The Fixed Podcast

Behind the Arch: A Deep Dive with Dr. Nestor Marquez (Dr. Ness): Part 2

• Fixed Podcast

Share episode

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.

Dr. Tolbert:

My name is Dr Tyler Tolbert and I'm Dr Soren Papi, and you're listening to the Fix Podcast, your source for all things implant dentistry. Yeah, so yeah, ways of the Artist. I learned that from let me adjust my camera just a little bit here. I learned that from my best. Buddy is Mexican, so we exchange a lot of Mexican jokes, or at least he exchanges them with me. So I picked up some casual Spanish, but I won't insult you with my very cursory Spanish knowledge.

Dr. Ness:

I don't think you could fight back on the ones I know.

Dr. Tolbert:

Yeah, that's right, Exactly right. But yeah, so let's talk about the course. What does it offer? Who's it right for? What makes it different? I mean?

Dr. Ness:

I think it's very wide spectrum. The Ways of the Arts is very wide spectrum, but it's a very, I would say, psychological approach to the arches. Okay, because I definitely talk a lot about in the beginning at least, about the reason we do arches about. I have a secret hashtag called Ways of the Heart, because I've been through. I've been through hell and back again in my personal life with what I love to attribute to the arches being a factor. You know the way I started arches, the way I started to have complications, I started growing my business around arches and I forgot that. I forgot about, I guess, the key ingredient in life, which is love, family, your close circle, you, you know, like I'm sure if I die tomorrow, this podcast might be around for many years, you know, but nobody's going to print a picture of Dr Nestor and put it on their walls, yeah, right.

Dr. Ness:

My son, might you know Like, oh, that was my dad. I'm going to keep a picture of him in my wallet. That'd be cool, yeah, yeah, but that's it, man. Like, we are here not for the fame 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 be the best, I want to everybody to be to know me for this, you know, and I followed the wrong way, the wrong path, you know so. Waste Path, you know so. Waste of the arches is kind of all-encompassing. It not only encompasses the way we should think regarding life, love Protocols, yeah, surgical techniques, you know, we discuss both analog and digital and we show you how to do it analogically, which is starting to become an old book, a dusted old book. It's a dying art, yeah yeah, yeah and.

Dr. Ness:

But we also teach, uh, digital, you know, like the protocols of how to, you know, do immediate load in a digital way, blah, blah, blah. Uh, I don't like guided surgery, so we stick kind of away from it. You know, it's got, it's got its place, but that's not something you learn at ways of the arches, like how to do stackable guides and stuff like that. 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, and starting point is not or should not be models and photography and CT scan, starting point should be you, how are you doing?

Dr. Ness:

Make sure that what you tell your patient and you communicate through your patient secures that you will remain doing good. You will remain doing good. When you've got that covered, like, okay, I'm going to have a workflow and I'm going to offer something to my patient that is so good that I know I will sleep okay at night, that I know that I'm charging something that is worth much more than what I'm delivering. Right, you know what I'm saying?

Dr. Ness:

Yeah, no, I do what you're delivering is worth more than what I'm delivering. Right, you know what I'm saying. Yeah, no, I do. What you're delivering is worth more than what you're charging. Yes, so you can be content with that.

Dr. Ness:

Be like I'm happy about that, man, like I am happy about how we did things, and it'll shine back to your life, you know, because if you don't, if you start getting in trouble because you're like, ah, this is my, I'm going to do pterygoids, although I've been doing three arches, you know. But I'm here, here's my first psycho. I'm going to do a psycho to prove to your friends that around you maybe, that you can already do psychos Like who cares, man? Yeah, who cares Anyway? Uh, so ways of the arches starts there, you know. Then it starts everything we do protocol wise for for our patients, you know, with starting at the prosthetic, 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 also joins us. So he brings patsy and he brings his technique on pterygoids. I bring my technique on pterygoids. Although it started with juan's, I've modified it and made it my own which is okay, you everybody ends up doing in surgery.

Dr. Ness:

You modify your technique, yeah, and then juan covers cycles a little bit and then we end up the course with. I'm just talking about theory here. I'm going to tell you about something else. And we end up the course with phase two and delivering final prosthetics. Now, something cool about Ways of the Arches man unlike so many courses I've been to is we show about three, four, sometimes five live surgeries. You know Most courses you go to. It's like you watch one live surgery. It's over, voila. Here I'm doing a surgery in one unit, juan's doing a surgery in the other unit Interns are rotating.

Dr. Ness:

Oh cool, you get 10 minutes in one surgery, 10 minutes in the other. Yeah, usually I let them like hey, has anybody placed a pterygoid before? No, you want to? Yeah, come on, they'll sit down with 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 let you do it if the patient is, is okay with it and usually everybody is, so everybody gets a little bit of hands-on in actual surgery because we have so many surgeries.

Dr. Ness:

Alright, we're going to do a lower, 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 do it. I would show you this trick. Oh, wow, cool, I'd never done that. Well, now you know, you know little tips and tricks. Yeah, and by looking at more than one surgery, it Like this. We're doing surgery all the time. We do model work too, man, it's like it's four days it's a little bit of everything, yeah.

Dr. Ness:

It's a four-day internship, so it's a lot In the evenings, man, that's where it's wild. Because it's, I like to consider Arizona and this part of Mexico like the Wild West.

Dr. Tolbert:

It is yeah.

Dr. Ness:

And the people that live in it too, you know. So we hit up the desert more than one time and, uh, we go off-roading into the sand dunes that's one of them, you know. Um, then we go and take a lot of guns and beer and nothing more, nothing more illegal. But we take it out to the desert and we literally blow up stuff, like we blow up tannerite. We get gas cans, we get gasoline, yeah, yeah.

Dr. Tolbert:

No, you keep going. It's fine. It's just the feed, it's fine.

Dr. Ness:

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 about Ways of the Arches man, and this is a real thing and I need you to know this if you're planning on coming to the Ways of the Arches.

Dr. Ness:

Okay, okay, there's a waiver that you have to sign that says this is great. It literally says if you die, you die and I'm not responsible. It's so wild man, because, well, in reality, like it sounds funny, but we actually do have a waiver and it's because we use guns. You know, and although this last course there was two trained, actual law enforcement people teaching us and being careful and giving us like the pros, like you know, the way you should handle a gun yeah, trigger discipline and things.

Dr. Tolbert:

Yeah, even if you were a connoisseur, there could be an accident.

Dr. Ness:

you gun yeah trigger discipline and things. Yeah, even if you're a connoisseur, there could be an accident, you know. Yeah, we try to keep it very safe, but it's wild. And in that same night where we do shooting and exploding things in the desert, we also have a complications lecture in the desert which has become, like this, just very special thing. It's Juan's complication lecture which we keep adding to it. Uh, complication stuff. But as Juan is speaking in the desert of Arizona, man, it's in the US, don't worry, we're not shooting guns in Mexico.

Dr. Ness:

People would shoot back yeah this complication lecture has become so special because we're out there where Juan is speaking complications in the desert and it's also kind of like philosophically engaging about being in the desert, you know it's a it's a spiritual awakening we're having here it's almost like a spiritual awakening man. Yeah, I kid you not, yeah no I believe it. And we're grilling, we're making carne asada out there. You know like it's almost like a camping trip, you know yeah there's some alcohol involved, of course, so it's.

Dr. Ness:

It's very. There's not been a person that comes to ways of the archers. There's not like dude, it's just.

Dr. Tolbert:

I've never done continuing education like that yeah, it's a different way ce like what like that's huge wait, yeah, I do it, can I come back again?

Dr. Ness:

you know, I'm like you can man, you know. But double dip.

Dr. Ness:

So it's, it's everything, man it's it's yeah you get exposed to our protocol, which may not be the protocol that your current mentor has, and that's okay, but it could be, or you could be a badass full archer already that comes and realizes that you needed, you know, something that lightened your heart a weekend, a something that lightened your heart a weekend, a getaway that lightened your heart. Everything's safe. We don't do anything like crazy. We're not hitting up strip clubs or anything like that. People can if they want to, but we don't. Keep it very safe.

Dr. Tolbert:

This is for all the wives watching this podcast.

Dr. Ness:

Everything is very safe and girls are definitely definitely invited. There's been a couple girls that sign up to it. I think our our marketing for ways of the arches has kept some girls away, I think because they're like that seems like a boy's trip. You know it's masculine, it is it seems masculine, but we're like it's not. You know, you like yeah, yeah, please come join us.

Dr. Tolbert:

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 an absolute blast. And yeah, I mean I know a couple guys that have been out there. Chris Epperson did it not too long ago. Skylar Morton as well is a good friend of mine and he had yeah, he's, he's about.

Dr. Ness:

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:

No, they both had really positive reviews about it and um, they recommended.

Dr. Ness:

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 guy there, just like any other course you take, probably there's there's access to us after the course too, you know like, oh sure, yeah, he's called me before like hey, he's an alum think about this how would you do this? I'm like dude, yeah, this, this and scholar is really efficient already, so, yeah, he's great. I'm like, oh, I just move a little bit this way and he starts nailing things, so he's great, yeah, yeah he picks it up quick, awesome, um.

Dr. Tolbert:

So I do want to kind of get into you, you know, some nittier, grittier details of just like clinical protocols and things that you post about as well, just because we always try to, you know, have some actionable things for folks watching the show. So, something that I had actually commented on one of your posts recently about and I'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. So in one of the posts that you made it was an upper fixed six implants and you had, with the distal, tilted implants, you had actually perfed the buckle plate intentionally. So it's very, very little, just the apex of the implant had gone through. So I've actually gotten some questions about this A, why, when is it indicated? What are some issues that can come 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 these things?

Dr. Ness:

Yeah, you know what I mean. I don't think it's been called yet, so all I call it is apical fenestration technique. Apical fenestration, okay, yeah, so why? Because the, the tip of the implant, fenestrates, you know, epically wherever you're trying to engage, and it's basically an anchorage technique. It's not remote, it's close proximity. Yeah, it's anchorage into hard or cortical bone.

Dr. Tolbert:

It's local anchorage.

Dr. Ness:

It's local anchorage. Exactly, it's not remote, it's local anchorage. Yeah, yeah, it's very simple, you know.

Dr. Tolbert:

Okay.

Dr. Ness:

I actually let me read a comment that somebody made on Instagram.

Dr. Ness:

I agree with you, Somebody was like hey, man, you know, let me read the comment because I thought it was good. I'm not sure what I answered, but Okay. So this person said hey, I don't know, doc, like I'm not sure about it, in some cases that I have left the implant tip, like that, I had to reopen and do implantoplasty because the patients kept having pain in that area. I don't think I think soft tissue and sharp edges don't go well together. Yeah, sure, in most cases I would agree, and my answer to him is the one I'm going to give here and it explains the technique very simply. We don't want coat hangers. Anything that overextends past the millimeter into the osteotomy, into the fenestration, can have problems, just like lifting nasal mucosa to place an implant into the nasal floor. The way I teach that one is don't overdo it. You want to make sure you stay one millimeter to two millimeters engaging into that area. So if you see the pictures that I post, you'll never see this.

Dr. Ness:

Right, right, you'll see probably that and you'll see it kind of sideway, so you can, you can see it more. If you were to look at it like that, it would probably be like that and that's never been an issue and I've been doing it for many years now we probably have to write about it. Um, yeah, with complications, where it has been an issue and that there's actually literature about fenestrations like that is if it's overextended, kind of like with cheekbone, with zygomas. You know, sure, we, sure we can definitely have some fistulas, we, we can have pain in the area. And if that happened to you because your drilling protocol was off and I'll talk about drilling protocol right now all you have to do is, as you mentioned, kind of like an apicoectomy on the tip of the implant. You polish that tip of the implant, voila, it's gone. It's simple, even if you had to come back to it three months later and the patient's like, yeah, something here feels a little off, oh honey, don't worry, slide it open, polish it off, close it.

Dr. Tolbert:

Yeah, just where it's at. You don't even have to do the full flap really.

Dr. Ness:

You were able to load your implant. It's very simple. I talk about this. It's just actually in the Ways of the Arches. We talk about something called the Empire State Concept and the Empire State Concept man is just an under-drill sequence. You know, we go to desired length with 2.0 or with your initial drill, which usually the tip is around the same diameter tip of your implant 2.2, something like that.

Dr. Ness:

Any fenestration that you make, you just want to make sure the channel is open. The moment you overextend that osteotomy or you overdrill it with like 3.5 or 3, the body of your implant will have to go in more.

Dr. Tolbert:

Yeah, you would have to overextend to get anything out of it.

Dr. Ness:

Yeah, and that's where that complication will happen. And then you have a coat hanger coming out of that, out of that osteotomy. I think you're off again, man.

Dr. Tolbert:

Just keep going, I'll get a resort.

Dr. Ness:

So, anyways, very simple technique. It's an underprepping technique. You want to make sure that what you always fenestrate, you, you don't want to make your implant try to fenestrate, because if the implant reaches that cortical it will spin, it'll become a spinner without you having created a little axis for it. So you do fenestrate, at least with your initial drills, and I think I have videos on that on my instagram. Initial drill fenestrates and that's it. The next drill, which usually is a 3.5 for me, doesn't even get close to it. It goes probably mid, mid osteotomy, uh of of the full implant length that I want to place in the area. So just kind of creating the channel. And why do we say that? Because we believe that the magic is in the tip, so kind of like remote anchorage. It's all tip related, you know.

Dr. Ness:

So yeah, that's basically that with that technique. It's a technique where you fenestrate. Why do we fenestrate buckley, you know, kind of towards the end point because bone is dense there. Also, I like to see, you know, a lot of the times when we fenestrate into the nasal floor. You know you fenestrated, you can feel if you lift the nasal mucosa but you really don't see where you're at. You know, sometimes you don't see. So it's become a simplicity thing for me to just be like, even if I, as soon as I know that the area doesn't have very dense bone, just a conventional all within body implant, all within bone implant and I'll just fenestrate?

Dr. Ness:

yeah, I'll just fenestrate buckley towards the end point. Okay, golden triangle, that's somebody something to say. Yeah, I'll fenestrate immediately. I know my implant's going to get good torque. If that wasn't an option, if that doesn't work, I'll redirect my implant, probably going to the nasal floor. There's a good cortical there too cortical bone. I'll engage it. I'll lift my the nasal mucosa and I'll engage the implant. Now, tip for that is make sure you always lift nasal mucosa, because some people just like to drill and fenestrate. You don't know where you're at. You know, and you could be very posterior or very anterior. Usually, as a tip patients, if you poke your nose and they're like, will they feel it? It would be in the rim, like in the piriform rim. So you want to make sure you're at least two millimeters into the nasal floor. Does that make sense? Yeah, it does, and stuff that I can share if you want to put an image here for that Sure, sure, sure.

Dr. Ness:

Very simple, very easy, and it saves you 80% of needing remote anchorage techniques.

Dr. Tolbert:

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, what would you be your protocol, and when?

Dr. Ness:

do you? Know, that it's adequately polished. I usually use and I've had to use, I've done this technique a lot, probably like 4 or 5 times the 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 I feel like if the implant already had doubtful torque, I feel like I mess with that.

Dr. Tolbert:

You're shaking it. I make with that so you're shaking.

Dr. Ness:

I make sure that my technique is on point. You have to. I saw somebody and I don't want to criticize some recently post I'm not gonna say the name, I don't think he's he's that popular yet he should be. He's really good. But he posted fenestrating into the nose like quite a bit on purpose, and then doing the alveoplasty, like what for? You know, yeah, start off with a small 8mm implant. If you were just going to cut it to 8mm anyway, you know, and fenestrate slightly, that's it Right. The less we do, the better. Yeah, or I don't know, if I became lazy, I, I really don't want to do that unless it's necessary. Yeah, I'm gonna post the follow-up of that, that case coming up, cool, um, I just kind of have like different and I'll show you how the mucosa looks. There's no fenestration. Patients are happy. I don't have complaints from irritability in the zone. Why? Because I stayed within a millimeter.

Dr. Tolbert:

All you want to do is engage, yeah, yeah.

Dr. Ness:

If you're engaged and you did it correctly, that's where the torque is.

Dr. Tolbert:

Right, right, right, because that's the part of the implant that's ballooning out and it's that sort of compression that's really giving you that torque from the cortical plate. So my second question then is and you talked a little bit about your options there, right Either going directly into or staying endosius in that sort of golden triangle, versus going into the nasal floor, versus doing this apical fenestration technique, what's like your go-to? Which one are you trying to do first and foremost? And then, if you suspect you're not going to get torque, are you then opting for the apical fenestration or the nasal cavity? What, what's your decision tree there?

Dr. Ness:

yeah, I, I think it's, it's kind of become uh, obviously I try immediately to do be have the implant completely within bone, you know, and yeah, that's the safest thing it's like a probe.

Dr. Ness:

You know, as you're drilling, it feels like a probe. Okay, I'm within bone that's 60 millimeters, which is my go-to. Yeah, great, then I'll take, I'll follow my drill sequence and blah, blah, blah. I don't like the torque because I drilled with my initial drill, which is the probe, and I'm like I think it could be better. Immediately I go into fenestration apical fenestration. At that point, okay, I just have had really good results.

Dr. Tolbert:

It's easy.

Dr. Ness:

I don't have to like put a instrument into the nasal mucosa Not that that's hard at all, you know, but it's just it's already there. All I'll do is like I'll stay in position. It's just the tip angling yeah, and I'll hit it. I'll feel resistance and all of a sudden, punch yeah, yeah.

Dr. Ness:

Yeah, clean it up, clean the debris, drill the next drill and usually man, 90% of the time even more like I'll get really good torque there. Sometimes you don't even have to fenestrate as you're engaging that Every time you're proximal to a cortical it's like if you had a cushion against the wall yeah you know the bone, just as you start getting closer, the bone condenses there to go, so it like densifies there yeah yeah you don't even have to fenestrate you're.

Dr. Tolbert:

You have your path carved out to the fenestration, but your implant's getting close you 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 know I've done it at least one or two times and I think the times when I did it, it wasn't. It wasn't because I knew that it was a good technique, it was because I um, it's more of an anatomical thing. At least in the ones that I've done it and moving forward, I think I'll actually consider it as more of an anatomical thing. At least in the ones that I've done it and moving forward, I think I'll actually consider it as more of like a technical thing. That's just a smart thing to do. But in my cases it was, you know, 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's usually going to be something like, let's say, I'm doing an upper single arch and the patient has a proclined maxilla and so I'm trying to come from that distal position and as I'm trying to angle myself for the nose, it's just that undercut. I can't do it in such a way without adopting a really extreme angle.

Dr. Tolbert:

As I try and get that tip I guess the word is palatal enough to purchase the nose and it ends up coming out the buccal plate, and so I was like, well, you know what, screw it. I'm going to do it because I know I'm going to get torque and it's not going to. I'm just not going to overextend it, and it works, um. So I definitely think it's a, it's a useful thing for anatomical considerations as well, not just to get torque in any situation, but you know, it might be the better situation because prosthetically that ends up being better, because I don't have to angle so severely, buckly and then count on my multi-unit to try and bring that back in, you know, to my occlusal table where my, where my access is going to be, and then, furthermore, have to rely on an angle correcting screw to get it. You know where it needs to be.

Dr. Ness:

so, um, exactly, and I would add to that man beware, you know. Let's say this is, this is your bone. You want to make sure, on that technique, that you're actually engaging or starting your osteotomy a bit more, in that case palatally. It's got to be palatal.

Dr. Ness:

Yeah, it's got to be palatal, so like, if this is your bone, this is palate. You want to make sure you're starting on this area and not here, or else, because I've seen people try to do that, trying to do the technique, and they fenestrate but the bone is so thick that, uh, so thin right there, 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 to whoever's been doing it for a while, but that's one of the things like, hey, I tried it, but look what happened.

Dr. Ness:

You know, it's a big chunk of bone just fractured. I'm like, ah, you need to start a bit more palatal yeah, yeah.

Dr. Tolbert:

so it's not like you're going in the exact same osteotomy. You're really going to have to come more palatal, so you kind of transsecting that, that alveolar process, instead of just like riding along the buckle plate.

Dr. Ness:

Yeah, and it gets corrected with a multi-unit super easily. Man, it's not a lot, it's not like a psycho. That was super easily placed.

Dr. Tolbert:

Yeah, like the intrasinus zygos that come out of the roof of them exactly right, right, okay, you know, but no, no, of course.

Dr. Ness:

Of course that usually works out. You can do it also. Then mandible I don't know if you've done it, oh sure, yeah, in the mandible you can fenestrate buccally too. That's a very, very, very, uh thick cortical.

Dr. Tolbert:

So yeah, absolutely. I. I recently um I've done it. I think I've I early in my journey, I'm sure.

Dr. Ness:

I saw you post a mandible with that too. I think so right, yeah well on the other side.

Dr. Tolbert:

I did a lingual, I did like a translingual.

Dr. Ness:

Yeah, man, I've never done that, I got to see how that turns out. Man, me too I wonder if a patient'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 cool case.

Dr. Tolbert:

Just that was anatomy driven too, right, totally. Yeah, I mean that it was. She just had that very like sort of sigmoid, like hourglass mandible and, um, if I got any more interior there'd been almost zero spread. There really wasn't even spread to 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 knew I was probably going to have to do this in the first place. I tried, not on the other side I managed to stay entirely in bone, but in this one it just wasn't there for me. Um, so I kind of I had to perf through, uh, that lingual plate, go through it and then re-engage that inferior portion. So it's, you know, multi-corticalization Torked out, great, but the key was trying to stay as flush to the bone as I could, because if I got those threads hanging out there and they start playing with it with their tongue, it's not going to be a good story.

Dr. Tolbert:

She hasn't said anything about it, we'll see. It's still very early, but yeah, we'll see the long term. On that one, I don't want it to be something where I just, you know, post it and be like, yeah, this, this will work long term. But if it weren't, if it weren't that it was gonna be a snap. And I and I and I had a backup plan. I had a two implant overdenture ready to to load if, if, if it ended up going that way, but fortunately we didn't need it on the day. But, um, but yeah, no, I definitely have done that on the lower before, but I think that was like early on in the journey and probably because I wasn't flapping adequately and probably a mistake, and that's.

Dr. Ness:

it's funny that you say that, but I think we've all all together, worldwide, have made enough mistakes that have broken the rules. We've found out that rules can be broken. Sometimes they're like okay yeah we can do this. This technique makes this work.

Dr. Tolbert:

I'm convinced that's where root banking came from, like we just couldn't get the damn thing out of there. They're like no, no, no, it preserved bone, it's fine.

Dr. Ness:

Just leave it, man. Just a coronectomy.

Dr. Tolbert:

That's what we do, it's just a coronectomy is all it is. We just got to call it a name and it's not a mistake anymore. Um, but, uh, I lost my camera feed again, so I'm just going to start the next question. But, um, so, uh, I do want to talk. So we already talked ways of arches test for surgical. Okay, here's a good question. So what would you say? We talked about pterygoids. We talked about the apical fenestration. Um, what would you say in your practice and you've posted a lot of powder approach all these crazy things. Approach all these crazy things. If you had to say, like one technique that's really transformed your full arch practice more than anything.

Dr. Ness:

What would that have been? Wow, um, there's so many men. I feel like there's so many little tips and tricks, you know like, I feel like drilling protocol, what I call the empire state. Um, that, that changed my practice, because my torque went from being happy with getting 25 to 30 to being at 60 or 70. Nowadays, comfortably, all my implants will normally be 60, 70. Pterigoids obviously I think they're not trendy, um, pterygoids, obviously like I think they're not trendy.

Dr. Ness:

I think they just changed our idea of what CTV is for the arch community, which, at the end of the day, just makes us all sleep better tonight. You know, when people ask me, hey, who gets pterygoids? I, to this day say everybody gets pterygoids. Why? Because I like to sleep at night. To this day say everybody gets terror goods. Why? Because I like to sleep at night. You know, yeah, to know that my torque value addition it's way past 120. And then if the patient wants to go and cheat a little bit and need something that they're doing it.

Dr. Ness:

They're a bit safer, you know so, obviously, pterygoids are great. Palatal approaches is is amazing. Yeah, there's a lot of discussion, you know, like, who created it? Who invented it? Um, which why I'm considering changing it to palatal exposure technique instead of total approach, just to just to hammer into the drama of like, oh no, I did it first.

Dr. Tolbert:

No, I did it first. No, there's nuances, it's different, I swear there's nuances, it's different, I swear.

Dr. Ness:

Yeah, so like what I'm doing a lot is when I do palatal fenestration or palatal exposure technique, what I do is I fenestrate to the end point to like add my little thing.

Dr. Tolbert:

Oh that is different, that is very different. Yeah, so that's really interesting. Yeah, that is different, that is very different. Yeah, so that's that's really interesting. Yeah, so I mean, typically when I've, when I've taught folks palatal approach, I'm always saying, like very rarely is that a fully endoskeletal implant, like it's going to have to purchase something like it needs to be the nasal cortex, but I've never, I've never done that with an apical fenestration. That's really smart. Yeah, that, that is that is different, that's novel Apical fenestration.

Dr. Ness:

That's really smart. Yeah, that is different, that's novel. Most of mine will have that apical fenestration and it ends up sometimes anatomically driven to have to be into the nasal floor, yeah, or just anywhere fenestrating, anywhere in the piriform rim, I don't know.

Dr. Tolbert:

Right.

Dr. Ness:

Right. That apical fenestration at an end point has been a game changer for me.

Dr. Tolbert:

Yeah.

Dr. Ness:

I feel like that one's To add to the list of things that have changed the game for me. You know, yeah, yeah.

Dr. Tolbert:

I feel like that one's kind of tricky too, because with palatal approach you're already having to correct for the palatal bias that the implant already has. You know, part of the trick of it is actually buccalizing the implant against the ridge to try and get it to a better restorable position. Because when I first started doing it I'd be like, oh cool, I got torque and everything. But then I look at my prosthetic and I'm like totally palatable to the tooth and I've made too thick of a of a prosthetic. So with that, in order to get you know, you, as we discussed, in order to do that apical fenestration technique, you need to kind of already be more palatable. So maybe it's more appropriate for that, but at the same time, like you can't, you can't cheat even more palatable, because then you're going to have a bit of a emergence issue, right. So that's tricky, that's tricky. You've definitely got to have the end in mind to nail that.

Dr. Ness:

You have to have the experience to know. You know also where you want your MUA to be totally aesthetically driven and not overdo 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:

Uh, but yeah, fenestration, apical fenestration but you definitely you surprised me with that answer, though, because I feel like almost everybody is gonna you know, uh, they're gonna point out, um, you know. They're gonna say, um, you know a technique. They're gonna say pterygoid, pal approach, everything you just said, the empire state thing, right, just creating that taper with the osteotomy and learning how to create torque out of just a course traditional placement, 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 and um, I found too, in my cases where I always opted for much longer implants and always try to get cortical stability and things, if I don't need it, I probably shouldn't do it like, uh, you know, just for the sake of the conservancy and like being able to retreat this art, this arch, if I, you know, I usually 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 need it, a lot of times I will opt for like a 4.013, get the torque with just the bone that I have available, and then, if that fails, I know I can go right back in that same spot. Now I can get the nose of the 4.016 and boom, it's a two for one deal. Like I got two options out of one osteotomy, so you Just knowing how to really massage the bone and get it to where it's going to give you torque on its own, without the need for cortical anchorage. Like that's a skill and that's one that only comes with time.

Dr. Ness:

I've always said and I stand true to this is stability is about drilling. You know, that's where stability is about drilling. Yeah, absolutely. And what you said, like the the, I call it the probe, you know. But the initial drill is is that probe to see like, ah, this bone feels good, this bone doesn't feel good? This is where the surgery is going to go, you know, yeah.

Dr. Tolbert:

Yeah, absolutely, and just having that, you know, repeatable, like going right back through the same osteotomy and not, you know, I think, uh, uh, like a more amateur clinician, like they will adjust inside the osteotomy or they won't go back in the exactly the same path and end up widening it. And then they get surprised when they don't have torque and that's because you, you know, even with the smaller drill, you created a bigger hole, right? So if you don't have that setting, 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 get towards the end of our interview here. I know we both are seeing patients and things. So one of my big questions that I always like to ask my guests is what is your most controversial opinion in full arch about trends, things going on, things that you're seeing? Um, what's something that you feel is like kind of counterculture?

Dr. Ness:

I am very pro evolution. Um, so I will say this. I will say not everything that shines is gold, but the only way to find anything shiny is by digging yeah, does that make sense?

Dr. Tolbert:

Yeah, it does yeah.

Dr. Ness:

So I will be the first one to tell you try it. You know, like, try it. I am not a close-minded person to I don't know if you recently saw somebody I'm not. I'm totally hope you don don't post this or you are going to post this. Somebody comment on my, on my palatal fenestration technique, somebody very famous. I don't know if you got some of that hype going on. Sure, and it was a somebody I respect and somebody I you know. I don't know them personally, but I respect them. Somebody I respect and somebody I you know. I don't know them personally but I respect them, and I think they did a lot of good to our profession, but they stayed as if the peak that they reached was the peak of the world.

Dr. Tolbert:

Does that make sense, yeah, yeah, I understand.

Dr. Ness:

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 discovering things. I think we are realizing things that we thought didn't work can work with the proper techniques or the proper science to back it up Implant designs, drilling techniques. So I'll repeat what I said. I said not everything that shines is gold, but the only way to find anything shiny is by digging just keep digging, that's good.

Dr. Tolbert:

Keep, yeah, that's good. No, I, I think that's a great mentality and that's really what's pushed our field forward. I mean, if we always, um, did things the way they've been done, we wouldn't be having this conversation, because this whole modality wouldn't exist. Um, so, yeah, that's a good point, that's a very good point. I I really look up to the folks that have been in our field for a long time, to the you know, michael Picos of the world that are just students forever and are always humble and willing to help out folks, and I feel like it's those types of mentalities that really push us forward and grow our profession. So, no, that's solid, that's really solid. Um. So I'm curious to you know what is next for you? You know, professionally, in terms of not just your clinic but also just the impact that you wish to have in the full arts world with your courses, with you know, being on the lecture circuit and things like that. Um, you know what, what? What are you looking forward to?

Dr. Ness:

Yeah, so, um, there's definitely things coming up that I can't say yet. But there's partnerships coming up with with people that you guys already know, sure yet. But there's, oh, nice ships coming up with with people that you guys already know, sure, um, and we're we're thinking like pretty big actually, we're thinking about pretty cool things coming up that we can hopefully help contribute or at least unite into the full arch world. Um, definitely through education through, through um, not only, but merging education with um, with breakthroughs in our world through technology, yeah, um, continuing that. Obviously I love teaching men, I love talking, uh, I love people. So being out there and doing a course, doing a conference, is always, uh, brings satisfaction to me. You know, being able to have somebody, um, somebody said it, it sounds dirty, but pop their terroquid cherry. You know what I'm saying.

Dr. Tolbert:

Of course yeah.

Dr. Ness:

So, like I love, I love being somebody that's like come here, man, I will guide you through 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 do it right. And when it's done, man, you know, it's like it's like planting a tree, yeah, and having somebody else water it and having somebody else take care of that, and, like you are, the fruit of that tree is going to feed people, yeah, and you were part of it. And it's kind of like I, I'm kind of spiritual, you know, so I believe in the spirituality of like, just through something, through a wave that you sent out or that you wholeheartedly like, this is good, man, this is how you do it, this is teaching.

Dr. Ness:

You know, that's what teachers are Like. Teachers just have ripples that they'll never even know, but somebody's getting blessed somewhere because of something you did, you know. And I find you know, and I find I found you know fulfillment in that, yeah, no, I totally other than that you can delete this, but fuck full arch, you know. And like I just care about my family, my kids I'd like, I like this actually if I die tomorrow, ain't nobody gonna post a picture of Dr Nestor, you know?

Dr. Ness:

Yeah, my kids, my family, my wife, that's the most important thing in life for me. And I could lose both hands tomorrow and still be a happy man if I have them, you know.

Dr. Tolbert:

Man, that's awesome. You know something about full arches. There's not really an end point with it. You know it's not like if you just keep chasing it and keep always doing the newest technique or trying something new, that one day you're just going to get happy off a full arch. It just doesn't work like that and you know you're only going to find contentedness, you know, with the people that are in your immediate life and making sure you're paying attention to them and you're keeping all those things in check. And really that's the secret of doing this long-term anyway, is just making sure that things are at home or in in the heart or in check. And um, yeah, that's probably one of the most valuable lessons has been on the show in a long time. So I really appreciate you bringing that forward. Thank you, man.

Dr. Ness:

Thank you, I appreciate that.

Dr. Tolbert:

It's been, it's been awesome. I been wanting to do this for a while and it's I know, so I know we get little good clips out of all this man, but thanks, yeah, yeah, for sure. Inviting me, tyler? Yeah, yeah, absolutely, and I think in my next episode I'll bring the cowboy hat that I recently acquired as well, just uh, just to honor you do it, man, I would love that awesome man.

Dr. Tolbert:

Well, I really appreciate your time. Thanks so much for coming on and dealing with my technical difficulties. Um, everybody, this is nester marquez. Look him up on instagram, dr ness. He's got amazing cases and he's got a lot of things to teach and share. Definitely, look up Ways of the Arches. It looks like an amazing course that teaches a lot more than just arches. So, thanks so much, and until next time, my man, until next time, man Appreciate you.