the tuber that's thesecond best, for sure you go to
the tuber yeah, okay the.
Dr. Bernardo De Sousa (25:51):
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.
It's a transplant.
I did many of them in thebeginning when I was afraid of
the greater palatine.
(26:12):
You know, I was going to thetuber and I started having a few
necrosis here and there and Iwas like, okay, maybe I should
lose the fear of the greaterpelotin.
That's another thing.
Doctors starting now have tounderstand that the bleeding
from the greater pelotin maylook like a lot to you but from
(26:34):
a surgeon perspective it'speanuts, 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 astudent that with the flap
elevator, when he was raisingthe flap on the tuberosity, he
was making so much strength withthe arm that it slipped from
(26:56):
the crest and cut the greaterpelotin at the origin.
You know and you know, the guywas a bit in panic and his
colleague was also in panic andwe were like, trying to be very
pedagogical with the situation,he's like, okay, guys, this is a
bit of bleeding, but it's notthat serious.
Okay, it's not that much.
(27:17):
If you see a serious bleedingin 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 completelygone if you do the right
(27:39):
maneuvers I think we chatted tooon.
Dr. Soren Paape (27:42):
I posted something a couple weeks ago
about how you know maybe notlife-saving, but a great tool to
have in your toolkit is justsome sort of electrocouter unit.
Dr. Bernardo De Sousa (27:52):
Right, if you can get a bovie you know
everyone should have, yeah, andif you're unfamiliar you can use
Bovi pens.
Dr. Soren Paape (28:00):
There's disposable Bovi pens for like
anywhere from like 10 to 20bucks a piece.
You can even get Bovi pens withexchangeable tips that are
around $100.
And you can just get differenttips but just spending that $100
to have something that cancauterize that bleed in your
operatory is A simple monopolar.
Dr. Bernardo De Sousa (28:20):
one is more than enough, or even the
pen.
Dr. Soren Paape (28:23):
Yeah, and if you have questions about which
one I've used before, you canreach out to me.
I'm happy to answer them.
But there'll be just one lessthing that you need to worry
about, because if you do have ableed that doesn't you can't get
it to stop with compression orwith epinephrine or whatever.
You have a bovie willdefinitely solve that issue for
you.
Dr. Bernardo De Sousa (28:43):
Yeah and losing.
And it's actually quitepedagogical, you know, to hit
the greater pelotin one time ortwo times or three times,
because you start to, you know,not worry so much when these
things happen.
And sometimes, on the taking agraft from the palate, the
connective tissue graft or evena free gingival graft, sometimes
it happens, start squirting,but you keep your cool, you do
(29:05):
what you you are supposed to doand it will always stop.
As a friend of mine told memany years ago, a maxillofacial
surgeon, when I was in theresidency, all bleeding
eventually stops.
What's coming, eventually italways stops.
Dr. Soren Paape (29:22):
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 pterygoidregion and you reflect a lot,
sometimes you'll get a littlebit of bleeding from that
greater palatine coming fromunder the flap.
And the way I like to solvethat is, you know one, I don't
want to sit there and spend 10,20 minutes of my surgery just
(29:43):
compressing it.
I just grab my hemostat clampthe tissue right there and it
goes away.
And I keep working with thehemostat clamp there and you
know when you remove it, itstopped.
Yep, yep, and by the you know,15, 10, 15 minutes later.
You know you've been doingsomething else that you know you
need.
Take the hemostat out andyou're good to go, and that way
you're not sitting there, youknow, wasting your precious
(30:05):
surgical time where thepatient's under anesthesia.
You know you can think if youhave an anesthesiologist there,
I mean you're paying a goodcouple hundred bucks for every
15 minutes.
Maybe not quite that much, butyou know that time is critical.
Dr. Bernardo De Sousa (30:18):
And that's, that's another.
Sorry to interrupt, that'sanother lecture we introduced in
the bootcamp in Brazil.
First day is how to deal withheavy bleeding, for example.
It's another thing that we werechanging and improving because
we saw people panic a bit and Iunderstand, I also panicked in
my first ones, but it's reallynot something that that big.
You know, I panicked in myfirst ones, but it's really not
(30:39):
something that big.
It's big for dentists.
It's not big when you are usedto other kinds of bleeding.
I remember in the Netherlands Isaw a guy that was in a fight
with someone that had an axe.
Can you imagine Fightingsomeone with an axe?
The guy had a major cut.
This was the most serious thingI saw in my life, you know, and
(31:03):
still solvable, yeah.
Dr. Soren Paape (31:05):
You know, one thing I wanted to mention that I
forgot to say before and I'mit's.
It's kind of a question for youtoo, bernardo, when you're
doing a rotated pedicle flaps.
Another pro, in myunderstanding, is, compared to a
buckle fat pad is a lot oftimes that connective tissue
regenerates so you're able to re, you know, not right away, but
(31:26):
once it heals up, especially in.
You know, I see a lot ofpatients that have palatal
tissue, that is, it's thick,it's really thick and a lot of
surgery, you know much.
It's too much.
You need to thin it out.
But if you're able to, insteadof thinning it, you can use that
to wrap around the implant topreserve keratinized tissue.
That's always a solution tocome back to again to use if you
(31:46):
need to down the line.
Dr. Bernardo De Sousa (31:47):
Yeah, yeah, exactly.
I think I mentioned this before.
That's one of the pros of usingthe palatal tissue is it
regenerates not fully.
Actually, a friend of mine dida study exactly on how many
cubic millimeters it regeneratesafter one year it was.
He found out that it was notfully, but it was about 85 90 if
(32:12):
I remember correctly.
So it's almost everything andand, yeah, one year later you
have it there again.
So, yeah, it's, it's like aninfinite pool of good tissue for
you.
You know that keeps coming back, keep keeps spawning Is this
the right word Like thePokemon's when they spawn, spawn
.
Dr. Tyler Tolbert (32:30):
Spawning.
Okay, then you edit thisRespawn.
It's a renewable energy source.
Dr. Bernardo De Sousa (32:35):
Oh no, that's staying in Respawn.
I like that.
Dr. Soren Paape (32:38):
Yeah.
Dr. Tyler Tolbert (32:39):
It respawn.
Dr. Bernardo De Sous (32:39):
Connective tissue respawns.
Dr. Tyler Tolbert (32:41):
Yes, yes, absolutely that's good.
Dr. Soren Paape (32:43):
Well, hey, bernardo, you know we went over
so much in this episode and I'veactually, if you're watching
this on YouTube, you've probablywatched Bernardo's sun setting
behind him throughout theepisode.
So you know we reallyappreciate all of your time on
this episode and this will beone that gets cut up into a few
episodes because it's been ajourney throughout.
But you know we reallyappreciate all of your time and
(33:06):
I think that anybody who'slooking to up their full arch
game and get you knowprosthetics that have no
cantilever and are looking forsolutions to bleeds and looking
for ways that they can take onmore patients without going
through larger approaches likezygomatic implants and stuff, it
is critical to check out theFull Arch Club.
Additionally, you know I don'tthink that you're able to get in
(33:28):
.
I had questions too, like hey,how do I get into Bernardo's
WhatsApp group?
And it's go to the mastercourse, go to the bootcamp, and
you'll get access to a lot ofclinicians some of the best
clinicians in the world who areable to answer some of these
questions that you haveimmediately.
You know, I think everybody inthat group is very transparent
with you.
Know, I'm in a surgery, I havethis issue.
What do you recommend and youget a lot of responses from
(33:50):
wonderful clinicians throughoutthe world just by having access
to that group.
So I think it's a wonderful CEto take if you're looking to get
into.
You know more advanced casesand again, we really appreciate
your time.
Today you can follow Bernardo.
What's your Instagram, bernardo?
Just so people can look throughyour stuff and see the Full
Arts Club.
Dr. Bernardo De Sousa (34:09):
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 offbefore this goes to air, we are
at the moment preparing coursesthat have never been done until
today, not only to help youbecome the best surgeon possible
(34:33):
, but also that you become thebest person operating.
I will not disclose moreinformation now, but, to be
something radically differentfrom what has been done until
now, we are also going to launchsoft tissue only stuff, because
(34:53):
a lot of doctors are asking,and they ask on the group and on
the WhatsApp group as well.
So we are preparing what Ibelieve to be the most complete
full arch soft tissue course fordoctors, where you learn all
the techniques that you need inthe Full Arch game, with a bonus
.
I think I can say that it alsoinvolves soft tissue, but it
(35:18):
stresses your nerves.
So I will not discloseeverything now.
Dr. Tyler Tolbert (35:22):
The more you tell me, the more questions I
have.
It's not actually making iteasier so it's going to be fun.
Dr. Bernardo De Sousa (35:30):
So, yeah, keep tuned and also on the
website, because all if a courseexists better than asking me or
the manager or anyone is to seeon the website if it exists, is
there?
So, fullarchclubcom, when Iwhen I have to know where I have
to fly for a course orsomething, I go to my website
because I don't know.
Dr. Soren Paape (35:52):
So it's my calendar well, hey, thanks so
much.
And again, you can always findtyler and I at my instagrams dr
soren poppy tyler's is dr tylertrobert, and then you can reach
both of us at the fixed PodcastInstagram.
Again, if you're listening tothis on Spotify or whatever
platform you use, we always havethese videos on YouTube as well
(36:12):
, where you can see all of ourfaces, and we try to incorporate
as many panos and stuff intothe videos as possible.
So definitely take a look atthose.
And again, thank you for yourtime, bernardo.
Dr. Bernardo De Sousa (36:22):
Thank you very much.
It's the second interview thatwe do and I feel like a bit of a
death for you too.
You know because I saw you inthe very beginning and now two,
two years later, it's really,honestly, it's impressive the
way you two are growing, and andother guys from the boot camp
(36:44):
as well, and your new projectwith the clinics.
And you remember we talkedabout the brain.
You guys have the right brain,okay, and this is, as I said,
the clinical part is the easiestto learn.
But having the right brain issomething difficult to teach and
if you are born with it, use itwisely and you are born with it
, and I'm really proud of thethings that you are
(37:07):
accomplishing, not only in theclinic, but also with the
podcast previously with theother one and now with the Fixed
podcast and I think you deserveeverything good that is going
to happen to you because youwork hard, you are smart and you
apply your smartness into doinggood things to people.
So keep doing what you aredoing, into doing good things to
people.
So keep doing what you're doing.
It's really motivating to me tohave contributed with something
(37:31):
to this.
Dr. Soren Paape (37:34):
Well, hey, thanks so much, Bernardo.
That means a lot coming fromyou and you've always been a
wonderful mentor to us and wereally appreciate it.
So thanks so much everyone forlistening and tune in next time
for the Fix podcast.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Boysober
Have you ever wondered what life might be like if you stopped worrying about being wanted, and focused on understanding what you actually want? That was the question Hope Woodard asked herself after a string of situationships inspired her to take a break from sex and dating. She went "boysober," a personal concept that sparked a global movement among women looking to prioritize themselves over men. Now, Hope is looking to expand the ways we explore our relationship to relationships. Taking a bold, unfiltered look into modern love, romance, and self-discovery, Boysober will dive into messy stories about dating, sex, love, friendship, and breaking generational patterns—all with humor, vulnerability, and a fresh perspective.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com