July 21, 2025 • 42 mins
Discover the unexpected intersection of technical mastery and life philosophy in this enlightening conversation with Dr. Nester Marquez, who brings a refreshingly holistic approach to full arch implant dentistry.
Dr. Marquez takes us behind the scenes of his renowned "Ways of the Arches" course—an unconventional educational experience combining rigorous clinical training with desert adventures that include shooting ranges, explosions, and sunset complication lectures. It's a CE course where you literally sign a waiver acknowledging the risks, yet participants consistently describe it as transformative both professionally and personally.
The clinical pearls in this episode are abundant and practical. Dr. Marquez details his apical fenestration technique, an approach where the implant tip intentionally perforates the buccal plate by 1-2mm to achieve cortical engagement and superior stability. He walks through his Empire State drilling concept that consistently yields torque values of 60-70 Ncm rather than the typical 25-30 Ncm. These aren't just theoretical concepts—they're battle-tested techniques explained with the clarity that comes from extensive experience.
What truly distinguishes this conversation is Dr. Marquez's philosophical depth. He candidly discusses how his early chase for professional recognition left important aspects of his life unattended, leading to his "Ways of the Heart" philosophy. His perspective on innovation—"Not everything that shines is gold, but the only way to find anything shiny is by digging"—reminds us that advancement requires exploration and occasional rule-breaking. Most poignantly, he emphasizes that while technical skill matters, true fulfillment comes from family and meaningful relationships.
Whether you're an experienced implant surgeon or just beginning your journey into full arch treatment, this episode offers valuable technical insights while reminding us of the bigger picture: At the end of the day, no one will hang your dental achievements on their wall, but the impact you have on patients and loved ones creates a legacy worth pursuing.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Tolbert (00:01):
My name is Dr Tyler Tolbert and I'm Dr Soren Papi,
and you're listening to the FixPodcast, your source for all
things implant dentistry.
Yeah, so yeah, ways of theArtist.
I learned that from let meadjust my camera just a little
bit here.
I learned that from my best.
Buddy is Mexican, so weexchange a lot of Mexican jokes,
(00:24):
or at least he exchanges themwith me.
So I picked up some casualSpanish, but I won't insult you
with my very cursory Spanishknowledge.
Dr. Ness (00:36):
I don't think you could fight back on the ones I
know.
Dr. Tolbert (00:39):
Yeah, that's right, Exactly right.
But yeah, so let's talk aboutthe course.
What does it offer?
Who's it right for?
What makes it different?
I mean?
Dr. Ness (00:47):
I think it's very wide spectrum.
The Ways of the Arts is verywide spectrum, but it's a very,
I would say, psychologicalapproach to the arches.
Okay, because I definitely talka lot about in the beginning at
least, about the reason we doarches about.
(01:11):
I have a secret hashtag calledWays of the Heart, because I've
been through.
I've been through hell and backagain in my personal life with
what I love to attribute to thearches being a factor.
You know the way I startedarches, the way I started to
(01:32):
have complications, I startedgrowing my business around
arches and I forgot that.
I forgot about, I guess, thekey ingredient in life, which is
love, family, your close circle, you, you know, like I'm sure
if I die tomorrow, this podcastmight be around for many years,
you know, but nobody's going toprint a picture of Dr Nestor and
(01:54):
put it on their walls, yeah,right.
My son, might you know Like, oh,that was my dad.
I'm going to keep a picture ofhim in my wallet.
That'd be cool, yeah, yeah, butthat's it, man.
Like, we are here not for thefame of it, you know, not for
the, but I searched that man, I,in the beginning years of my
career, I was like I want to bethe best, I want to everybody to
(02:16):
be to know me for this, youknow, and I followed the wrong
way, the wrong path, you know so.
Waste Path, you know so.
Waste of the arches is kind ofall-encompassing.
It not only encompasses the waywe should think regarding life,
love Protocols, yeah, surgicaltechniques, you know, we discuss
(02:39):
both analog and digital and weshow you how to do it
analogically, which is startingto become an old book, a dusted
old book.
It's a dying art, yeah yeah,yeah and.
But we also teach, uh, digital,you know, like the protocols of
how to, you know, do immediateload in a digital way, blah,
blah, blah.
Uh, I don't like guided surgery, so we stick kind of away from
(03:02):
it.
You know, it's got, it's gotits place, but that's not
something you learn at ways ofthe arches, like how to do
stackable guides and stuff likethat.
Yeah, there's not enough time,but, um, yeah, so ways of the
arches is, is that we?
It's an a to through, z course,but when you when I say a, I
mean like starting point, andstarting point is not or should
(03:22):
not be models and photographyand CT scan, starting point
should be you, how are you doing?
Make sure that what you tellyour patient and you communicate
through your patient securesthat you will remain doing good.
You will remain doing good.
(03:43):
When you've got that covered,like, okay, I'm going to have a
workflow and I'm going to offersomething to my patient that is
so good that I know I will sleepokay at night, that I know that
I'm charging something that isworth much more than what I'm
delivering.
Right, you know what I'm saying?
Yeah, no, I do what you'redelivering is worth more than
(04:04):
what I'm delivering.
Right, you know what I'm saying.
Yeah, no, I do.
What you're delivering is worthmore than what you're charging.
Yes, so you can be content withthat.
Be like I'm happy about that,man, like I am happy about how
we did things, and it'll shineback to your life, you know,
because if you don't, if youstart getting in trouble because
you're like, ah, this is my,I'm going to do pterygoids,
although I've been doing threearches, you know.
(04:25):
But I'm here, here's my firstpsycho.
I'm going to do a psycho toprove to your friends that
around you maybe, that you canalready do psychos Like who
cares, man?
Yeah, who cares Anyway?
Uh, so ways of the archesstarts there, you know.
Then it starts everything we doprotocol wise for for our
patients, you know, withstarting at the prosthetic,
(04:48):
prosthetic necessities,prosthetic alignment with
surgery.
Then we go through surgery,surgical techniques.
I give kind of the basic uh,you know propositions for
distribution of implants.
And then juan gonzalez alsojoins us.
So he brings patsy and hebrings his technique on
pterygoids.
(05:08):
I bring my technique onpterygoids.
Although it started with juan's, I've modified it and made it
my own which is okay, youeverybody ends up doing in
surgery.
You modify your technique, yeah,and then juan covers cycles a
little bit and then we end upthe course with.
I'm just talking about theoryhere.
I'm going to tell you aboutsomething else.
And we end up the course withphase two and delivering final
(05:32):
prosthetics.
Now, something cool about Waysof the Arches man unlike so many
courses I've been to is we showabout three, four, sometimes
five live surgeries.
You know Most courses you go to.
It's like you watch one livesurgery.
It's over, voila.
Here I'm doing a surgery in oneunit, juan's doing a surgery in
(05:57):
the other unit Interns arerotating.
Oh cool, you get 10 minutes inone surgery, 10 minutes in the
other.
Yeah, usually I let them likehey, has anybody placed a
pterygoid before?
No, you want to?
Yeah, come on, they'll sit downwith me and we'll start placing
.
Uh, has anybody, you know,exposed nasal crest and like
exposed into the nose?
No, come here, I'm gonna letyou do it if the patient is, is
(06:18):
okay with it and usuallyeverybody is, so everybody gets
a little bit of hands-on inactual surgery because we have
so many surgeries.
Alright, we're going to do alower, which we rarely do, a
lower.
Who wants to have a go at it?
You know, open up.
Oh, that's not how I would doit.
I would show you this trick.
Oh, wow, cool, I'd never donethat.
Well, now you know, you knowlittle tips and tricks.
Yeah, and by looking at morethan one surgery, it Like this.
(06:40):
We're doing surgery all thetime.
We do model work too, man, it'slike it's four days it's a
little bit of everything, yeah.
It's a four-day internship, soit's a lot In the evenings, man,
that's where it's wild.
Because it's, I like toconsider Arizona and this part
of Mexico like the Wild West.
Dr. Tolbert (06:57):
It is yeah.
Dr. Ness (06:59):
And the people that live in it too, you know.
So we hit up the desert morethan one time and, uh, we go
off-roading into the sand dunesthat's one of them, you know.
Um, then we go and take a lotof guns and beer and nothing
more, nothing more illegal.
But we take it out to thedesert and we literally blow up
(07:21):
stuff, like we blow up tannerite.
We get gas cans, we getgasoline, yeah, yeah.
Dr. Tolbert (07:28):
No, you keep going.
It's fine.
It's just the feed, it's fine.
Dr. Ness (07:33):
So we blow stuff up.
Juan Gonzalez brings guns.
I have a lot of guns.
We shoot a lot of things.
Here's the funny thing aboutWays of the Arches man, and this
is a real thing and I need youto know this if you're planning
on coming to the Ways of theArches.
Okay, okay, there's a waiverthat you have to sign that says
this is great.
It literally says if you die,you die and I'm not responsible.
(07:55):
It's so wild man, because, well, in reality, like it sounds
funny, but we actually do have awaiver and it's because we use
guns.
You know, and although thislast course there was two
trained, actual law enforcementpeople teaching us and being
(08:15):
careful and giving us like thepros, like you know, the way you
should handle a gun yeah,trigger discipline and things.
Dr. Tolbert (08:21):
Yeah, even if you were a connoisseur, there could
be an accident.
Dr. Ness (08:23):
you gun yeah trigger discipline and things.
Yeah, even if you're aconnoisseur, there could be an
accident, you know.
Yeah, we try to keep it verysafe, but it's wild.
And in that same night where wedo shooting and exploding
things in the desert, we alsohave a complications lecture in
the desert which has become,like this, just very special
thing.
(08:43):
It's Juan's complicationlecture which we keep adding to
it.
Uh, complication stuff.
But as Juan is speaking in thedesert of Arizona, man, it's in
the US, don't worry, we're notshooting guns in Mexico.
People would shoot back yeahthis complication lecture has
become so special because we'reout there where Juan is speaking
(09:03):
complications in the desert andit's also kind of like
philosophically engaging aboutbeing in the desert, you know
it's a it's a spiritualawakening we're having here it's
almost like a spiritualawakening man.
Yeah, I kid you not, yeah no Ibelieve it.
And we're grilling, we'remaking carne asada out there.
You know like it's almost likea camping trip, you know yeah
(09:26):
there's some alcohol involved,of course, so it's.
It's very.
There's not been a person thatcomes to ways of the archers.
There's not like dude, it'sjust.
Dr. Tolbert (09:35):
I've never done continuing education like that
yeah, it's a different way celike what like that's huge wait,
yeah, I do it, can I come backagain?
Dr. Ness (09:43):
you know, I'm like you can man, you know.
But double dip.
So it's, it's everything, manit's it's yeah you get exposed
to our protocol, which may notbe the protocol that your
current mentor has, and that'sokay, but it could be, or you
could be a badass full archeralready that comes and realizes
that you needed, you know,something that lightened your
(10:04):
heart a weekend, a somethingthat lightened your heart a
weekend, a getaway thatlightened your heart.
Everything's safe.
We don't do anything like crazy.
We're not hitting up stripclubs or anything like that.
People can if they want to, butwe don't.
Keep it very safe.
Dr. Tolbert (10:17):
This is for all the wives watching this podcast.
Dr. Ness (10:19):
Everything is very safe and girls are definitely
definitely invited.
There's been a couple girlsthat sign up to it.
I think our our marketing forways of the arches has kept some
girls away, I think becausethey're like that seems like a
boy's trip.
You know it's masculine, it isit seems masculine, but we're
like it's not.
You know, you like yeah, yeah,please come join us.
Dr. Tolbert (10:41):
So yeah, yeah, yeah , of course.
Yes, it's gender neutral.
It's gender neutral for sure.
That's awesome, that's great.
I mean that sounds like anabsolute blast.
And yeah, I mean I know acouple guys that have been out
there.
Chris Epperson did it not toolong ago.
Skylar Morton as well is a goodfriend of mine and he had yeah,
he's, he's about.
Dr. Ness (11:01):
It was kind of his vibe too.
Man, skyler was like yeah,skyler was like dude, I use it
all in there.
Yeah, he was, yeah, yeah yeah,yeah.
Dr. Tolbert (11:09):
No, they both had really positive reviews about it
and um, they recommended.
Dr. Ness (11:13):
You know we get around to at some point, which I'm
sure I will, um, but uh yeah,you're more than welcome, yeah
of course and then it's guythere, just like any other
course you take, probablythere's there's access to us
after the course too, you knowlike, oh sure, yeah, he's called
me before like hey, he's analum think about this how would
you do this?
I'm like dude, yeah, this, thisand scholar is really efficient
(11:33):
already, so, yeah, he's great.
I'm like, oh, I just move alittle bit this way and he
starts nailing things, so he'sgreat, yeah, yeah he picks it up
quick, awesome, um.
Dr. Tolbert (11:42):
So I do want to kind of get into you, you know,
some nittier, grittier detailsof just like clinical protocols
and things that you post aboutas well, just because we always
try to, you know, have someactionable things for folks
watching the show.
So, something that I hadactually commented on one of
your posts recently about andI'd seen it a few times and I've
actually done it a couple times, but I need to talk to you to
make sure I'm doing it right.
(12:02):
So in one of the posts that youmade it was an upper fixed six
implants and you had, with thedistal, tilted implants, you had
actually perfed the buckleplate intentionally.
So it's very, very little, justthe apex of the implant had
gone through.
So I've actually gotten somequestions about this A, why,
(12:25):
when is it indicated?
What are some issues that cancome about with it?
Do we polish the implant?
All that kind of stuff?
And also, what do you call it?
You know what do we call thesethings?
Dr. Ness (12:34):
Yeah, you know what I mean.
I don't think it's been calledyet, so all I call it is apical
fenestration technique.
Apical fenestration, okay, yeah, so why?
Because the, the tip of theimplant, fenestrates, you know,
epically wherever you're tryingto engage, and it's basically an
anchorage technique.
It's not remote, it's closeproximity.
Yeah, it's anchorage into hardor cortical bone.
Dr. Tolbert (12:57):
It's local anchorage.
Dr. Ness (12:59):
It's local anchorage.
Exactly, it's not remote, it'slocal anchorage.
Yeah, yeah, it's very simple,you know.
Dr. Tolbert (13:04):
Okay.
Dr. Ness (13:05):
I actually let me read a comment that somebody made on
Instagram.
I agree with you, Somebody waslike hey, man, you know, let me
read the comment because Ithought it was good.
I'm not sure what I answered,but Okay.
So this person said hey, Idon't know, doc, like I'm not
sure about it, in some casesthat I have left the implant tip
, like that, I had to reopen anddo implantoplasty because the
(13:29):
patients kept having pain inthat area.
I don't think I think softtissue and sharp edges don't go
well together.
Yeah, sure, in most cases Iwould agree, and my answer to
him is the one I'm going to givehere and it explains the
technique very simply.
We don't want coat hangers.
Anything that overextends pastthe millimeter into the
(13:54):
osteotomy, into the fenestration, can have problems, just like
lifting nasal mucosa to place animplant into the nasal floor.
The way I teach that one isdon't overdo it.
You want to make sure you stayone millimeter to two
millimeters engaging into thatarea.
So if you see the pictures thatI post, you'll never see this.
(14:18):
Right, right, you'll seeprobably that and you'll see it
kind of sideway, so you can, youcan see it more.
If you were to look at it likethat, it would probably be like
that and that's never been anissue and I've been doing it for
many years now we probably haveto write about it.
Um, yeah, with complications,where it has been an issue and
that there's actually literatureabout fenestrations like that
(14:39):
is if it's overextended, kind oflike with cheekbone, with
zygomas.
You know, sure, we, sure we candefinitely have some fistulas,
we, we can have pain in the area.
And if that happened to youbecause your drilling protocol
was off and I'll talk aboutdrilling protocol right now all
you have to do is, as youmentioned, kind of like an
(14:59):
apicoectomy on the tip of theimplant.
You polish that tip of theimplant, voila, it's gone.
It's simple, even if you had tocome back to it three months
later and the patient's like,yeah, something here feels a
little off, oh honey, don'tworry, slide it open, polish it
off, close it.
Dr. Tolbert (15:18):
Yeah, just where it's at.
You don't even have to do thefull flap really.
Dr. Ness (15:22):
You were able to load your implant.
It's very simple.
I talk about this.
It's just actually in the Waysof the Arches.
We talk about something calledthe Empire State Concept and the
Empire State Concept man isjust an under-drill sequence.
You know, we go to desiredlength with 2.0 or with your
(15:44):
initial drill, which usually thetip is around the same diameter
tip of your implant 2.2,something like that.
Any fenestration that you make,you just want to make sure the
channel is open.
The moment you overextend thatosteotomy or you overdrill it
with like 3.5 or 3, the body ofyour implant will have to go in
(16:06):
more.
Dr. Tolbert (16:06):
Yeah, you would have to overextend to get
anything out of it.
Dr. Ness (16:09):
Yeah, and that's where that complication will happen.
And then you have a coat hangercoming out of that, out of that
osteotomy.
I think you're off again, man.
Dr. Tolbert (16:17):
Just keep going, I'll get a resort.
Dr. Ness (16:19):
So, anyways, very simple technique.
It's an underprepping technique.
You want to make sure that whatyou always fenestrate, you, you
don't want to make your implanttry to fenestrate, because if
the implant reaches thatcortical it will spin, it'll
become a spinner without youhaving created a little axis for
it.
So you do fenestrate, at leastwith your initial drills, and I
(16:40):
think I have videos on that onmy instagram.
Initial drill fenestrates andthat's it.
The next drill, which usuallyis a 3.5 for me, doesn't even
get close to it.
It goes probably mid, midosteotomy, uh of of the full
implant length that I want toplace in the area.
(17:00):
So just kind of creating thechannel.
And why do we say that?
Because we believe that themagic is in the tip, so kind of
like remote anchorage.
It's all tip related, you know.
So yeah, that's basically thatwith that technique.
It's a technique where youfenestrate.
Why do we fenestrate buckley,you know, kind of towards the
(17:24):
end point because bone is densethere.
Also, I like to see, you know,a lot of the times when we
fenestrate into the nasal floor.
You know you fenestrated, youcan feel if you lift the nasal
mucosa but you really don't seewhere you're at.
You know, sometimes you don'tsee.
So it's become a simplicitything for me to just be like,
(17:47):
even if I, as soon as I knowthat the area doesn't have very
dense bone, just a conventionalall within body implant, all
within bone implant and I'lljust fenestrate?
yeah, I'll just fenestratebuckley towards the end point.
Okay, golden triangle, that'ssomebody something to say.
Yeah, I'll fenestrateimmediately.
(18:09):
I know my implant's going toget good torque.
If that wasn't an option, ifthat doesn't work, I'll redirect
my implant, probably going tothe nasal floor.
There's a good cortical theretoo cortical bone.
I'll engage it.
I'll lift my the nasal mucosaand I'll engage the implant.
Now, tip for that is make sureyou always lift nasal mucosa,
because some people just like todrill and fenestrate.
(18:30):
You don't know where you're at.
You know, and you could be veryposterior or very anterior.
Usually, as a tip patients, ifyou poke your nose and they're
like, will they feel it?
It would be in the rim, like inthe piriform rim.
So you want to make sure you'reat least two millimeters into
the nasal floor.
Does that make sense?
Yeah, it does, and stuff that Ican share if you want to put an
(18:53):
image here for that Sure, sure,sure.
Very simple, very easy, and itsaves you 80% of needing remote
anchorage techniques.
Dr. Tolbert (19:05):
I see so two questions.
One anchorage techniques.
I see so um.
So two questions.
One um, how would you like,what do you use for the
implantoplasty, if it, let's say, you've overextended a little
bit?
Um, what kind of burl, whatwould you be your protocol, and
when?
Dr. Ness (19:21):
do you?
Know, that it's adequatelypolished.
I usually use and I've had touse, I've done this technique a
lot, probably like 4 or 5 timesthe same alveoplasty burr.
I have a big lab burr.
You know that'll cut it up easy.
I don't like to do it because Ifeel like if the implant
(19:42):
already had doubtful torque, Ifeel like I mess with that.
Dr. Tolbert (19:48):
You're shaking it.
I make with that so you'reshaking.
Dr. Ness (19:49):
I make sure that my technique is on point.
You have to.
I saw somebody and I don't wantto criticize some recently post
I'm not gonna say the name, Idon't think he's he's that
popular yet he should be.
He's really good.
But he posted fenestrating intothe nose like quite a bit on
purpose, and then doing thealveoplasty, like what for?
(20:10):
You know, yeah, start off witha small 8mm implant.
If you were just going to cutit to 8mm anyway, you know, and
fenestrate slightly, that's itRight.
The less we do, the better.
Yeah, or I don't know, if Ibecame lazy, I, I really don't
want to do that unless it'snecessary.
Yeah, I'm gonna post thefollow-up of that, that case
(20:33):
coming up, cool, um, I just kindof have like different and I'll
show you how the mucosa looks.
There's no fenestration.
Patients are happy.
I don't have complaints fromirritability in the zone.
Why?
Because I stayed within amillimeter.
Dr. Tolbert (20:48):
All you want to do is engage, yeah, yeah.
Dr. Ness (20:52):
If you're engaged and you did it correctly, that's
where the torque is.
Dr. Tolbert (20:55):
Right, right, right , because that's the part of the
implant that's ballooning outand it's that sort of
compression that's really givingyou that torque from the
cortical plate.
So my second question then isand you talked a little bit
about your options there, rightEither going directly into or
staying endosius in that sort ofgolden triangle, versus going
into the nasal floor, versusdoing this apical fenestration
(21:19):
technique, what's like yourgo-to?
Which one are you trying to dofirst and foremost?
And then, if you suspect you'renot going to get torque, are
you then opting for the apicalfenestration or the nasal cavity
?
What, what's your decision treethere?
Dr. Ness (21:32):
yeah, I, I think it's, it's kind of become uh,
obviously I try immediately todo be have the implant
completely within bone, you know, and yeah, that's the safest
thing it's like a probe.
You know, as you're drilling, itfeels like a probe.
Okay, I'm within bone that's 60millimeters, which is my go-to.
Yeah, great, then I'll take,I'll follow my drill sequence
(21:55):
and blah, blah, blah.
I don't like the torque becauseI drilled with my initial drill
, which is the probe, and I'mlike I think it could be better.
Immediately I go intofenestration apical fenestration
.
At that point, okay, I justhave had really good results.
Dr. Tolbert (22:11):
It's easy.
Dr. Ness (22:11):
I don't have to like put a instrument into the nasal
mucosa Not that that's hard atall, you know, but it's just
it's already there.
All I'll do is like I'll stayin position.
It's just the tip angling yeah,and I'll hit it.
I'll feel resistance and all ofa sudden, punch yeah, yeah.
Yeah, clean it up, clean thedebris, drill the next drill and
(22:35):
usually man, 90% of the timeeven more like I'll get really
good torque there.
Sometimes you don't even haveto fenestrate as you're engaging
that Every time you're proximalto a cortical it's like if you
had a cushion against the wallyeah you know the bone, just as
you start getting closer, thebone condenses there to go, so
(22:57):
it like densifies there yeahyeah you don't even have to
fenestrate you're.
Dr. Tolbert (23:01):
You have your path carved out to the fenestration,
but your implant's getting closeyou don't even get there yeah,
go anywhere, so you have to yeah, cool very cool, that's a way
to view yeah, I think you knowI've done it at least one or two
times and I think the timeswhen I did it, it wasn't.
It wasn't because I knew thatit was a good technique, it was
(23:22):
because I um, it's more of ananatomical thing.
At least in the ones that I'vedone it and moving forward, I
think I'll actually consider itas more of an anatomical thing.
At least in the ones that I'vedone it and moving forward, I
think I'll actually consider itas more of like a technical
thing.
That's just a smart thing to do.
But in my cases it was, youknow, let's say, and I'm going
to have to show you something,and of course, my anyway, the
times where I've done it, it'susually going to be something
like, let's say, I'm doing anupper single arch and the
(23:43):
patient has a proclined maxillaand so I'm trying to come from
that distal position and as I'mtrying to angle myself for the
nose, it's just that undercut.
I can't do it in such a waywithout adopting a really
extreme angle.
As I try and get that tip Iguess the word is palatal enough
to purchase the nose and itends up coming out the buccal
(24:03):
plate, and so I was like, well,you know what, screw it.
I'm going to do it because Iknow I'm going to get torque and
it's not going to.
I'm just not going tooverextend it, and it works, um.
So I definitely think it's a,it's a useful thing for
anatomical considerations aswell, not just to get torque in
any situation, but you know, itmight be the better situation
because prosthetically that endsup being better, because I
don't have to angle so severely,buckly and then count on my
(24:27):
multi-unit to try and bring thatback in, you know, to my
occlusal table where my, wheremy access is going to be, and
then, furthermore, have to relyon an angle correcting screw to
get it.
You know where it needs to be.
Dr. Ness (24:37):
so, um, exactly, and I would add to that man beware,
you know.
Let's say this is, this is yourbone.
You want to make sure, on thattechnique, that you're actually
engaging or starting yourosteotomy a bit more, in that
case palatally.
It's got to be palatal.
Yeah, it's got to be palatal, solike, if this is your bone,
this is palate.
You want to make sure you'restarting on this area and not
(24:58):
here, or else, because I've seenpeople try to do that, trying
to do the technique, and theyfenestrate but the bone is so
thick that, uh, so thin rightthere, they'll have a.
They'll have a buckle fracture.
You know, yeah, yeah, yeah,technique sensitive for sure.
You know, it just made sense towhoever's been doing it for a
while, but that's one of thethings like, hey, I tried it,
but look what happened.
You know, it's a big chunk ofbone just fractured.
(25:19):
I'm like, ah, you need to starta bit more palatal yeah, yeah.
Dr. Tolbert (25:23):
so it's not like you're going in the exact same
osteotomy.
You're really going to have tocome more palatal, so you kind
of transsecting that, thatalveolar process, instead of
just like riding along thebuckle plate.
Dr. Ness (25:34):
Yeah, and it gets corrected with a multi-unit
super easily.
Man, it's not a lot, it's notlike a psycho.
That was super easily placed.
Dr. Tolbert (25:41):
Yeah, like the intrasinus zygos that come out
of the roof of them exactlyright, right, okay, you know,
but no, no, of course.
Dr. Ness (25:48):
Of course that usually works out.
You can do it also.
Then mandible I don't know ifyou've done it, oh sure, yeah,
in the mandible you canfenestrate buccally too.
That's a very, very, very, uhthick cortical.
Dr. Tolbert (26:00):
So yeah, absolutely .
I.
I recently um I've done it.
I think I've I early in myjourney, I'm sure.
Dr. Ness (26:07):
I saw you post a mandible with that too.
I think so right, yeah well onthe other side.
Dr. Tolbert (26:11):
I did a lingual, I did like a translingual.
Dr. Ness (26:15):
Yeah, man, I've never done that, I got to see how that
turns out.
Man, me too I wonder if apatient's tongue you know could,
could Right, right, we'll see,but that could could right.
Right, we'll see.
Um, but that's a really coolcase.
Dr. Tolbert (26:32):
Just that was anatomy driven too, right,
totally.
Yeah, I mean that it was.
She just had that very likesort of sigmoid, like hourglass
mandible and, um, if I got anymore interior there'd been
almost zero spread.
There really wasn't even spreadto speak of anyway, um, but uh,
but yeah, I, I try to keep it,uh, totally in dossiers, but, um
, it just ended up, you know, uh, cutting through and I mean I
(26:53):
knew I was probably going tohave to do this in the first
place.
I tried, not on the other sideI managed to stay entirely in
bone, but in this one it justwasn't there for me.
Um, so I kind of I had to perfthrough, uh, that lingual plate,
go through it and thenre-engage that inferior portion.
So it's, you know,multi-corticalization Torked out
, great, but the key was tryingto stay as flush to the bone as
(27:14):
I could, because if I got thosethreads hanging out there and
they start playing with it withtheir tongue, it's not going to
be a good story.
She hasn't said anything aboutit, we'll see.
It's still very early, but yeah, we'll see the long term.
On that one, I don't want it tobe something where I just, you
know, post it and be like, yeah,this, this will work long term.
But if it weren't, if itweren't that it was gonna be a
snap.
And I and I and I had a backupplan.
I had a two implant overdentureready to to load if, if, if it
(27:36):
ended up going that way, butfortunately we didn't need it on
the day.
But, um, but yeah, no, Idefinitely have done that on the
lower before, but I think thatwas like early on in the journey
and probably because I wasn'tflapping adequately and probably
a mistake, and that's.
Dr. Ness (27:50):
it's funny that you say that, but I think we've all
all together, worldwide, havemade enough mistakes that have
broken the rules.
We've found out that rules canbe broken.
Sometimes they're like okayyeah we can do this.
This technique makes this work.
Dr. Tolbert (28:07):
I'm convinced that's where root banking came
from, like we just couldn't getthe damn thing out of there.
They're like no, no, no, itpreserved bone, it's fine.
Dr. Ness (28:15):
Just leave it, man.
Just a coronectomy.
Dr. Tolbert (28:17):
That's what we do, it's just a coronectomy is all
it is.
We just got to call it a nameand it's not a mistake anymore.
Um, but, uh, I lost my camerafeed again, so I'm just going to
start the next question.
But, um, so, uh, I do want totalk.
So we already talked ways ofarches test for surgical.
Okay, here's a good question.
So what would you say?
We talked about pterygoids.
We talked about the apicalfenestration.
Um, what would you say in yourpractice and you've posted a lot
(28:39):
of powder approach all thesecrazy things.
Approach all these crazy things.
If you had to say, like onetechnique that's really
transformed your full archpractice more than anything.
Dr. Ness (28:53):
What would that have been?
Wow, um, there's so many men.
I feel like there's so manylittle tips and tricks, you know
like, I feel like drillingprotocol, what I call the empire
state.
Um, that, that changed mypractice, because my torque went
from being happy with getting25 to 30 to being at 60 or 70.
Nowadays, comfortably, all myimplants will normally be 60, 70
(29:19):
.
Pterigoids obviously I thinkthey're not trendy, um,
pterygoids, obviously like Ithink they're not trendy.
I think they just changed ouridea of what CTV is for the arch
community, which, at the end ofthe day, just makes us all
sleep better tonight.
You know, when people ask me,hey, who gets pterygoids?
(29:39):
I, to this day say everybodygets pterygoids.
Why?
Because I like to sleep atnight.
To this day say everybody getsterror goods.
Why?
Because I like to sleep atnight.
You know, yeah, to know that mytorque value addition it's way
past 120.
And then if the patient wantsto go and cheat a little bit and
need something that they'redoing it.
They're a bit safer, you know so, obviously, pterygoids are
(30:00):
great.
Palatal approaches is isamazing.
Yeah, there's a lot ofdiscussion, you know, like, who
created it?
Who invented it?
Um, which why I'm consideringchanging it to palatal exposure
technique instead of totalapproach, just to just to hammer
into the drama of like, oh no,I did it first.
Dr. Tolbert (30:21):
No, I did it first.
No, there's nuances, it'sdifferent, I swear there's
nuances, it's different, I swear.
Dr. Ness (30:25):
Yeah, so like what I'm doing a lot is when I do
palatal fenestration or palatalexposure technique, what I do is
I fenestrate to the end pointto like add my little thing.
Dr. Tolbert (30:39):
Oh that is different, that is very
different.
Yeah, so that's reallyinteresting.
Yeah, that is different, thatis very different.
Yeah, so that's that's reallyinteresting.
Yeah, so I mean, typically whenI've, when I've taught folks
palatal approach, I'm alwayssaying, like very rarely is that
a fully endoskeletal implant,like it's going to have to
purchase something like it needsto be the nasal cortex, but
I've never, I've never done thatwith an apical fenestration.
(31:01):
That's really smart.
Yeah, that, that is that isdifferent, that's novel Apical
fenestration.
Dr. Ness (31:04):
That's really smart.
Yeah, that is different, that'snovel.
Most of mine will have thatapical fenestration and it ends
up sometimes anatomically drivento have to be into the nasal
floor, yeah, or just anywherefenestrating, anywhere in the
piriform rim, I don't know.
Dr. Tolbert (31:19):
Right.
Dr. Ness (31:20):
Right.
That apical fenestration at anend point has been a game
changer for me.
Dr. Tolbert (31:25):
Yeah.
Dr. Ness (31:26):
I feel like that one's To add to the list of things
that have changed the game forme.
You know, yeah, yeah.
Dr. Tolbert (31:30):
I feel like that one's kind of tricky too,
because with palatal approachyou're already having to correct
for the palatal bias that theimplant already has.
You know, part of the trick ofit is actually buccalizing the
implant against the ridge to tryand get it to a better
restorable position.
Because when I first starteddoing it I'd be like, oh cool, I
got torque and everything.
But then I look at myprosthetic and I'm like totally
(31:51):
palatable to the tooth and I'vemade too thick of a of a
prosthetic.
So with that, in order to getyou know, you, as we discussed,
in order to do that apicalfenestration technique, you need
to kind of already be morepalatable.
So maybe it's more appropriatefor that, but at the same time,
like you can't, you can't cheateven more palatable, because
then you're going to have a bitof a emergence issue, right.
So that's tricky, that's tricky.
You've definitely got to havethe end in mind to nail that.
Dr. Ness (32:14):
You have to have the experience to know.
You know also where you wantyour MUA to be totally
aesthetically driven and notoverdo it.
But those are two good options.
You know you either go, yeah,you either don't fenestrate, or
you go to the endpoint.
Dr. Tolbert (32:30):
Uh, but yeah, fenestration, apical
fenestration but you definitelyyou surprised me with that
answer, though, because I feellike almost everybody is gonna
you know, uh, they're gonnapoint out, um, you know.
They're gonna say, um, you knowa technique.
They're gonna say pterygoid,pal approach, everything you
just said, the empire statething, right, just creating that
taper with the osteotomy andlearning how to create torque
(32:51):
out of just a course traditionalplacement, and, uh, that's
something that I've actually.
Yeah, totally, it's haptic,right, like you have to be able
to, um, read with your hands andum, I found too, in my cases
where I always opted for muchlonger implants and always try
to get cortical stability andthings, if I don't need it, I
probably shouldn't do it like,uh, you know, just for the sake
(33:13):
of the conservancy and likebeing able to retreat this art,
this arch, if I, you know, Iusually place like a 40, yeah,
like I usually place like a 4016, try and put it to the nose,
but like, if I really don't needit, a lot of times I will opt
for like a 4.013, get the torquewith just the bone that I have
available, and then, if thatfails, I know I can go right
back in that same spot.
Now I can get the nose of the4.016 and boom, it's a two for
(33:35):
one deal.
Like I got two options out ofone osteotomy, so you Just
knowing how to really massagethe bone and get it to where
it's going to give you torque onits own, without the need for
cortical anchorage.
Like that's a skill and that'sone that only comes with time.
Dr. Ness (33:58):
I've always said and I stand true to this is stability
is about drilling.
You know, that's wherestability is about drilling.
Yeah, absolutely.
And what you said, like the the, I call it the probe, you know.
But the initial drill is isthat probe to see like, ah, this
bone feels good, this bonedoesn't feel good?
This is where the surgery isgoing to go, you know, yeah.
Dr. Tolbert (34:15):
Yeah, absolutely, and just having that, you know,
repeatable, like going rightback through the same osteotomy
and not, you know, I think, uh,uh, like a more amateur
clinician, like they will adjustinside the osteotomy or they
won't go back in the exactly thesame path and end up widening
it.
And then they get surprisedwhen they don't have torque and
that's because you, you know,even with the smaller drill, you
created a bigger hole, right?
(34:37):
So if you don't have thatsetting, this repeatability, you
won't get that.
You know.
Repeated torque, um, yeah,that's a good point there.
So, yeah, we're starting to gettowards the end of our
interview here.
I know we both are seeingpatients and things.
So one of my big questions thatI always like to ask my guests
is what is your mostcontroversial opinion in full
(34:58):
arch about trends, things goingon, things that you're seeing?
Um, what's something that youfeel is like kind of
counterculture?
Dr. Ness (35:07):
I am very pro evolution.
Um, so I will say this.
I will say not everything thatshines is gold, but the only way
to find anything shiny is bydigging yeah, does that make
sense?
Dr. Tolbert (35:27):
Yeah, it does yeah.
Dr. Ness (35:29):
So I will be the first one to tell you try it.
You know, like, try it.
I am not a close-minded personto I don't know if you recently
saw somebody I'm not.
I'm totally hope you don don'tpost this or you are going to
post this.
Somebody comment on my, on mypalatal fenestration technique,
(35:52):
somebody very famous.
I don't know if you got some ofthat hype going on.
Sure, and it was a somebody Irespect and somebody I you know.
I don't know them personally,but I respect them.
Somebody I respect and somebodyI you know.
I don't know them personallybut I respect them, and I think
they did a lot of good to ourprofession, but they stayed as
(36:12):
if the peak that they reachedwas the peak of the world.
Dr. Tolbert (36:16):
Does that make sense, yeah, yeah, I understand.
Dr. Ness (36:21):
And I think we are a science in evolution.
I think we are learning things.
I think we are learning things.
I think we are discoveringthings.
I think we are realizing thingsthat we thought didn't work can
work with the proper techniquesor the proper science to back
it up Implant designs, drillingtechniques.
So I'll repeat what I said.
I said not everything thatshines is gold, but the only way
(36:43):
to find anything shiny is bydigging just keep digging,
that's good.
Dr. Tolbert (36:47):
Keep, yeah, that's good.
No, I, I think that's a greatmentality and that's really
what's pushed our field forward.
I mean, if we always, um, didthings the way they've been done
, we wouldn't be having thisconversation, because this whole
modality wouldn't exist.
Um, so, yeah, that's a goodpoint, that's a very good point.
I I really look up to the folksthat have been in our field for
a long time, to the you know,michael Picos of the world that
(37:08):
are just students forever andare always humble and willing to
help out folks, and I feel likeit's those types of mentalities
that really push us forward andgrow our profession.
So, no, that's solid, that'sreally solid.
Um.
So I'm curious to you know whatis next for you?
You know, professionally, interms of not just your clinic
but also just the impact thatyou wish to have in the full
(37:29):
arts world with your courses,with you know, being on the
lecture circuit and things likethat.
Um, you know what, what?
What are you looking forward to?
Dr. Ness (37:36):
Yeah, so, um, there's definitely things coming up that
I can't say yet.
But there's partnerships comingup with with people that you
guys already know, sure yet.
But there's, oh, nice shipscoming up with with people that
you guys already know, sure, um,and we're we're thinking like
pretty big actually, we'rethinking about pretty cool
things coming up that we canhopefully help contribute or at
least unite into the full archworld.
(37:58):
Um, definitely througheducation through, through um,
not only, but merging educationwith um, with breakthroughs in
our world through technology,yeah, um, continuing that.
Obviously I love teaching men,I love talking, uh, I love
(38:19):
people.
So being out there and doing acourse, doing a conference, is
always, uh, brings satisfactionto me.
You know, being able to havesomebody, um, somebody said it,
it sounds dirty, but pop theirterroquid cherry.
You know what I'm saying.
Dr. Tolbert (38:37):
Of course yeah.
Dr. Ness (38:38):
So, like I love, I love being somebody that's like
come here, man, I will guide youthrough this and I'll make sure
you do it right.
Somebody that's like come here,man, I will guide you through
this and I'll make sure you doit right.
And when it's done, man, youknow, it's like it's like
planting a tree, yeah, andhaving somebody else water it
and having somebody else takecare of that, and, like you are,
the fruit of that tree is goingto feed people, yeah, and you
(39:00):
were part of it.
And it's kind of like I, I'mkind of spiritual, you know, so
I believe in the spirituality oflike, just through something,
through a wave that you sent outor that you wholeheartedly like
, this is good, man, this is howyou do it, this is teaching.
You know, that's what teachersare Like.
Teachers just have ripples thatthey'll never even know, but
(39:21):
somebody's getting blessedsomewhere because of something
you did, you know.
And I find you know, and I findI found you know fulfillment in
that, yeah, no, I totally otherthan that you can delete this,
but fuck full arch, you know.
And like I just care about myfamily, my kids I'd like, I like
this actually if I die tomorrow, ain't nobody gonna post a
(39:45):
picture of Dr Nestor, you know?
Yeah, my kids, my family, mywife, that's the most important
thing in life for me.
And I could lose both handstomorrow and still be a happy
man if I have them, you know.
Dr. Tolbert (39:57):
Man, that's awesome .
You know something about fullarches.
There's not really an end pointwith it.
You know it's not like if youjust keep chasing it and keep
always doing the newesttechnique or trying something
new, that one day you're justgoing to get happy off a full
arch.
It just doesn't work like thatand you know you're only going
to find contentedness, you know,with the people that are in
(40:18):
your immediate life and makingsure you're paying attention to
them and you're keeping allthose things in check.
And really that's the secret ofdoing this long-term anyway, is
just making sure that thingsare at home or in in the heart
or in check.
And um, yeah, that's probablyone of the most valuable lessons
has been on the show in a longtime.
So I really appreciate youbringing that forward.
Thank you, man.
Dr. Ness (40:32):
Thank you, I appreciate that.
Dr. Tolbert (40:45):
It's been, it's been awesome.
I been wanting to do this for awhile and it's I know, so I
know we get little good clipsout of all this man, but thanks,
yeah, yeah, for sure.
Inviting me, tyler?
Yeah, yeah, absolutely, and Ithink in my next episode I'll
bring the cowboy hat that Irecently acquired as well, just
uh, just to honor you do it, man, I would love that awesome man.
Well, I really appreciate yourtime.
Thanks so much for coming onand dealing with my technical
difficulties.
Um, everybody, this is nestermarquez.
Look him up on instagram, drness.
He's got amazing cases and he'sgot a lot of things to teach
and share.
Definitely, look up Ways of theArches.
(41:05):
It looks like an amazing coursethat teaches a lot more than
just arches.
So, thanks so much, and untilnext time, my man, until next
time, man Appreciate you.
My name is Dr Tyler Tolbert and I'm Dr Soren Papi,
and you're listening to the FixPodcast, your source for all
things implant dentistry.
Yeah, so yeah, ways of theArtist.
I learned that from let meadjust my camera just a little
bit here.
I learned that from my best.
Buddy is Mexican, so weexchange a lot of Mexican jokes,
(00:24):
or at least he exchanges themwith me.
So I picked up some casualSpanish, but I won't insult you
with my very cursory Spanishknowledge.
Dr. Ness (00:36):
I don't think you could fight back on the ones I
know.
Dr. Tolbert (00:39):
Yeah, that's right, Exactly right.
But yeah, so let's talk aboutthe course.
What does it offer?
Who's it right for?
What makes it different?
I mean?
Dr. Ness (00:47):
I think it's very wide spectrum.
The Ways of the Arts is verywide spectrum, but it's a very,
I would say, psychologicalapproach to the arches.
Okay, because I definitely talka lot about in the beginning at
least, about the reason we doarches about.
(01:11):
I have a secret hashtag calledWays of the Heart, because I've
been through.
I've been through hell and backagain in my personal life with
what I love to attribute to thearches being a factor.
You know the way I startedarches, the way I started to
(01:32):
have complications, I startedgrowing my business around
arches and I forgot that.
I forgot about, I guess, thekey ingredient in life, which is
love, family, your close circle, you, you know, like I'm sure
if I die tomorrow, this podcastmight be around for many years,
you know, but nobody's going toprint a picture of Dr Nestor and
(01:54):
put it on their walls, yeah,right.
My son, might you know Like, oh,that was my dad.
I'm going to keep a picture ofhim in my wallet.
That'd be cool, yeah, yeah, butthat's it, man.
Like, we are here not for thefame of it, you know, not for
the, but I searched that man, I,in the beginning years of my
career, I was like I want to bethe best, I want to everybody to
(02:16):
be to know me for this, youknow, and I followed the wrong
way, the wrong path, you know so.
Waste Path, you know so.
Waste of the arches is kind ofall-encompassing.
It not only encompasses the waywe should think regarding life,
love Protocols, yeah, surgicaltechniques, you know, we discuss
(02:39):
both analog and digital and weshow you how to do it
analogically, which is startingto become an old book, a dusted
old book.
It's a dying art, yeah yeah,yeah and.
But we also teach, uh, digital,you know, like the protocols of
how to, you know, do immediateload in a digital way, blah,
blah, blah.
Uh, I don't like guided surgery, so we stick kind of away from
(03:02):
it.
You know, it's got, it's gotits place, but that's not
something you learn at ways ofthe arches, like how to do
stackable guides and stuff likethat.
Yeah, there's not enough time,but, um, yeah, so ways of the
arches is, is that we?
It's an a to through, z course,but when you when I say a, I
mean like starting point, andstarting point is not or should
(03:22):
not be models and photographyand CT scan, starting point
should be you, how are you doing?
Make sure that what you tellyour patient and you communicate
through your patient securesthat you will remain doing good.
You will remain doing good.
(03:43):
When you've got that covered,like, okay, I'm going to have a
workflow and I'm going to offersomething to my patient that is
so good that I know I will sleepokay at night, that I know that
I'm charging something that isworth much more than what I'm
delivering.
Right, you know what I'm saying?
Yeah, no, I do what you'redelivering is worth more than
(04:04):
what I'm delivering.
Right, you know what I'm saying.
Yeah, no, I do.
What you're delivering is worthmore than what you're charging.
Yes, so you can be content withthat.
Be like I'm happy about that,man, like I am happy about how
we did things, and it'll shineback to your life, you know,
because if you don't, if youstart getting in trouble because
you're like, ah, this is my,I'm going to do pterygoids,
although I've been doing threearches, you know.
(04:25):
But I'm here, here's my firstpsycho.
I'm going to do a psycho toprove to your friends that
around you maybe, that you canalready do psychos Like who
cares, man?
Yeah, who cares Anyway?
Uh, so ways of the archesstarts there, you know.
Then it starts everything we doprotocol wise for for our
patients, you know, withstarting at the prosthetic,
(04:48):
prosthetic necessities,prosthetic alignment with
surgery.
Then we go through surgery,surgical techniques.
I give kind of the basic uh,you know propositions for
distribution of implants.
And then juan gonzalez alsojoins us.
So he brings patsy and hebrings his technique on
pterygoids.
(05:08):
I bring my technique onpterygoids.
Although it started with juan's, I've modified it and made it
my own which is okay, youeverybody ends up doing in
surgery.
You modify your technique, yeah,and then juan covers cycles a
little bit and then we end upthe course with.
I'm just talking about theoryhere.
I'm going to tell you aboutsomething else.
And we end up the course withphase two and delivering final
(05:32):
prosthetics.
Now, something cool about Waysof the Arches man unlike so many
courses I've been to is we showabout three, four, sometimes
five live surgeries.
You know Most courses you go to.
It's like you watch one livesurgery.
It's over, voila.
Here I'm doing a surgery in oneunit, juan's doing a surgery in
(05:57):
the other unit Interns arerotating.
Oh cool, you get 10 minutes inone surgery, 10 minutes in the
other.
Yeah, usually I let them likehey, has anybody placed a
pterygoid before?
No, you want to?
Yeah, come on, they'll sit downwith me and we'll start placing
.
Uh, has anybody, you know,exposed nasal crest and like
exposed into the nose?
No, come here, I'm gonna letyou do it if the patient is, is
(06:18):
okay with it and usuallyeverybody is, so everybody gets
a little bit of hands-on inactual surgery because we have
so many surgeries.
Alright, we're going to do alower, which we rarely do, a
lower.
Who wants to have a go at it?
You know, open up.
Oh, that's not how I would doit.
I would show you this trick.
Oh, wow, cool, I'd never donethat.
Well, now you know, you knowlittle tips and tricks.
Yeah, and by looking at morethan one surgery, it Like this.
(06:40):
We're doing surgery all thetime.
We do model work too, man, it'slike it's four days it's a
little bit of everything, yeah.
It's a four-day internship, soit's a lot In the evenings, man,
that's where it's wild.
Because it's, I like toconsider Arizona and this part
of Mexico like the Wild West.
Dr. Tolbert (06:57):
It is yeah.
Dr. Ness (06:59):
And the people that live in it too, you know.
So we hit up the desert morethan one time and, uh, we go
off-roading into the sand dunesthat's one of them, you know.
Um, then we go and take a lotof guns and beer and nothing
more, nothing more illegal.
But we take it out to thedesert and we literally blow up
(07:21):
stuff, like we blow up tannerite.
We get gas cans, we getgasoline, yeah, yeah.
Dr. Tolbert (07:28):
No, you keep going.
It's fine.
It's just the feed, it's fine.
Dr. Ness (07:33):
So we blow stuff up.
Juan Gonzalez brings guns.
I have a lot of guns.
We shoot a lot of things.
Here's the funny thing aboutWays of the Arches man, and this
is a real thing and I need youto know this if you're planning
on coming to the Ways of theArches.
Okay, okay, there's a waiverthat you have to sign that says
this is great.
It literally says if you die,you die and I'm not responsible.
(07:55):
It's so wild man, because, well, in reality, like it sounds
funny, but we actually do have awaiver and it's because we use
guns.
You know, and although thislast course there was two
trained, actual law enforcementpeople teaching us and being
(08:15):
careful and giving us like thepros, like you know, the way you
should handle a gun yeah,trigger discipline and things.
Dr. Tolbert (08:21):
Yeah, even if you were a connoisseur, there could
be an accident.
Dr. Ness (08:23):
you gun yeah trigger discipline and things.
Yeah, even if you're aconnoisseur, there could be an
accident, you know.
Yeah, we try to keep it verysafe, but it's wild.
And in that same night where wedo shooting and exploding
things in the desert, we alsohave a complications lecture in
the desert which has become,like this, just very special
thing.
(08:43):
It's Juan's complicationlecture which we keep adding to
it.
Uh, complication stuff.
But as Juan is speaking in thedesert of Arizona, man, it's in
the US, don't worry, we're notshooting guns in Mexico.
People would shoot back yeahthis complication lecture has
become so special because we'reout there where Juan is speaking
(09:03):
complications in the desert andit's also kind of like
philosophically engaging aboutbeing in the desert, you know
it's a it's a spiritualawakening we're having here it's
almost like a spiritualawakening man.
Yeah, I kid you not, yeah no Ibelieve it.
And we're grilling, we'remaking carne asada out there.
You know like it's almost likea camping trip, you know yeah
(09:26):
there's some alcohol involved,of course, so it's.
It's very.
There's not been a person thatcomes to ways of the archers.
There's not like dude, it'sjust.
Dr. Tolbert (09:35):
I've never done continuing education like that
yeah, it's a different way celike what like that's huge wait,
yeah, I do it, can I come backagain?
Dr. Ness (09:43):
you know, I'm like you can man, you know.
But double dip.
So it's, it's everything, manit's it's yeah you get exposed
to our protocol, which may notbe the protocol that your
current mentor has, and that'sokay, but it could be, or you
could be a badass full archeralready that comes and realizes
that you needed, you know,something that lightened your
(10:04):
heart a weekend, a somethingthat lightened your heart a
weekend, a getaway thatlightened your heart.
Everything's safe.
We don't do anything like crazy.
We're not hitting up stripclubs or anything like that.
People can if they want to, butwe don't.
Keep it very safe.
Dr. Tolbert (10:17):
This is for all the wives watching this podcast.
Dr. Ness (10:19):
Everything is very safe and girls are definitely
definitely invited.
There's been a couple girlsthat sign up to it.
I think our our marketing forways of the arches has kept some
girls away, I think becausethey're like that seems like a
boy's trip.
You know it's masculine, it isit seems masculine, but we're
like it's not.
You know, you like yeah, yeah,please come join us.
Dr. Tolbert (10:41):
So yeah, yeah, yeah , of course.
Yes, it's gender neutral.
It's gender neutral for sure.
That's awesome, that's great.
I mean that sounds like anabsolute blast.
And yeah, I mean I know acouple guys that have been out
there.
Chris Epperson did it not toolong ago.
Skylar Morton as well is a goodfriend of mine and he had yeah,
he's, he's about.
Dr. Ness (11:01):
It was kind of his vibe too.
Man, skyler was like yeah,skyler was like dude, I use it
all in there.
Yeah, he was, yeah, yeah yeah,yeah.
Dr. Tolbert (11:09):
No, they both had really positive reviews about it
and um, they recommended.
Dr. Ness (11:13):
You know we get around to at some point, which I'm
sure I will, um, but uh yeah,you're more than welcome, yeah
of course and then it's guythere, just like any other
course you take, probablythere's there's access to us
after the course too, you knowlike, oh sure, yeah, he's called
me before like hey, he's analum think about this how would
you do this?
I'm like dude, yeah, this, thisand scholar is really efficient
(11:33):
already, so, yeah, he's great.
I'm like, oh, I just move alittle bit this way and he
starts nailing things, so he'sgreat, yeah, yeah he picks it up
quick, awesome, um.
Dr. Tolbert (11:42):
So I do want to kind of get into you, you know,
some nittier, grittier detailsof just like clinical protocols
and things that you post aboutas well, just because we always
try to, you know, have someactionable things for folks
watching the show.
So, something that I hadactually commented on one of
your posts recently about andI'd seen it a few times and I've
actually done it a couple times, but I need to talk to you to
make sure I'm doing it right.
(12:02):
So in one of the posts that youmade it was an upper fixed six
implants and you had, with thedistal, tilted implants, you had
actually perfed the buckleplate intentionally.
So it's very, very little, justthe apex of the implant had
gone through.
So I've actually gotten somequestions about this A, why,
(12:25):
when is it indicated?
What are some issues that cancome about with it?
Do we polish the implant?
All that kind of stuff?
And also, what do you call it?
You know what do we call thesethings?
Dr. Ness (12:34):
Yeah, you know what I mean.
I don't think it's been calledyet, so all I call it is apical
fenestration technique.
Apical fenestration, okay, yeah, so why?
Because the, the tip of theimplant, fenestrates, you know,
epically wherever you're tryingto engage, and it's basically an
anchorage technique.
It's not remote, it's closeproximity.
Yeah, it's anchorage into hardor cortical bone.
Dr. Tolbert (12:57):
It's local anchorage.
Dr. Ness (12:59):
It's local anchorage.
Exactly, it's not remote, it'slocal anchorage.
Yeah, yeah, it's very simple,you know.
Dr. Tolbert (13:04):
Okay.
Dr. Ness (13:05):
I actually let me read a comment that somebody made on
Instagram.
I agree with you, Somebody waslike hey, man, you know, let me
read the comment because Ithought it was good.
I'm not sure what I answered,but Okay.
So this person said hey, Idon't know, doc, like I'm not
sure about it, in some casesthat I have left the implant tip
, like that, I had to reopen anddo implantoplasty because the
(13:29):
patients kept having pain inthat area.
I don't think I think softtissue and sharp edges don't go
well together.
Yeah, sure, in most cases Iwould agree, and my answer to
him is the one I'm going to givehere and it explains the
technique very simply.
We don't want coat hangers.
Anything that overextends pastthe millimeter into the
(13:54):
osteotomy, into the fenestration, can have problems, just like
lifting nasal mucosa to place animplant into the nasal floor.
The way I teach that one isdon't overdo it.
You want to make sure you stayone millimeter to two
millimeters engaging into thatarea.
So if you see the pictures thatI post, you'll never see this.
(14:18):
Right, right, you'll seeprobably that and you'll see it
kind of sideway, so you can, youcan see it more.
If you were to look at it likethat, it would probably be like
that and that's never been anissue and I've been doing it for
many years now we probably haveto write about it.
Um, yeah, with complications,where it has been an issue and
that there's actually literatureabout fenestrations like that
(14:39):
is if it's overextended, kind oflike with cheekbone, with
zygomas.
You know, sure, we, sure we candefinitely have some fistulas,
we, we can have pain in the area.
And if that happened to youbecause your drilling protocol
was off and I'll talk aboutdrilling protocol right now all
you have to do is, as youmentioned, kind of like an
(14:59):
apicoectomy on the tip of theimplant.
You polish that tip of theimplant, voila, it's gone.
It's simple, even if you had tocome back to it three months
later and the patient's like,yeah, something here feels a
little off, oh honey, don'tworry, slide it open, polish it
off, close it.
Dr. Tolbert (15:18):
Yeah, just where it's at.
You don't even have to do thefull flap really.
Dr. Ness (15:22):
You were able to load your implant.
It's very simple.
I talk about this.
It's just actually in the Waysof the Arches.
We talk about something calledthe Empire State Concept and the
Empire State Concept man isjust an under-drill sequence.
You know, we go to desiredlength with 2.0 or with your
(15:44):
initial drill, which usually thetip is around the same diameter
tip of your implant 2.2,something like that.
Any fenestration that you make,you just want to make sure the
channel is open.
The moment you overextend thatosteotomy or you overdrill it
with like 3.5 or 3, the body ofyour implant will have to go in
(16:06):
more.
Dr. Tolbert (16:06):
Yeah, you would have to overextend to get
anything out of it.
Dr. Ness (16:09):
Yeah, and that's where that complication will happen.
And then you have a coat hangercoming out of that, out of that
osteotomy.
I think you're off again, man.
Dr. Tolbert (16:17):
Just keep going, I'll get a resort.
Dr. Ness (16:19):
So, anyways, very simple technique.
It's an underprepping technique.
You want to make sure that whatyou always fenestrate, you, you
don't want to make your implanttry to fenestrate, because if
the implant reaches thatcortical it will spin, it'll
become a spinner without youhaving created a little axis for
it.
So you do fenestrate, at leastwith your initial drills, and I
(16:40):
think I have videos on that onmy instagram.
Initial drill fenestrates andthat's it.
The next drill, which usuallyis a 3.5 for me, doesn't even
get close to it.
It goes probably mid, midosteotomy, uh of of the full
implant length that I want toplace in the area.
(17:00):
So just kind of creating thechannel.
And why do we say that?
Because we believe that themagic is in the tip, so kind of
like remote anchorage.
It's all tip related, you know.
So yeah, that's basically thatwith that technique.
It's a technique where youfenestrate.
Why do we fenestrate buckley,you know, kind of towards the
(17:24):
end point because bone is densethere.
Also, I like to see, you know,a lot of the times when we
fenestrate into the nasal floor.
You know you fenestrated, youcan feel if you lift the nasal
mucosa but you really don't seewhere you're at.
You know, sometimes you don'tsee.
So it's become a simplicitything for me to just be like,
(17:47):
even if I, as soon as I knowthat the area doesn't have very
dense bone, just a conventionalall within body implant, all
within bone implant and I'lljust fenestrate?
yeah, I'll just fenestratebuckley towards the end point.
Okay, golden triangle, that'ssomebody something to say.
Yeah, I'll fenestrateimmediately.
(18:09):
I know my implant's going toget good torque.
If that wasn't an option, ifthat doesn't work, I'll redirect
my implant, probably going tothe nasal floor.
There's a good cortical theretoo cortical bone.
I'll engage it.
I'll lift my the nasal mucosaand I'll engage the implant.
Now, tip for that is make sureyou always lift nasal mucosa,
because some people just like todrill and fenestrate.
(18:30):
You don't know where you're at.
You know, and you could be veryposterior or very anterior.
Usually, as a tip patients, ifyou poke your nose and they're
like, will they feel it?
It would be in the rim, like inthe piriform rim.
So you want to make sure you'reat least two millimeters into
the nasal floor.
Does that make sense?
Yeah, it does, and stuff that Ican share if you want to put an
(18:53):
image here for that Sure, sure,sure.
Very simple, very easy, and itsaves you 80% of needing remote
anchorage techniques.
Dr. Tolbert (19:05):
I see so two questions.
One anchorage techniques.
I see so um.
So two questions.
One um, how would you like,what do you use for the
implantoplasty, if it, let's say, you've overextended a little
bit?
Um, what kind of burl, whatwould you be your protocol, and
when?
Dr. Ness (19:21):
do you?
Know, that it's adequatelypolished.
I usually use and I've had touse, I've done this technique a
lot, probably like 4 or 5 timesthe same alveoplasty burr.
I have a big lab burr.
You know that'll cut it up easy.
I don't like to do it because Ifeel like if the implant
(19:42):
already had doubtful torque, Ifeel like I mess with that.
Dr. Tolbert (19:48):
You're shaking it.
I make with that so you'reshaking.
Dr. Ness (19:49):
I make sure that my technique is on point.
You have to.
I saw somebody and I don't wantto criticize some recently post
I'm not gonna say the name, Idon't think he's he's that
popular yet he should be.
He's really good.
But he posted fenestrating intothe nose like quite a bit on
purpose, and then doing thealveoplasty, like what for?
(20:10):
You know, yeah, start off witha small 8mm implant.
If you were just going to cutit to 8mm anyway, you know, and
fenestrate slightly, that's itRight.
The less we do, the better.
Yeah, or I don't know, if Ibecame lazy, I, I really don't
want to do that unless it'snecessary.
Yeah, I'm gonna post thefollow-up of that, that case
(20:33):
coming up, cool, um, I just kindof have like different and I'll
show you how the mucosa looks.
There's no fenestration.
Patients are happy.
I don't have complaints fromirritability in the zone.
Why?
Because I stayed within amillimeter.
Dr. Tolbert (20:48):
All you want to do is engage, yeah, yeah.
Dr. Ness (20:52):
If you're engaged and you did it correctly, that's
where the torque is.
Dr. Tolbert (20:55):
Right, right, right , because that's the part of the
implant that's ballooning outand it's that sort of
compression that's really givingyou that torque from the
cortical plate.
So my second question then isand you talked a little bit
about your options there, rightEither going directly into or
staying endosius in that sort ofgolden triangle, versus going
into the nasal floor, versusdoing this apical fenestration
(21:19):
technique, what's like yourgo-to?
Which one are you trying to dofirst and foremost?
And then, if you suspect you'renot going to get torque, are
you then opting for the apicalfenestration or the nasal cavity
?
What, what's your decision treethere?
Dr. Ness (21:32):
yeah, I, I think it's, it's kind of become uh,
obviously I try immediately todo be have the implant
completely within bone, you know, and yeah, that's the safest
thing it's like a probe.
You know, as you're drilling, itfeels like a probe.
Okay, I'm within bone that's 60millimeters, which is my go-to.
Yeah, great, then I'll take,I'll follow my drill sequence
(21:55):
and blah, blah, blah.
I don't like the torque becauseI drilled with my initial drill
, which is the probe, and I'mlike I think it could be better.
Immediately I go intofenestration apical fenestration
.
At that point, okay, I justhave had really good results.
Dr. Tolbert (22:11):
It's easy.
Dr. Ness (22:11):
I don't have to like put a instrument into the nasal
mucosa Not that that's hard atall, you know, but it's just
it's already there.
All I'll do is like I'll stayin position.
It's just the tip angling yeah,and I'll hit it.
I'll feel resistance and all ofa sudden, punch yeah, yeah.
Yeah, clean it up, clean thedebris, drill the next drill and
(22:35):
usually man, 90% of the timeeven more like I'll get really
good torque there.
Sometimes you don't even haveto fenestrate as you're engaging
that Every time you're proximalto a cortical it's like if you
had a cushion against the wallyeah you know the bone, just as
you start getting closer, thebone condenses there to go, so
(22:57):
it like densifies there yeahyeah you don't even have to
fenestrate you're.
Dr. Tolbert (23:01):
You have your path carved out to the fenestration,
but your implant's getting closeyou don't even get there yeah,
go anywhere, so you have to yeah, cool very cool, that's a way
to view yeah, I think you knowI've done it at least one or two
times and I think the timeswhen I did it, it wasn't.
It wasn't because I knew thatit was a good technique, it was
(23:22):
because I um, it's more of ananatomical thing.
At least in the ones that I'vedone it and moving forward, I
think I'll actually consider itas more of an anatomical thing.
At least in the ones that I'vedone it and moving forward, I
think I'll actually consider itas more of like a technical
thing.
That's just a smart thing to do.
But in my cases it was, youknow, let's say, and I'm going
to have to show you something,and of course, my anyway, the
times where I've done it, it'susually going to be something
like, let's say, I'm doing anupper single arch and the
(23:43):
patient has a proclined maxillaand so I'm trying to come from
that distal position and as I'mtrying to angle myself for the
nose, it's just that undercut.
I can't do it in such a waywithout adopting a really
extreme angle.
As I try and get that tip Iguess the word is palatal enough
to purchase the nose and itends up coming out the buccal
(24:03):
plate, and so I was like, well,you know what, screw it.
I'm going to do it because Iknow I'm going to get torque and
it's not going to.
I'm just not going tooverextend it, and it works, um.
So I definitely think it's a,it's a useful thing for
anatomical considerations aswell, not just to get torque in
any situation, but you know, itmight be the better situation
because prosthetically that endsup being better, because I
don't have to angle so severely,buckly and then count on my
(24:27):
multi-unit to try and bring thatback in, you know, to my
occlusal table where my, wheremy access is going to be, and
then, furthermore, have to relyon an angle correcting screw to
get it.
You know where it needs to be.
Dr. Ness (24:37):
so, um, exactly, and I would add to that man beware,
you know.
Let's say this is, this is yourbone.
You want to make sure, on thattechnique, that you're actually
engaging or starting yourosteotomy a bit more, in that
case palatally.
It's got to be palatal.
Yeah, it's got to be palatal, solike, if this is your bone,
this is palate.
You want to make sure you'restarting on this area and not
(24:58):
here, or else, because I've seenpeople try to do that, trying
to do the technique, and theyfenestrate but the bone is so
thick that, uh, so thin rightthere, they'll have a.
They'll have a buckle fracture.
You know, yeah, yeah, yeah,technique sensitive for sure.
You know, it just made sense towhoever's been doing it for a
while, but that's one of thethings like, hey, I tried it,
but look what happened.
You know, it's a big chunk ofbone just fractured.
(25:19):
I'm like, ah, you need to starta bit more palatal yeah, yeah.
Dr. Tolbert (25:23):
so it's not like you're going in the exact same
osteotomy.
You're really going to have tocome more palatal, so you kind
of transsecting that, thatalveolar process, instead of
just like riding along thebuckle plate.
Dr. Ness (25:34):
Yeah, and it gets corrected with a multi-unit
super easily.
Man, it's not a lot, it's notlike a psycho.
That was super easily placed.
Dr. Tolbert (25:41):
Yeah, like the intrasinus zygos that come out
of the roof of them exactlyright, right, okay, you know,
but no, no, of course.
Dr. Ness (25:48):
Of course that usually works out.
You can do it also.
Then mandible I don't know ifyou've done it, oh sure, yeah,
in the mandible you canfenestrate buccally too.
That's a very, very, very, uhthick cortical.
Dr. Tolbert (26:00):
So yeah, absolutely .
I.
I recently um I've done it.
I think I've I early in myjourney, I'm sure.
Dr. Ness (26:07):
I saw you post a mandible with that too.
I think so right, yeah well onthe other side.
Dr. Tolbert (26:11):
I did a lingual, I did like a translingual.
Dr. Ness (26:15):
Yeah, man, I've never done that, I got to see how that
turns out.
Man, me too I wonder if apatient's tongue you know could,
could Right, right, we'll see,but that could could right.
Right, we'll see.
Um, but that's a really coolcase.
Dr. Tolbert (26:32):
Just that was anatomy driven too, right,
totally.
Yeah, I mean that it was.
She just had that very likesort of sigmoid, like hourglass
mandible and, um, if I got anymore interior there'd been
almost zero spread.
There really wasn't even spreadto speak of anyway, um, but uh,
but yeah, I, I try to keep it,uh, totally in dossiers, but, um
, it just ended up, you know, uh, cutting through and I mean I
(26:53):
knew I was probably going tohave to do this in the first
place.
I tried, not on the other sideI managed to stay entirely in
bone, but in this one it justwasn't there for me.
Um, so I kind of I had to perfthrough, uh, that lingual plate,
go through it and thenre-engage that inferior portion.
So it's, you know,multi-corticalization Torked out
, great, but the key was tryingto stay as flush to the bone as
(27:14):
I could, because if I got thosethreads hanging out there and
they start playing with it withtheir tongue, it's not going to
be a good story.
She hasn't said anything aboutit, we'll see.
It's still very early, but yeah, we'll see the long term.
On that one, I don't want it tobe something where I just, you
know, post it and be like, yeah,this, this will work long term.
But if it weren't, if itweren't that it was gonna be a
snap.
And I and I and I had a backupplan.
I had a two implant overdentureready to to load if, if, if it
(27:36):
ended up going that way, butfortunately we didn't need it on
the day.
But, um, but yeah, no, Idefinitely have done that on the
lower before, but I think thatwas like early on in the journey
and probably because I wasn'tflapping adequately and probably
a mistake, and that's.
Dr. Ness (27:50):
it's funny that you say that, but I think we've all
all together, worldwide, havemade enough mistakes that have
broken the rules.
We've found out that rules canbe broken.
Sometimes they're like okayyeah we can do this.
This technique makes this work.
Dr. Tolbert (28:07):
I'm convinced that's where root banking came
from, like we just couldn't getthe damn thing out of there.
They're like no, no, no, itpreserved bone, it's fine.
Dr. Ness (28:15):
Just leave it, man.
Just a coronectomy.
Dr. Tolbert (28:17):
That's what we do, it's just a coronectomy is all
it is.
We just got to call it a nameand it's not a mistake anymore.
Um, but, uh, I lost my camerafeed again, so I'm just going to
start the next question.
But, um, so, uh, I do want totalk.
So we already talked ways ofarches test for surgical.
Okay, here's a good question.
So what would you say?
We talked about pterygoids.
We talked about the apicalfenestration.
Um, what would you say in yourpractice and you've posted a lot
(28:39):
of powder approach all thesecrazy things.
Approach all these crazy things.
If you had to say, like onetechnique that's really
transformed your full archpractice more than anything.
Dr. Ness (28:53):
What would that have been?
Wow, um, there's so many men.
I feel like there's so manylittle tips and tricks, you know
like, I feel like drillingprotocol, what I call the empire
state.
Um, that, that changed mypractice, because my torque went
from being happy with getting25 to 30 to being at 60 or 70.
Nowadays, comfortably, all myimplants will normally be 60, 70
(29:19):
.
Pterigoids obviously I thinkthey're not trendy, um,
pterygoids, obviously like Ithink they're not trendy.
I think they just changed ouridea of what CTV is for the arch
community, which, at the end ofthe day, just makes us all
sleep better tonight.
You know, when people ask me,hey, who gets pterygoids?
(29:39):
I, to this day say everybodygets pterygoids.
Why?
Because I like to sleep atnight.
To this day say everybody getsterror goods.
Why?
Because I like to sleep atnight.
You know, yeah, to know that mytorque value addition it's way
past 120.
And then if the patient wantsto go and cheat a little bit and
need something that they'redoing it.
They're a bit safer, you know so, obviously, pterygoids are
(30:00):
great.
Palatal approaches is isamazing.
Yeah, there's a lot ofdiscussion, you know, like, who
created it?
Who invented it?
Um, which why I'm consideringchanging it to palatal exposure
technique instead of totalapproach, just to just to hammer
into the drama of like, oh no,I did it first.
Dr. Tolbert (30:21):
No, I did it first.
No, there's nuances, it'sdifferent, I swear there's
nuances, it's different, I swear.
Dr. Ness (30:25):
Yeah, so like what I'm doing a lot is when I do
palatal fenestration or palatalexposure technique, what I do is
I fenestrate to the end pointto like add my little thing.
Dr. Tolbert (30:39):
Oh that is different, that is very
different.
Yeah, so that's reallyinteresting.
Yeah, that is different, thatis very different.
Yeah, so that's that's reallyinteresting.
Yeah, so I mean, typically whenI've, when I've taught folks
palatal approach, I'm alwayssaying, like very rarely is that
a fully endoskeletal implant,like it's going to have to
purchase something like it needsto be the nasal cortex, but
I've never, I've never done thatwith an apical fenestration.
(31:01):
That's really smart.
Yeah, that, that is that isdifferent, that's novel Apical
fenestration.
Dr. Ness (31:04):
That's really smart.
Yeah, that is different, that'snovel.
Most of mine will have thatapical fenestration and it ends
up sometimes anatomically drivento have to be into the nasal
floor, yeah, or just anywherefenestrating, anywhere in the
piriform rim, I don't know.
Dr. Tolbert (31:19):
Right.
Dr. Ness (31:20):
Right.
That apical fenestration at anend point has been a game
changer for me.
Dr. Tolbert (31:25):
Yeah.
Dr. Ness (31:26):
I feel like that one's To add to the list of things
that have changed the game forme.
You know, yeah, yeah.
Dr. Tolbert (31:30):
I feel like that one's kind of tricky too,
because with palatal approachyou're already having to correct
for the palatal bias that theimplant already has.
You know, part of the trick ofit is actually buccalizing the
implant against the ridge to tryand get it to a better
restorable position.
Because when I first starteddoing it I'd be like, oh cool, I
got torque and everything.
But then I look at myprosthetic and I'm like totally
(31:51):
palatable to the tooth and I'vemade too thick of a of a
prosthetic.
So with that, in order to getyou know, you, as we discussed,
in order to do that apicalfenestration technique, you need
to kind of already be morepalatable.
So maybe it's more appropriatefor that, but at the same time,
like you can't, you can't cheateven more palatable, because
then you're going to have a bitof a emergence issue, right.
So that's tricky, that's tricky.
You've definitely got to havethe end in mind to nail that.
Dr. Ness (32:14):
You have to have the experience to know.
You know also where you wantyour MUA to be totally
aesthetically driven and notoverdo it.
But those are two good options.
You know you either go, yeah,you either don't fenestrate, or
you go to the endpoint.
Dr. Tolbert (32:30):
Uh, but yeah, fenestration, apical
fenestration but you definitelyyou surprised me with that
answer, though, because I feellike almost everybody is gonna
you know, uh, they're gonnapoint out, um, you know.
They're gonna say, um, you knowa technique.
They're gonna say pterygoid,pal approach, everything you
just said, the empire statething, right, just creating that
taper with the osteotomy andlearning how to create torque
(32:51):
out of just a course traditionalplacement, and, uh, that's
something that I've actually.
Yeah, totally, it's haptic,right, like you have to be able
to, um, read with your hands andum, I found too, in my cases
where I always opted for muchlonger implants and always try
to get cortical stability andthings, if I don't need it, I
probably shouldn't do it like,uh, you know, just for the sake
(33:13):
of the conservancy and likebeing able to retreat this art,
this arch, if I, you know, Iusually place like a 40, yeah,
like I usually place like a 4016, try and put it to the nose,
but like, if I really don't needit, a lot of times I will opt
for like a 4.013, get the torquewith just the bone that I have
available, and then, if thatfails, I know I can go right
back in that same spot.
Now I can get the nose of the4.016 and boom, it's a two for
(33:35):
one deal.
Like I got two options out ofone osteotomy, so you Just
knowing how to really massagethe bone and get it to where
it's going to give you torque onits own, without the need for
cortical anchorage.
Like that's a skill and that'sone that only comes with time.
Dr. Ness (33:58):
I've always said and I stand true to this is stability
is about drilling.
You know, that's wherestability is about drilling.
Yeah, absolutely.
And what you said, like the the, I call it the probe, you know.
But the initial drill is isthat probe to see like, ah, this
bone feels good, this bonedoesn't feel good?
This is where the surgery isgoing to go, you know, yeah.
Dr. Tolbert (34:15):
Yeah, absolutely, and just having that, you know,
repeatable, like going rightback through the same osteotomy
and not, you know, I think, uh,uh, like a more amateur
clinician, like they will adjustinside the osteotomy or they
won't go back in the exactly thesame path and end up widening
it.
And then they get surprisedwhen they don't have torque and
that's because you, you know,even with the smaller drill, you
created a bigger hole, right?
(34:37):
So if you don't have thatsetting, this repeatability, you
won't get that.
You know.
Repeated torque, um, yeah,that's a good point there.
So, yeah, we're starting to gettowards the end of our
interview here.
I know we both are seeingpatients and things.
So one of my big questions thatI always like to ask my guests
is what is your mostcontroversial opinion in full
(34:58):
arch about trends, things goingon, things that you're seeing?
Um, what's something that youfeel is like kind of
counterculture?
Dr. Ness (35:07):
I am very pro evolution.
Um, so I will say this.
I will say not everything thatshines is gold, but the only way
to find anything shiny is bydigging yeah, does that make
sense?
Dr. Tolbert (35:27):
Yeah, it does yeah.
Dr. Ness (35:29):
So I will be the first one to tell you try it.
You know, like, try it.
I am not a close-minded personto I don't know if you recently
saw somebody I'm not.
I'm totally hope you don don'tpost this or you are going to
post this.
Somebody comment on my, on mypalatal fenestration technique,
(35:52):
somebody very famous.
I don't know if you got some ofthat hype going on.
Sure, and it was a somebody Irespect and somebody I you know.
I don't know them personally,but I respect them.
Somebody I respect and somebodyI you know.
I don't know them personallybut I respect them, and I think
they did a lot of good to ourprofession, but they stayed as
(36:12):
if the peak that they reachedwas the peak of the world.
Dr. Tolbert (36:16):
Does that make sense, yeah, yeah, I understand.
Dr. Ness (36:21):
And I think we are a science in evolution.
I think we are learning things.
I think we are learning things.
I think we are discoveringthings.
I think we are realizing thingsthat we thought didn't work can
work with the proper techniquesor the proper science to back
it up Implant designs, drillingtechniques.
So I'll repeat what I said.
I said not everything thatshines is gold, but the only way
(36:43):
to find anything shiny is bydigging just keep digging,
that's good.
Dr. Tolbert (36:47):
Keep, yeah, that's good.
No, I, I think that's a greatmentality and that's really
what's pushed our field forward.
I mean, if we always, um, didthings the way they've been done
, we wouldn't be having thisconversation, because this whole
modality wouldn't exist.
Um, so, yeah, that's a goodpoint, that's a very good point.
I I really look up to the folksthat have been in our field for
a long time, to the you know,michael Picos of the world that
(37:08):
are just students forever andare always humble and willing to
help out folks, and I feel likeit's those types of mentalities
that really push us forward andgrow our profession.
So, no, that's solid, that'sreally solid.
Um.
So I'm curious to you know whatis next for you?
You know, professionally, interms of not just your clinic
but also just the impact thatyou wish to have in the full
(37:29):
arts world with your courses,with you know, being on the
lecture circuit and things likethat.
Um, you know what, what?
What are you looking forward to?
Dr. Ness (37:36):
Yeah, so, um, there's definitely things coming up that
I can't say yet.
But there's partnerships comingup with with people that you
guys already know, sure yet.
But there's, oh, nice shipscoming up with with people that
you guys already know, sure, um,and we're we're thinking like
pretty big actually, we'rethinking about pretty cool
things coming up that we canhopefully help contribute or at
least unite into the full archworld.
(37:58):
Um, definitely througheducation through, through um,
not only, but merging educationwith um, with breakthroughs in
our world through technology,yeah, um, continuing that.
Obviously I love teaching men,I love talking, uh, I love
(38:19):
people.
So being out there and doing acourse, doing a conference, is
always, uh, brings satisfactionto me.
You know, being able to havesomebody, um, somebody said it,
it sounds dirty, but pop theirterroquid cherry.
You know what I'm saying.
Dr. Tolbert (38:37):
Of course yeah.
Dr. Ness (38:38):
So, like I love, I love being somebody that's like
come here, man, I will guide youthrough this and I'll make sure
you do it right.
Somebody that's like come here,man, I will guide you through
this and I'll make sure you doit right.
And when it's done, man, youknow, it's like it's like
planting a tree, yeah, andhaving somebody else water it
and having somebody else takecare of that, and, like you are,
the fruit of that tree is goingto feed people, yeah, and you
(39:00):
were part of it.
And it's kind of like I, I'mkind of spiritual, you know, so
I believe in the spirituality oflike, just through something,
through a wave that you sent outor that you wholeheartedly like
, this is good, man, this is howyou do it, this is teaching.
You know, that's what teachersare Like.
Teachers just have ripples thatthey'll never even know, but
(39:21):
somebody's getting blessedsomewhere because of something
you did, you know.
And I find you know, and I findI found you know fulfillment in
that, yeah, no, I totally otherthan that you can delete this,
but fuck full arch, you know.
And like I just care about myfamily, my kids I'd like, I like
this actually if I die tomorrow, ain't nobody gonna post a
(39:45):
picture of Dr Nestor, you know?
Yeah, my kids, my family, mywife, that's the most important
thing in life for me.
And I could lose both handstomorrow and still be a happy
man if I have them, you know.
Dr. Tolbert (39:57):
Man, that's awesome .
You know something about fullarches.
There's not really an end pointwith it.
You know it's not like if youjust keep chasing it and keep
always doing the newesttechnique or trying something
new, that one day you're justgoing to get happy off a full
arch.
It just doesn't work like thatand you know you're only going
to find contentedness, you know,with the people that are in
(40:18):
your immediate life and makingsure you're paying attention to
them and you're keeping allthose things in check.
And really that's the secret ofdoing this long-term anyway, is
just making sure that thingsare at home or in in the heart
or in check.
And um, yeah, that's probablyone of the most valuable lessons
has been on the show in a longtime.
So I really appreciate youbringing that forward.
Thank you, man.
Dr. Ness (40:32):
Thank you, I appreciate that.
Dr. Tolbert (40:45):
It's been, it's been awesome.
I been wanting to do this for awhile and it's I know, so I
know we get little good clipsout of all this man, but thanks,
yeah, yeah, for sure.
Inviting me, tyler?
Yeah, yeah, absolutely, and Ithink in my next episode I'll
bring the cowboy hat that Irecently acquired as well, just
uh, just to honor you do it, man, I would love that awesome man.
Well, I really appreciate yourtime.
Thanks so much for coming onand dealing with my technical
difficulties.
Um, everybody, this is nestermarquez.
Look him up on instagram, drness.
He's got amazing cases and he'sgot a lot of things to teach
and share.
Definitely, look up Ways of theArches.
(41:05):
It looks like an amazing coursethat teaches a lot more than
just arches.
So, thanks so much, and untilnext time, my man, until next
time, man Appreciate you.
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