#20 - Dr. Alejandro Lanis – Socket Management & GBR in the Aesthetic Zone

00:00:00: Hi, Alejandro!

00:00:02: Very nice to have you here at BOTIS in Berlin.

00:00:05: Thank you very much for accepting our invitation.

00:00:09: Thanks

00:00:09: a lot for having me today.

00:00:12: We're very excited that we'll be meeting the whole team and everyone who has already

00:00:19: met them.

00:00:20: So thank-you so much for being with us.

00:00:24: Today I want to talk about socket management because it's a topic that we are currently looking into very intensively, and we're providing new solutions for this group of indications.

00:00:47: And yeah... That is why I would like to chat with you about the topic.

00:00:52: Yeah sure!

00:00:53: Thank You!

00:00:54: Let's go for it.

00:00:56: How did you hear about BOTUS?

00:00:58: or how do you come to BOTIS?

00:01:02: I could say that maybe six years ago, it was still based in Chile and I was working with different biomaterials.

00:01:12: And so then we were working with a Different...I don't remember this time what kind of protocol but i remembered there was very innovative thing.

00:01:24: This is something they really like innovation.

00:01:27: and then I focused on the brand, And i started to work with certain products in my country.

00:01:33: Then I moved to the

00:01:34: U.S.,

00:01:34: and Boston was impossible to get both these materials because it's related to regulations.

00:01:41: Um...and they came back to Chile!

00:01:45: ...And..I realized that the whole portfolio is already there.

00:01:51: We met And we started to collaborate and since then I have been working with bodies in, i would say a hundred percent of my first generative cases.

00:02:02: The portfolio that you have it's very unique and complete... This is something also changing the way companies are facing what they do.

00:02:14: It changes from selling just products to solutions or experiences And this is what I think it's super important for our patients.

00:02:22: We're not selling just or treating with only one product, but a solution and in that sense you have everything we need to give the patient the best treatment they can.

00:02:34: You put very nicely so.

00:02:36: this was exactly our goal at BOTIS to offer complete portfolio solutions and being able to tackle any situation, any clinical situations.

00:02:55: Because we know that there are different factors from... We have different patients with different defects, different technical techniques you can apply or different preferences also for clinicians.

00:03:13: So that's why we think there is no single bio-material.

00:03:18: That it the best option for every case, but... There was an optimal combination and were always developing new solutions as you said not just products but solutions.

00:03:40: You made a good point here There's no single biomaterial for every single solution or case.

00:03:48: I always say the same, when you have a hammer in your hand everything looks like an ale In our profession and what we do... Every day each patient is different.

00:04:02: We try to approach them with this personalized healthcare approach meaning that you need to choose or select specific biomaterials and a specific influence on the specific materials for every single case in particular.

00:04:17: And, if that says...and this is something I always was discussing with my residents when it's working here at Boston is That Every Single Material It Has Its Own Indication Depending On The Case The Situation And The Medical Situation Of The Patient.

00:04:33: You Can Change A Little Bit what you want to use.

00:04:35: You can select different things instead of just focusing in one only single material.

00:04:41: I don't think this is the right way to do it or too proceed, i think its important because when we are doing a specialty training for example and expert means have criteria know how to select best biomaterial or implant or indication.

00:05:03: In that sense, I think that POTIS has a very good portfolio.

00:05:06: A very comprehensive portfolio with lots of options in order for you to select the right material and write an indication.

00:05:14: Yeah... Very well said!

00:05:18: That's exactly what we aim for so happy to collaborate here again.

00:05:26: Thank You.

00:05:27: So remember when we met in Rio last October, the ITI-Rio.

00:05:33: The section meeting biggest ITI section of the world and you were a speaker there.

00:05:42: I remember that i approached before and told to you let's meet in Rio And then when it came for me... I didn't recognize.

00:06:00: I just think that you look different in real life than in the pictures.

00:06:06: But it's fine, so after this we received already your case right?

00:06:17: Your Novamax shield case which is a really nice one from you and this is already shared on our social media, it had very good reception.

00:06:36: We are happy with the documentation.

00:06:42: I remember that in Rio you told me that Novamax Shield was a smart solution.

00:06:49: so why do you think?

00:06:53: Because when you have this type of defects, like a Type III socket after the... Let's suppose that you do an extraction and don't have the bakalmowo in central incisors just to give you example.

00:07:05: Reconstructing in predictable way with these defect is not that simple okay?

00:07:11: And there are still people.

00:07:13: they their skills They're able manage situation and place an implant immediately having beautiful results.

00:07:21: In my hands, I think it's a little bit more difficult and i prefer to go slowly in this type of cases because... ...I cannot take the risk of having complications.

00:07:38: Because I rushed with an implant placement for example.

00:07:42: So on these situations.. ..I believe that most important thing is to reconstruct this backbone wall which isn't there anymore.

00:07:48: There are different techniques to do that but having something in there that can create a barrier, But also the stiffness to contain the grafting material In an appropriate way without Having to close the tissues because you Can leave it exposed.

00:08:11: this is Something That Is very Smart.

00:08:13: and Also Having A membrane That Is Designed And Created by salts that we already have in our bodies like magnesium.

00:08:24: I think it's a very innovative solution, and remember when i was waiting to put my hands over this membrane as soon they came back to Chile?

00:08:47: and I had this beautiful case that i think the indication was a right one to try it.

00:08:53: And,I was so surprised by the result!

00:08:56: This is something that have to say very honestly... ...i wasn't expecting to have these type of results with this technique.. ..and the result was really good !

00:09:05: Then ,i took a CVCT of patient before placing the implant after feeling the healing phase and you could see how the back album was completely reconstructed, that the socket was preserved very well.

00:09:20: And then we were ready to place the implant with a flat-place approach.

00:09:24: so no more GVR or maybe a little bit of soft tissue management just create better profile.

00:09:30: but the bond effect was corrected by maintaining this space adequately in time And this is what I think it's one of the beauty for these specific solutions.

00:09:45: It's a very innovative and nice solution, Of course!

00:09:48: It has its own indication.

00:09:50: You have to be careful with certain things... ...I've talked with different colleagues about using this specific product or membrane... ...and there are learning curves that're important to go through.

00:10:04: But once you manage your product over the membrane deal with it, I think is a very nice solution for these specific situations.

00:10:14: You mentioned the learning curve.

00:10:17: when you are using the Novamax Shield in this specific indication what would be your tips and tricks?

00:10:36: Well, based on my experience because I want to make sure that i'm not an expert in the topic but based on My experience.

00:10:46: I think first managing very well the soft tissues before placing The membrane you need To have a Very good pouch to be able to place it without any tension.

00:10:58: remember That this is A very stiff membrane so if It's tight or it's compressing the tissues from inside, you can create an ulcer or a tear of the soft tissue and it can also create a little bit of pain because of the sharp edges that you can created when you are trimming.

00:11:18: So you have to be careful as well.

00:11:20: has second tip When you're trimming this membrane with these specific instruments And then I think another important thing is how fixated you have specific screws or tags to fix the membrane in a right position that they are also resorbable.

00:11:38: I like to use them, but when it's difficult for example this type of situations because we don't want open a flap suturing with the right technique is important.

00:11:47: just keep everything in place.

00:11:49: if your movement has any gvr you're not going get the result as expected.

00:11:58: recommendation for clinicians that they are starting with this membrane is to be careful when managing the membrane and also the soft tissues.

00:12:07: just avoid having any type of complication.

00:12:11: So we need create a right pouch And we need to take care of the sharp edges, so not too have a sharp edge.

00:12:22: We need to create smooth edges right?

00:12:25: The other thing that I believe it's important is to explain this to the patient... ...that the degradation process for dismembering is by our reaction.. ..that its going to create bubbles and they don't notice!

00:12:37: So they can get scared or concerned about these situations.... This something normal as part of their processes.

00:12:45: We need to know it and they need to try too.

00:12:47: Yes, that's correct.

00:12:49: so patient education is also key when you are suggesting a treatment You explain your patients what the can expect right during the healing process.

00:13:01: And in the case of the Novamark membrane It adds its made of Novamak of metal magnesium metal Its pure magnesium and it will absorb into magnesium salts.

00:13:15: And this wheel release hydrogen gas, but hydrogen gas we know that is no problem for the tissue or for...for the patient because its really you know Hydrogen is smallest molecule in the table of elements so It's not a big deal.

00:13:38: And especially when using the shield, it is a small magnesium membrane.

00:13:43: You have not another huge amount of hydrogen gas so bubbles but... When the patient knows what's happening and that he can maybe feel some kind of prickly

00:14:05: feeling then they will know.

00:14:07: Yeah, that's exactly my point.

00:14:10: And about the management of this soft tissue I think it is very important to release above the Mukhajini on margin or just be able to manipulate tissues in a good way because lady and here are not covering membrane but have space for appropriate fit off the membrane if you're If you don't have that type of movement from the tissue, so meaning that if didn't go through the mucongigital margin.

00:14:41: maybe You're not going to be able to feel it well and then It can move.

00:14:46: And then you could have particles coming out from the defect for example.

00:14:51: This is something we dont want.

00:14:55: I would say these are my tips & tricks and name them in that way.

00:15:07: But the rest is just mainly GVR concepts, I think we all know this as a different type of barrier.

00:15:15: And what about difference or application?

00:15:22: Do you feel it's easier to place a NUVAMAC membrane than a collagen membrane where maybe you need to suture?

00:15:32: So in this specific defect, when you have like a class three socket or with these days and yeah.

00:15:39: With this big day sense I think it's... It's a little bit easier to fix-to put it in place because with the collager membrane usually You need to.... It is difficult to fix it in right position Because if get folded then its not that simple too deep To manipulate.

00:15:57: The Nova Mac is very stiff, so you create the shape and then just put it in place.

00:16:04: So I think its a little bit easier now.

00:16:06: with Collagen members usually You need to close everything by first intention To avoid having collagen exposed.

00:16:14: That's one of the beauties for this product Is that you can leave it exposed And nothing should happen in time Because once it is reserving or you already have epithelium below and this is exactly what you want.

00:16:30: You want to have everything covered while the product or the membrane is resolving.

00:16:37: Exactly, that's when in Euro... case, where the keys that you sent us.

00:16:42: You used a Novamax shield in an L shape so that you were covering also this socket and leaving it exposed... Yeah!

00:16:52: So if take a look on that case ...and for people who are watching as they go to the case here They're gonna see I use the membrane with these L shapes.

00:17:00: but because my purpose was do two different things To give back or try to reconstruct the back album wall but at the same time to try and do a rich preservation.

00:17:13: My plan wasn't to place the implant right away because that effect was huge, my plan was to create new bone or a new platform for placing the implant in the right position.

00:17:27: But I needed it reconstructed Buckelbone World II And thats why i use a scenograph instead of an analog graph the material that I use for rich preservation, because in here i wanted to maintain the volume and time by reconstructing the Buckleman wall.

00:17:49: When I do reach-preservation procedures ,the purpose of the procedure itself is different.

00:17:55: this is not about only volume it's all also about the turnover into native bone as soon as possible to be able to place an implant and not only about from particles, so for all grafting particles.

00:18:14: That's why I prefer to use an analog graph than a xenograft for rich preservation.

00:18:19: but in that case it is little bit different because the purpose of this procedure was different.

00:18:26: It was reconstructed back at my work first then to have a scaffold for colonization on patient bone cells.

00:18:37: Now, so since you are mentioning different bone grafts and Do you consider or do use sometimes mix also xenograft and aloe graft?

00:18:47: Yeah.

00:18:48: So It depends on the situation.

00:18:52: okay For example if my main goal is to create volume or maintain volume in time Or do what it's called a contour craft usually I used a combination between a scenographed I am an autograft, so i try to take bone from the patient.

00:19:13: Uh...I mix it with the xenon graft and this is something that has been described for a long time And This Is Coming From Danny Wolzer & others For type two or type three implant placement in terms of timing where you need To reconstruct what Has Been Lost After The Extraction.

00:19:33: uh..and the idea here is to give this osteogenic and the osteoinductive potential to something that doesn't have it, like a scenograph.

00:19:41: That is very good scaffold but without these properties.

00:19:44: so when you combine different type of materials I don't combine much scenograph with allograft because i cannot find their purpose in doing that.

00:20:05: But I think that you can get the results of your looking for just by using them separately depending on The situation.

00:20:12: as i said before rich preservation.

00:20:14: I would prefer to go with a with an allograph because Of their turnover rate For something where want to keep it stable in time, I will prefer to work with a xenograft For sinuses.

00:20:25: today and we're using most of all Allographs or sometimes I combine them with scenograph depending on the size of that effect.

00:20:35: If i want to enlarge too much and keep this volume in time, Sometimes use as a scenograph but I was discussing it with someone in the morning... The particles are a little bit sharp so you have be careful about the membrane.

00:20:57: To avoid having any perforation.

00:20:59: So that's why I combine them, or use a cola corn or a cola fleece in between the membrane and the grafting even when i know that im limiting their osteogenetic potential coming from the membrane cells.

00:21:16: But i want to avoid having any type of perforation on the membrane.

00:21:21: so you used mainly serabone for when you need to keep the volume for a long time, or if want to reconstruct a contour Or something like this.

00:21:35: You would use cerebone.

00:21:37: Yes.

00:21:38: And what about cerebone plus?

00:21:41: Have you tried cerebone Plus?

00:21:43: yes I think it's very smart solution too But most of all when you have two deal with that effect.

00:21:52: That is not very well contained.

00:21:54: Okay because You get a very sticky consistency and then it's pretty easy to handle the material, put in place.

00:22:09: And of course you're going use some membrane that keeps everything where they should be.

00:22:15: I have realized using Serabon Plus for example immediately in plant placement sometimes is a little bit tricky because to move the particles back or away from the gap that you're trying to fill.

00:22:34: When you are filling this gap between the implant and the backbone wall, what do we want is a very well compacted situation?

00:22:42: And when you have hyaluronic acid in-between sometimes it tries... The grass tends to go out of the socket.

00:22:53: That's why I prefer to use Chocerabone but in bigger reconstructions where you want to have this consistency that is going make everything easier, I prefer to use Cerebon Plus.

00:23:03: So the same with Max Graph with the Alluronic Acid depending on size of the defect and shape of the effect... ...I also changed my indication of the material.

00:23:19: Have you tried to hydrate less the Cerebone Plus?

00:23:25: Yes, and it works better.

00:23:28: but I still think that is easier to manage the extraction or gap between the implant on the backbone wall with just CeraBone.

00:23:40: And you're going get a more compact situation because what we are looking at in this specific situation to contract the potential resorption that can happen after the extraction.

00:23:57: So you really need something in there, which keeps it at a volume of time without any movement and thats why I prefer to use Chocerabone without Yalronic Acid.

00:24:06: Im not saying its doesn't work but im just saying this is my choice for these specific situations.

00:24:15: Alright!

00:24:16: And do you mix also Cerebon Plus with Autologous Spoon?

00:24:22: Yes But this is because I'm following the same principle.

00:24:52: product and then it gets already a bit hydrated with the blood.

00:24:57: Yeah, yeah... And I use less water because if i used too much it's going to... It is not right consistency that you're looking for.

00:25:08: so I try this with blood Then it get already sticky and If need to use more water or saline solution its no water.

00:25:18: I put little bit more But you need to find that sweet spot where it really... You get what your looking for and its not too much.

00:25:26: You can always remove a little bit of this yellow-eronic acid with the suction or with a gauze, but there's no idea if we're just handling material without proper instruments.

00:25:39: Yeah!

00:25:39: It is not difficult right now?

00:25:41: No.

00:25:41: To handle these products?

00:25:44: I will say they are all designed for dentists as well as astronauts.

00:25:49: So those things are very easy to use.

00:25:53: Nice

00:25:57: Maybe let's go back to the shield To the case.

00:26:03: You said that you were impressed with the radiologic result.

00:26:10: because of the mechanical stability and also the properties of magnesium That promote bone formation.

00:26:17: we really see the back of wall being reconstructed.

00:26:23: So we see it looks almost like cortical bone, right?

00:26:28: And right up to the coronal part where you need most to have this bone, so what was your experience with that?

00:26:42: as I said before when Because what happened with this case is I performed the whole reconstructive procedure first and waited around, I would say six to eight months.

00:26:59: And then took a new CVC team plan my implant placement in guided approach because it was something that i usually do in the right position, et cetera.

00:27:16: And then what happened is that I'm using a software based on AI.

00:27:22: it does its own AI-assisted segmentation and he divided the scenograph because of their density from the rest... ...and i could see perfectly where there new bone was combined with the crafting material of course, and how the back album wall was created or reconstructed.

00:27:53: The shape looks almost like nothing happened before something that I believe is very difficult to achieve With other techniques...I'm not saying it's impossible.

00:28:06: I think this was a very simple way to manage these very big defects that were compromising the Backelman wall.

00:28:16: We all know it's important for aesthetic results when working with implants.

00:28:21: So, we talked about socket type III A lot and how the Novamax shield is smart solution for socket type IIIII.

00:28:32: I wanted you ask what do for socket type one and two, what kind of biomaterials would you use?

00:28:40: How will you decide.

00:28:42: Okay so let's start with the Type One.

00:28:45: if I have a type-one my approach today is work with an immigrant implant placement because the main idea of doing that is to maintain the profile because this is going to give you, if the situation is the proper one it's gonna give you best aesthetic result.

00:29:10: So... You always place immediate implants on a good one?

00:29:13: If its right indication yes but with purpose of doing an immediate loading.

00:29:22: An immediate loading.

00:29:24: I'm not talking only about placing restoration But it could be customized healing abutment Because they did have to maintain profile.

00:29:32: so if I can do it and i think that the profile is the right one to keep, I would prefer to go with an immediate implant placement.

00:29:39: And then use this type of restorative solutions to keep the profiling time.

00:29:45: but as we were discussing before you need put something in between the gap on the back oven wall just to maintain or give support for these back oven walls and avoid resorption.

00:30:00: What is happening, it's that you extract the tooth and remove the pre-tontal ligament.

00:30:05: So the bundle bone in the back albumin wall gets affected because of the lack of vascularity.

00:30:13: then when you have this bone remodeling In order to avoid that we like put something between and usually my preference use stavelling time.

00:30:24: for that reason I'm using a synograph in this case CeraBone When I'm working with type two socket, type of sockets.

00:30:35: I think here this is a very tricky situation because doing an immediate implant placement could be a little bit risky Because the potential defect that you can create or have after everything is stable After extraction.

00:30:56: So in those situations it depends.

00:31:00: Let's suppose that the defect is very contained as small, maybe I would go with an immediate implant placement and i'm going to use some acenograph in this case Sarabon and then probably am gonna find a way to manage soft tissue just create more volume and be able to mobilize these tissues too.

00:31:26: But if I consider that this is not the right indication for an immediate implant placement, then I would go with a rich preservation.

00:31:35: And in that situation... ...I'd prefer to use an allocraft because here's different.

00:31:42: The idea or purpose of procedure is create bone as soon as possible To place an implant and also have integration based on native bones.

00:31:54: re-enter earlier and this means between three to four months.

00:31:59: And in these cases, I think one of the solutions that you have is also very smart is perma-mem.

00:32:06: So perma mem as you know it's a PDFE membrane or that i like to put covering the crafting material into the socket.

00:32:23: You can fixate it by sutures or just doing like a pouch.

00:32:28: But the good thing is that, It's very clean membrane.

00:32:31: you get exposed nothings going to happen and what I have seen Is two different types of situations.

00:32:40: The most common one is that you have epithelium growing below the membrane And after couple weeks everything looks healed.

00:32:48: Doesn't mean its ready for implant You are going covered by the own tissues from the patient and then you have to wait for integration of the grafting.

00:33:00: The other situation that I've seen rarely is that the membrane gets covered with epithelium, so it's a very nice solution when the defects very well contained and it's a good way to separate the grafting from the oral environment.

00:33:29: Now, depending also on type of patient they manage their oral hygiene or other stuff.

00:33:39: sometimes I like place colacons that these are this collagen some esmostatic sponge made by Collagen that they resort very fast, I like to place them between the grafting and the perma-mem.

00:33:58: So you give an additional layer to protect their particles from moving or going away Or go outside of the socket And then compress everything with perma mem.

00:34:09: What i have seen is usually when we get soft tissue covering the grafting before I think it's safer to have everything maturing or healing faster.

00:34:26: This is the type of approach that i use in Type II sockets, which preservation with these specific materials?

00:34:34: To be able to reenter as soon as possible With my implant and here It will depend on how much Resorption did you get after the extraction.

00:34:44: sometimes You can go just with a flapless approach because Everything looks perfect.

00:34:49: Or sometimes you need to do something else and depending of the defect, let's suppose that we have a big horizontal defect or atrophy.

00:35:00: Sometimes You Need To Do A GBR And Go With This Type II or Type III Inplant Placement in Terms Of Timing Where You Do Contour Graphed OR You Can Just Manage It with Subtissue place a connective tissue graft or even mochoderm below, you go with the flatless approach.

00:35:23: These are at least where I say it in my decision tree.

00:35:32: You always want to do as fast possible with implants.

00:35:37: so if you can do immediate and not then you would use

00:35:40: holographic... But this is not related to the velocity or speed of the process.

00:35:48: It's more related with... ...the purpose, what I want do?

00:35:52: I don't like to rush it but if i can keep a profile in there before that is basically nature.

00:36:01: so we are trying to mimic nature and this something very difficult.

00:36:05: So If I try to mimic by maintaining what was in here then immediate implant placement I think is the best solution because you are going to give a fixation for this prosthetic solution that it's gonna maintain their profile in time.

00:36:24: If not, then you have other options and this when do reach preservation or something else.

00:36:30: We know by evidence now that rich preservation keeps volume better than an acidic healing but sometimes where we have huge defect of something very difficult An assisted healing is also good because it's going to create a lot of self-accuracy, nice tissue.

00:36:46: To then move in different directions just to achieve what you want to achieve after delivery construction.

00:36:53: So that why I talk about this personalized healthcare approach.

00:36:57: It depends on every single patient.

00:36:59: Every single patient is different and the situation is always different

00:37:04: Right.

00:37:05: That's why At Boutis we have the same concept of offering this white portfolio, different options and solutions.

00:37:15: We really like to talk with clinicians about what works in their hands so that they can learn new things from you today Like for example putting the max rough with colacone and premium on top, right?

00:37:40: This is new to me.

00:37:43: So like I'd like to hear that Let's go back maybe to the beginning of this conversation.

00:37:51: You mentioned that in your journey To getting to know both is you had a period of time That you didn't have access two boats by material.

00:38:00: so II imagine it was very Sad time of your life.

00:38:07: Yeah,

00:38:07: no I'm kidding

00:38:10: I was crying everything

00:38:14: But to entertain yourself with.

00:38:19: or you had a role in the Harvard Medical School right?

00:38:30: The Herbert School of Dental Medicine.

00:38:32: Of dental medicine, exactly!

00:38:34: So how was your experience?

00:38:38: It was an amazing experience.

00:38:39: I spent two years as the director for Advanced Graded Implant Program in Advanced Grided Program in Implant Dentistry at the RDBES department at HSDM in Boston.

00:38:52: it was an nice people and good people, smart people.

00:39:03: Academia is something that never stops.

00:39:07: so it's a twenty-four seven job.

00:39:10: you're always on something different projects research teaching traveling.

00:39:17: So was very intense but there were very very nice time.

00:39:22: I'm still connected to the school in some way.

00:39:26: i gave them lecture two weeks ago for the period of residence.

00:39:32: I really like to teach, this is something that i really enjoy and reason why we decided as a family go back to Chile.

00:39:41: it was more related to a family thing ,it wasn't related with job itself but yes... It's very nice!

00:40:00: And I imagine it was something that helped you or this time help to develop further as a global speaker and educator?

00:40:13: This is something maybe other people have to answer.

00:40:19: From my perspective, i think...i was already well positioned.

00:40:30: Of course, being at Harvard is something that gives you more exposure.

00:40:36: But also I didn't have much time to travel because it was a full-time faculty and even when I was traveling wasn't as simple.

00:40:49: Today am working in my practice but still have some connections with academia.

00:40:59: I trouble much more.

00:41:02: But certainly it was a good moment of my academic career, putting in that words

00:41:15: And you had lots students from many countries visiting right?

00:41:21: You have this education week or these programs where students visit you, right?

00:41:28: You were involved in that.

00:41:31: So the ITA week... I would say Harvard has one of the strongest weeks in terms of the ITI Weeks.

00:41:38: The program is very good.

00:41:40: It was designed and it's still under the responsibility of Dr.

00:41:48: Galucci, Hermann Galucci That he was my boss at school.

00:41:55: He's the one in charge, and I think he has been doing an amazing job with the ITA week.

00:42:02: And was invited by him to be part of it while i wasn't there.

00:42:06: It was a very good experience just sharing people from all over the world.

00:42:13: We had...I remember that we have different people like I would say forty countries.

00:42:20: It is something really nice and you get connections that they lost in time.

00:42:28: You made new friends, it was a nice experience.

00:42:33: yeah but the school is...it's place where you receive people from all over the world every single day.

00:42:40: It's very multi-cultural place And you have good ideas coming with different parts.

00:42:49: They are welcome to share these ideas with you and then this is the way new projects start.

00:42:59: It's a very interesting place to be in.

00:43:04: I imagine that it must be very insightful, also fun too have so many people coming from all over the world with their different backgrounds.

00:43:21: It is a very nice place, surrounded by very nice people.

00:43:27: Of course like everyplace you have problems and ups and downs but in the overall being at Harvard it's like family too.

00:43:39: so I think some way i'm gonna always be connected to this school even if not there physically.

00:43:48: I visit Boston once in a while, go there and lecture.

00:43:53: If not then I'll lecture online And i want to keep this connection because teaching is something that we really like.

00:44:02: That's why you are also present at many ITI meetings all around the world.

00:44:09: Nowadays, you are lecturing for over five thousand people like in the World ITI symposium in Singapore.

00:44:18: And how do feel standing on stage with this five-thousand people looking at you?

00:44:27: This was a very realistic experience because that event is massive and it's the biggest and stage that I have been in my life.

00:44:41: That day, there was around five to six thousand people in the room.

00:44:48: but of course you're super nervous But at the same time this is my experience...I'm very happy Very excited To be on a specific spot after Because what you start thinking is all the sacrifices that are behind people, they don't see this.

00:45:11: They just see your traveling and having fun and lecturing.

00:45:14: but behind everything that appears to be happening there's a family... ...there is a job.. there is flying not sleeping working in computer writing.

00:45:31: so it isn't only social media.

00:45:34: there are a lot of things behind.

00:45:37: So when I was in that specific moment, I was remembering all this journey to get into that place and it's been an emotional day too.

00:45:47: about the amount of people honestly between one thousand and five thousand you cannot perceive the difference because you don't see them.

00:45:56: There is so many lights on things like what happens with other people.

00:46:00: You just try to focus and people that you know, familiar faces in the first rows just to keep concentrated.

00:46:09: But it's very difficult to perceive the amount of things that are happening in the auditorium.

00:46:16: Now we have... The next one is going to be Milan, twenty-twenty seven.

00:46:21: I think they're expecting around seven thousand people And the program has already launched.

00:46:28: I don't want to promote myself but i'm gonna be lecturing with Florinco Farr together in a joint lecture.

00:46:36: Florin is very good friend, he's one of the smartest dentists that I know or probably one of them smart guys and i think it will be a pleasure at least for me to learn together.

00:46:51: Cool!

00:46:53: So I want ask you another personal question related to ITI.

00:47:00: It doesn't have to be related to standing on the stage, but it can.

00:47:05: But I wanted to ask you what is your favorite moment in the ITI?

00:47:14: I think there are two.

00:47:15: There're many!

00:47:16: Many...many.. I've enjoyed my time at the ITIS.

00:47:21: The same ITI as my second family.

00:47:24: This was also a part of my family.

00:47:26: about ITI being in the ATI changed my career.

00:47:32: So the first moment is when I went to Michigan as an ATA scholar, this was in twenty thirteen and Will Giannoli who was my mentor at that time will generally listen today's.

00:47:46: he's the dean of the Harvard School of Mental Medicine so he was in some way related to their fact that it was going to Harvard to work.

00:47:55: but i really enjoyed my time in michigan learned a lot.

00:48:00: It was my first time starting abroad.

00:48:04: And from that point, things started to change in my career because I'm somewhere...I think the ATI bets on you and gives you an opportunity for you to grow and develop yourself.

00:48:20: There are people who follow this pathway.

00:48:23: then there's others.

00:48:23: they prefer other type of thing.

00:48:26: This is okay.

00:48:28: In My Case I kept very attached to the ATI, and then more things happened.

00:48:35: And i could see how my life was changing... ...and suddenly it was working in Boston not because of the ADI but always related with it.

00:48:48: The second one is the Worst Impossum.

00:48:50: That moment was really incredible.

00:48:54: The whole week in Singapore was amazing, but when it wasn't the stage I felt It was a very surrealistic moment.

00:49:03: This is where i can describe this.

00:49:05: These are two main moments that I remember now even though lots of things have happened and I've met so many people friends you and the people from BOTIS connections, wherever I go.

00:49:24: I have a friend and they take me out to have dinner.

00:49:27: we catch up or it's incredible.

00:49:31: It's really nice thing And this is also why i really like what I do.

00:49:35: Uh...I love dentistry not because the crowns of the implants are obvious Because everything that has happened in my life related to My profession.

00:49:44: I have the lackie-to say Or am very lucky to say That I really enjoy What I Do.

00:50:13: Thank you very much for having me today.

00:50:15: It feels like home and we have a couple of days ahead yes with very interesting activities.

00:50:22: so thank you very much.

00:50:23: talking forward to it.